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Zhang X, Su Y, Zhu X. The association of diabetes with progression of sleep-disordered breathing based on a prospective cohort. Diabetes Obes Metab 2024; 26:3935-3939. [PMID: 38951866 DOI: 10.1111/dom.15742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/06/2024] [Accepted: 06/10/2024] [Indexed: 07/03/2024]
Abstract
AIM Prospective studies suggest that sleep-disordered breathing enhances the risk of diabetes. However, it remains unclear whether diabetes could worsen sleep-disordered breathing. METHODS The participants from Sleep Heart Health Study underwent two polysomnograms at a 5-year interval. The relationship of baseline diabetes to change in the apnoea-hypopnoea index (AHI) was examined based on general linear models, adjusting for demographics, lifestyles, history of hypertension, pulmonary function, length of follow-up and baseline AHI. RESULTS In total, 161 of the 2603 participants were diagnosed with diabetes at the first polysomnograms. Compared with participants without diabetes, those with diabetes had a higher baseline and larger increases in follow-up AHI and obstructive apnoea index (oAI). Diabetes increased 2.52 events per hour (95% confidence interval 0.45-4.59; p = .017) for AHI change and 1.13 events per hour (95% confidence interval 0.04-2.23; p = .042) for oAI change, respectively. In addition, subgroup analysis suggested that the association was consistent across baseline obstructive sleep apnoea severity and body mass index groups. CONCLUSIONS Baseline diabetes was associated with worsening sleep-disordered breathing over 5 years, which mainly increased the change in AHI and oAI.
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Affiliation(s)
- Xiujian Zhang
- Department of Respiratory Medicine, Nanjing Meishan Hospital, Nanjing, China
| | - Yingying Su
- Department of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Xuanfeng Zhu
- Department of Respiratory Medicine, Jiangsu Province Official Hospital, Nanjing, China
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Ranjan A, Biswas S, Mallick BN. Rapid eye movement sleep loss associated cytomorphometric changes and neurodegeneration. Sleep Med 2023; 110:25-34. [PMID: 37524037 DOI: 10.1016/j.sleep.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/10/2023] [Accepted: 07/22/2023] [Indexed: 08/02/2023]
Abstract
Rapid eye movement sleep (REMS) is essential for leading normal healthy living at least in higher-order mammals, including humans. In this review, we briefly survey the available literature for evidence linking cytomorphometric changes in the brain due to loss of REMS. As a mechanism of action, we add evidence that REMS loss elevates noradrenaline (NA) levels in the brain, which affects neuronal cytomorphology. These changes may be a compensatory mechanism as the changes return to normal after the subjects recover from the loss of REMS or if during REMS deprivation, the subjects are treated with NA-adrenoceptor antagonist prazosin (PRZ). We had proposed earlier that one of the fundamental functions of REMS is to maintain the level of NA in the brain. We elaborate on this idea to propose that if REMS loss continues without recovery, the sustained level of NA breaks down neurophysiologically active compensatory mechanism/s starting with changes in the neuronal cytomorphology, followed by their degeneration, leading to acute and chronic pathological conditions. Identification of neuronal cytomorphological changes could prove to be of significance for predicting future neuronal (brain) damage as well as an indicator for REMS health. Although current brain imaging techniques may not enable us to visualize changes in neuronal cytomorphology, given the rapid technological progress including use of artificial intelligence, we are optimistic that it may be a reality soon. Finally, we propose that maintenance of optimum REMS must be considered a criterion for leading a healthy life.
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Affiliation(s)
- Amit Ranjan
- Department of Zoology, Mahatma Gandhi Central University, Motihari, East Champaran, Bihar, 845401, India.
| | - Sudipta Biswas
- Math, Science, Engineering Department, South Mountain Community College, 7050 S 24th St, Phoenix, AZ, 85042, USA
| | - Birendra Nath Mallick
- Amity Institute of Neuropsychology & Neurosciences, Amity University Campus, Sector 125, Gautam Budh Nagar, Noida, 201313, Uttar Pradesh, India
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Musleh A, Abd El Maksoud WM, Dalboh A, Abbas KS, Alshehri S, Bawahab MA, Alqahtani AJ, Al-Malki AQ. Impact of Laparoscopic Sleeve Gastrectomy on Obstructive Sleep Apnea Symptoms Based on the STOP-BANG Questionnaire: A Prospective Study. Bariatr Surg Pract Patient Care 2023; 18:115-120. [DOI: 10.1089/bari.2022.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Affiliation(s)
- Abdullah Musleh
- Otorhinolaryngology Division, Surgery Department, King Khalid University College of Medicine, Abha, Saudi Arabia
| | | | - Abdullah Dalboh
- Surgery Department, King Khalid University College of Medicine, Abha, Saudi Arabia
| | - Khaled S. Abbas
- Surgery Department, King Khalid University College of Medicine, Abha, Saudi Arabia
| | - Sarah Alshehri
- Otorhinolaryngology Division, Surgery Department, King Khalid University College of Medicine, Abha, Saudi Arabia
| | - Mohammed A. Bawahab
- Surgery Department, King Khalid University College of Medicine, Abha, Saudi Arabia
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Mostafa SA, Mena SC, Antza C, Balanos G, Nirantharakumar K, Tahrani AA. Sleep behaviours and associated habits and the progression of pre-diabetes to type 2 diabetes mellitus in adults: A systematic review and meta-analysis. Diab Vasc Dis Res 2022; 19:14791641221088824. [PMID: 35616501 PMCID: PMC9152198 DOI: 10.1177/14791641221088824] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Certain sleep behaviours increase risk of type 2 diabetes mellitus (T2DM) in the general population, but whether they contribute to the progression from pre-diabetes to T2DM is uncertain. We conducted a systematic review to assess this. METHODS Structured searches were performed on bibliographic databases (MEDLINE, EMBASE and CINAHL) from inception to 26/04/2021 for longitudinal studies/trials consisting of adults⩾18 years with pre-diabetes and sleep behaviours (short or long sleep duration (SD), late chronotype, insomnia, obstructive sleep apnoea, daytime napping and/or night-shift employment) that reported on incident T2DM or glycaemic changes. The Newcastle-Ottawa Scale was used for quality assessment. RESULTS Six studies were included. Meta-analysis of three studies (n = 20,139) demonstrated that short SD was associated with greater risk of progression to T2DM, hazard ratio (HR) 1.59 (95% CI 1.29-1.97), I2 heterogeneity score 0%, p < 0.0001, but not for long SD, HR 1.50 (0.86-2.62), I2 heterogeneity 77%, p = 0.15. The systematic review showed insomnia and night-shift duty were associated with higher progression to T2DM. Studies were rated as moderate-to-high quality. CONCLUSIONS Progression from pre-diabetes to T2DM increases with short SD, but only limited data exists for insomnia and night-shift duty. Whether manipulating sleep could reduce progression from pre-diabetes to T2DM needs to be examined.
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Affiliation(s)
- Samiul A Mostafa
- Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre of Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partner, Birmingham, UK
- Samiul A Mostafa, Department of Diabetes, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Nuffield House, Birmingham B15 2PR, UK.
| | - Sandra Campos Mena
- Diabetes and Endocrinology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Christina Antza
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- 3rd Department of Internal Medicine, “Papageorgiou” Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Krishnarajah Nirantharakumar
- Centre of Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partner, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Midlands Health Data Research UK, Birmingham, UK
| | - Abd A Tahrani
- Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre of Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partner, Birmingham, UK
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Lee SSY, Nilagiri VK, Mackey DA. Sleep and eye disease: A review. Clin Exp Ophthalmol 2022; 50:334-344. [PMID: 35263016 PMCID: PMC9544516 DOI: 10.1111/ceo.14071] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/02/2022] [Accepted: 03/06/2022] [Indexed: 12/21/2022]
Abstract
There is a growing body of literature on the effects of sleep disorders, in particular obstructive sleep apnoea (OSA), on ocular health, with consistent evidence of an increased risk of floppy eyelid syndrome, non-arteritic anterior ischaemic optic neuropathy, diabetic macular oedema, and other retinal vasculature changes in individuals with OSA. However, reports on OSA's associations with glaucoma, papilloedema, diabetic retinopathy, central serous chorioretinopathy, and keratoconus have been conflicting, while links between OSA and age-related macular degeneration have only been described fairly recently. Despite numerous suggestions that OSA treatment may reduce risk of these eye diseases, well-designed studies to support these claims are lacking. In particular, the ocular hypertensive effects of continuous positive airway pressure (CPAP) therapy for OSA requires further investigation into its potential impact on glaucoma risk and management. Reports of ocular surface complications secondary to leaking CPAP masks highlights the importance of ensuring good mask fit. Poor sleep habits have also been linked with increased myopia risk; however, the evidence on this association remains weak.
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Affiliation(s)
- Samantha S Y Lee
- Centre for Ophthalmology and Visual Science (incorporating the Lions Eye Institute), University of Western Australia, Perth, Western Australia, Australia
| | - Vinay K Nilagiri
- Centre for Ophthalmology and Visual Science (incorporating the Lions Eye Institute), University of Western Australia, Perth, Western Australia, Australia
| | - David A Mackey
- Centre for Ophthalmology and Visual Science (incorporating the Lions Eye Institute), University of Western Australia, Perth, Western Australia, Australia.,Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia.,School of Medicine, Menzies Research Institute Tasmania, University of Tasmania, Hobart, Tasmania, Australia
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Yang R, Gao C, Yan Y, Huang Y, Wang J, Zhang C, Ma X, Li N, Du X, Zhang L, Wang Y, Li R, Qiao J. Analysis of the proportion and clinical characteristics of obstructive sleep apnea in women with polycystic ovary syndrome. Sleep Breath 2021; 26:497-503. [PMID: 34013438 DOI: 10.1007/s11325-021-02376-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 04/04/2021] [Accepted: 04/09/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate the proportion and clinical characteristics of obstructive sleep apnea (OSA) in Chinese patients with polycystic ovarian syndrome (PCOS) through home sleep apnea test (HSAT) and to evaluate the reproductive endocrine and metabolic characteristics in these patients. METHODS The study was a cross-sectional analysis of infertile PCOS patients who underwent sleep respiratory monitoring between January and December 2019 at Peking University Third Hospital Reproductive Medical Center and respiratory and critical care medicine department. The prevalence of OSA, body mass index (BMI), menstruation, reproductive endocrine, and metabolic characteristics were collected in patients with PCOS. Logistic regression was performed to identify significant relationships among these factors and OSA. RESULTS Amont 328 patients with PCOS, the prevalence of OSA was 40% (131/328), and six cases (5%) were severe. Univariate analysis showed that BMI and blood pressure were significantly higher in patients with OSA than in those without OSA (P < 0.05), whereas the anti-Mullerian hormone was lower than that in patients without OSA. In terms of glucose and lipid metabolism, the glycosylated hemoglobin (HbA1c), fasting plasma glucose, and fasting insulin levels were significantly higher in patients with PCOS and comorbid OSA than in those without OSA (all P < 0.05). Patients with OSA also had higher triglyceride, low-density lipoprotein cholesterol, and high-sensitivity C-reactive protein levels and lower high-density lipoprotein cholesterol levels (P < 0.05). Logistic regression analysis revealed that higher BMI, elevated serum testosterone, and decreased high-density lipoprotein cholesterol (HDL-C) are correlated with occurrence of OSA (P < 0.05). CONCLUSION OSA in patients with PCOS was associated with multiple alterations in indexes of reproductive endocrine and metabolic disorders.
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Affiliation(s)
- Rui Yang
- Reproductive Medical Center, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Chang Gao
- Reproductive Medical Center, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Yizhi Yan
- Reproductive Medical Center, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Yongwei Huang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Jianli Wang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Chunmei Zhang
- Reproductive Medical Center, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Xiaowei Ma
- Reproductive Medical Center, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Nannan Li
- Reproductive Medical Center, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Xiaoguo Du
- Reproductive Medical Center, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Liqiang Zhang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.
| | - Ying Wang
- Reproductive Medical Center, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.
| | - Rong Li
- Reproductive Medical Center, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Jie Qiao
- Reproductive Medical Center, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
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Alterki A, Joseph S, Thanaraj TA, Al-Khairi I, Cherian P, Channanath A, Sriraman D, Ebrahim MAK, Ibrahim A, Tiss A, Al-Mulla F, Rahman AMA, Abubaker J, Abu-Farha M. Targeted Metabolomics Analysis on Obstructive Sleep Apnea Patients after Multilevel Sleep Surgery. Metabolites 2020; 10:metabo10090358. [PMID: 32882816 PMCID: PMC7569907 DOI: 10.3390/metabo10090358] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/22/2020] [Accepted: 08/23/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is caused by partial or complete obstruction of the upper airways. Corrective surgeries aim at removing obstructions in the nasopharynx, oropharynx, and hypopharynx. OSA is associated with an increased risk of various metabolic diseases. Our objective was to evaluate the effect of surgery on the plasma metabolome. METHODS This study included 39 OSA patients who underwent Multilevel Sleep Surgery (MLS). Clinical and anthropometric measures were taken at baseline and five months after surgery. RESULTS The mean Apnea-Hypopnea Index (AHI) significantly dropped from 22.0 ± 18.5 events/hour to 8.97 ± 9.57 events/hour (p-Value < 0.001). Epworth's sleepiness Score (ESS) dropped from 12.8 ± 6.23 to 2.95 ± 2.40 (p-Value < 0.001), indicating the success of the surgery in treating OSA. Plasma levels of metabolites, phosphocholines (PC) PC.41.5, PC.42.3, ceremide (Cer) Cer.44.0, and triglyceride (TG) TG.53.6, TG.55.6 and TG.56.8 were decreased (p-Value < 0.05), whereas lysophosphatidylcholines (LPC) 20.0 and PC.39.3 were increased (p-Value < 0.05) after surgery. CONCLUSION This study highlights the success of MLS in treating OSA. Treatment of OSA resulted in an improvement of the metabolic status that was characterized by decreased TG, PCs, and Cer metabolites after surgery, indicating that the success of the surgery positively impacted the metabolic status of these patients.
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Affiliation(s)
- Abdulmohsen Alterki
- Department of Otolaryngology Head & Neck Surgery, Zain and Al Sabah Hospitals and Dasman Diabetes Institute, Dasman 15462, Kuwait; (A.A.); (M.A.K.E.); (A.I.)
| | - Shibu Joseph
- Special Service Facility Department, Dasman Diabetes Institute, Dasman 15462, Kuwait; (S.J.); (D.S.); (F.A.-M.)
| | - Thangavel Alphonse Thanaraj
- Department of Genetics and Bioinformatics, Dasman Diabetes Institute, Dasman 15462, Kuwait; (T.A.T.); (A.C.)
| | - Irina Al-Khairi
- Department of Biochemistry and Molecular Biology, Dasman Diabetes Institute, Dasman 15462, Kuwait; (I.A.-K.); (P.C.); (A.T.)
| | - Preethi Cherian
- Department of Biochemistry and Molecular Biology, Dasman Diabetes Institute, Dasman 15462, Kuwait; (I.A.-K.); (P.C.); (A.T.)
| | - Arshad Channanath
- Department of Genetics and Bioinformatics, Dasman Diabetes Institute, Dasman 15462, Kuwait; (T.A.T.); (A.C.)
| | - Devarajan Sriraman
- Special Service Facility Department, Dasman Diabetes Institute, Dasman 15462, Kuwait; (S.J.); (D.S.); (F.A.-M.)
| | - Mahmoud A. K. Ebrahim
- Department of Otolaryngology Head & Neck Surgery, Zain and Al Sabah Hospitals and Dasman Diabetes Institute, Dasman 15462, Kuwait; (A.A.); (M.A.K.E.); (A.I.)
| | - Alaaeldin Ibrahim
- Department of Otolaryngology Head & Neck Surgery, Zain and Al Sabah Hospitals and Dasman Diabetes Institute, Dasman 15462, Kuwait; (A.A.); (M.A.K.E.); (A.I.)
| | - Ali Tiss
- Department of Biochemistry and Molecular Biology, Dasman Diabetes Institute, Dasman 15462, Kuwait; (I.A.-K.); (P.C.); (A.T.)
| | - Fahd Al-Mulla
- Special Service Facility Department, Dasman Diabetes Institute, Dasman 15462, Kuwait; (S.J.); (D.S.); (F.A.-M.)
| | - Anas M. Abdel Rahman
- Department of Genetics, King Faisal Specialist Hospital and Research Centre (KFSHRC), Zahrawi Street, Al Maather, Riyadh 11211, Saudi Arabia;
- Department of Biochemistry and Molecular Medicine, College of Medicine, Al Faisal University, Riyadh 11533, Saudi Arabia
- Department of Chemistry, Memorial University of Newfoundland, St. John’s, NL A1B 3X7, Canada
| | - Jehad Abubaker
- Department of Chemistry, Memorial University of Newfoundland, St. John’s, NL A1B 3X7, Canada
- Correspondence: (J.A.); (M.A.-F.); Tel.: +965-2224-2999 (ext. 3563) (J.A.); +965-2224-2999 (ext. 3010) (M.A.-F.)
| | - Mohamed Abu-Farha
- Department of Chemistry, Memorial University of Newfoundland, St. John’s, NL A1B 3X7, Canada
- Correspondence: (J.A.); (M.A.-F.); Tel.: +965-2224-2999 (ext. 3563) (J.A.); +965-2224-2999 (ext. 3010) (M.A.-F.)
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Siriwat R, Wang L, Shah V, Mehra R, Ibrahim S. Obstructive sleep apnea and insulin resistance in children with obesity. J Clin Sleep Med 2020; 16:1081-1090. [PMID: 32118578 DOI: 10.5664/jcsm.8414] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
STUDY OBJECTIVES Because existing data investigating obstructive sleep apnea (OSA) and insulin resistance (IR) are inconsistent, we examine OSA and IR in a pediatric obesity clinic. METHODS Children (2-18 years) in the obesity clinic (2013-2017) undergoing polysomnography (PSG), anthropometric measurements, and fasting laboratory tests were included. Linear regression assessed OSA defined by the obstructive apnea-hypopnea index (oAHI) with the homeostatic model assessment of insulin resistance (HOMA-IR). Secondary aims assessed oxygen desaturation index (ODI) and age interactions with HOMA-IR. Logistic regression models and receiver operating characteristic analysis were performed to investigate optimal oAHI and ODI cutoffs relative to HOMA-IR ≥ 3. RESULTS Eighty children were included (mean age, 11.4 ± 4.0 years; 56% female; 46% Caucasian; median body mass index [BMI], 34.6 kg/m² [interquartile ratio, 29.9-40.1], median BMI z-score, 2.5 [interquartile ratio, 2.3-2.8); 46% with oAHI ≥ 5 events/h. HOMA-IR was higher in the OSA group (oAHI ≥ 5 events/h): 5 vs 3.8 (P = .034). After adjustment for sex, race, and BMI z-score, oAHI ≥ 5 events/h retained significance with HOMA-IR (P = .041). HOMA-IR increased in older children (age ≥ 12 years) when adjusting for waist circumference z-score and waist-height ratio (statistical interaction, P = .020 and .034, respectively). Receiver operating characteristic showed optimal cut points of oAHI and ODI for predicting significant IR 4.9 (area under the curve, 0.70; 95% confidence interval, 0.57-0.83; sensitivity, 0.76; specificity, 0.66) and 4.6 (area under the curve, 0.68; 95% confidence interval, 0.55-0.80; sensitivity, 0.70; specificity, 0.67), respectively. CONCLUSIONS In a clinic-based pediatric cohort with obesity, OSA is associated with increased IR even after adjusting for confounders including obesity defined by the BMI z-score. Age ≥ 12 years was associated with AHI relative to IR after adjustment for waist circumference z-score and waist-height ratio. Significant IR could be discriminated by oAHI ≥ 4.9 with moderate sensitivity/specificity. Future studies are needed to verify these findings.
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Affiliation(s)
| | - Lu Wang
- Sleep Disorders Center, Neurological Institute, Cleveland, Ohio
| | - Vaishal Shah
- Sleep Disorders Center, Neurological Institute, Cleveland, Ohio
| | - Reena Mehra
- Sleep Disorders Center, Neurological Institute, Cleveland, Ohio
| | - Sally Ibrahim
- Division of Pulmonary, Allergy and Sleep Medicine, Rainbow Babies and Children's Hospital of University Hospitals, Cleveland, Ohio
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Impaired endothelium-mediated cerebrovascular reactivity promotes anxiety and respiration disorders in mice. Proc Natl Acad Sci U S A 2020; 117:1753-1761. [PMID: 31896584 DOI: 10.1073/pnas.1907467117] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Carbon dioxide (CO2), the major product of metabolism, has a strong impact on cerebral blood vessels, a phenomenon known as cerebrovascular reactivity. Several vascular risk factors such as hypertension or diabetes dampen this response, making cerebrovascular reactivity a useful diagnostic marker for incipient vascular pathology, but its functional relevance, if any, is still unclear. Here, we found that GPR4, an endothelial H+ receptor, and endothelial Gαq/11 proteins mediate the CO2/H+ effect on cerebrovascular reactivity in mice. CO2/H+ leads to constriction of vessels in the brainstem area that controls respiration. The consequential washout of CO2, if cerebrovascular reactivity is impaired, reduces respiration. In contrast, CO2 dilates vessels in other brain areas such as the amygdala. Hence, an impaired cerebrovascular reactivity amplifies the CO2 effect on anxiety. Even at atmospheric CO2 concentrations, impaired cerebrovascular reactivity caused longer apneic episodes and more anxiety, indicating that cerebrovascular reactivity is essential for normal brain function. The site-specific reactivity of vessels to CO2 is reflected by regional differences in their gene expression and the release of vasoactive factors from endothelial cells. Our data suggest the central nervous system (CNS) endothelium as a target to treat respiratory and affective disorders associated with vascular diseases.
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Sharifpour P, Dehvan F, Dalvand S, Ghanei Gheshlagh R. Examination of the Relationship Between Metabolic Syndrome and Obstructive Sleep Apnea in Iranian Patients with Type 2 Diabetes: A Case-Control Study. Diabetes Metab Syndr Obes 2020; 13:2251-2257. [PMID: 32617014 PMCID: PMC7326211 DOI: 10.2147/dmso.s260677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/17/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a common risk factor for metabolic syndrome (MS) that increases the chance of cardiovascular disease, stroke, and mortality. Many studies have been conducted on this matter, but the results are still conflicting. The aim of the present study was to examine the relationship between metabolic syndrome (MS) and obstructive sleep apnea (OSA) in Iranian patients with type 2 diabetes (T2D). PATIENTS AND METHODS This matched case-control study was conducted with 190 patients with T2D in Sanandaj, Iran. The data were selected using the demographic questionnaire, clinical and anthropometric measures, the Berlin Questionnaire (BQ), and the National Cholesterol Education Program's Adult Treatment Panel III (NCEP-ATP III). Participants were divided into two groups of high risk of OSA (experimental) and low risk of OSA (control). The data were analyzed using Stata, version 14. RESULTS The frequency of MS was higher in the OSA group than the control group (81.1% vs 70.5%), but the group difference was not statistically significant (p=0.127). The results of crude and age-sex adjusted logistic regression analysis revealed no significant association between OSA and the other variables under study (P>0.05). Sensitivity analysis and external adjustment for BMI showed no significant relationship between OSA and the other variables under study (P=0.319). CONCLUSION In the present study, no significant association was found between metabolic syndrome (MS) and obstructive sleep apnea (OSA) in patients with T2D; therefore, more studies should be conducted on this subject.
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Affiliation(s)
- Pershang Sharifpour
- Student Research Committee, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Fazel Dehvan
- Clinical Care Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Sahar Dalvand
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Ghanei Gheshlagh
- Clinical Care Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
- Correspondence: Reza Ghanei Gheshlagh Clinical Care Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, IranTel +98 9144050284 Email
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Tang Y, Sun Q, Bai XY, Zhou YF, Zhou QL, Zhang M. Effect of dapagliflozin on obstructive sleep apnea in patients with type 2 diabetes: a preliminary study. Nutr Diabetes 2019; 9:32. [PMID: 31685792 PMCID: PMC6828696 DOI: 10.1038/s41387-019-0098-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 05/23/2019] [Accepted: 06/13/2019] [Indexed: 12/14/2022] Open
Abstract
Objective The aim of this case-control study was to assess the efficacy of dapagliflozin combined with metformin for type-2 diabetes mellitus (T2DM) with obstructive sleep apnea hypopnea syndrome (OSAHS). Methods A total of 36 patients with newly-diagnosed T2DM and OSAHS were randomized divided into two groups. Eighteen OSAHS patients with T2DM, who were treated with dapagliflozin and metformin, were assigned as the dapagliflozin group. These patients were given dapagliflozin and metformin for 24 weeks between February 2017 and February 2018. Another 18 OSAHS patients with T2DM, who were treated with glimepiride and metformin for 24 weeks, were assigned as the control group. Fasting plasma glucose (FPG) level, postprandial blood glucose (PPG), hemoglobin A1C (HbA1c), fasting insulin, homeostasis model assessment of insulin resistance (HOMA-IR), blood lipids, body mass index (BMI), blood pressure, apnea-hypopnea index (AHI), minimum oxygen saturation (LSpO2), and Epworth Somnolence Scale (ESS) score were measured before and at 24 weeks after the initiation of treatment. Results In the dapagliflozin group, triglyceride (TG), systolic pressure (SBP) and diastolic pressure (DBP) significantly decreased following treatment, while high-density lipoprotein cholesterol (HDL-C) significantly increased (P < 0.05). Furthermore, a reduction in AHI, an increase in LSpO2 and a decrease in ESS score were observed in the dapagliflozin group (P < 0.05), but not in the control group. Moreover, blood glucose, HbA1c, HOMA-IR, and BMI significantly decreased in these two groups, and the decrease was more significant in the dapagliflozin group. Conclusion These present results indicate that dapagliflozin can significantly reduce glucose, BMI, blood pressure and AHI, and improve hypoxemia during sleep and excessive daytime sleepiness, which thereby has potential as an effective treatment approach for OSAHS.
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Affiliation(s)
- Yi Tang
- Department of Endocrinology, The Fifth People's Hospital of Chengdu, 611130, Chengdu, P.R. China
| | - Qin Sun
- Center of Diabetes Mellitus, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, 610072, Chengdu, P. R. China.
| | - Xiao-Yan Bai
- Department of Respiratory, The Fifth People's Hospital of Chengdu, 611130, Chengdu, P.R. China
| | - Yun-Fan Zhou
- Department of Endocrinology, The Third People's Hospital of Chengdu, 610000, Chengdu, P.R. China
| | - Qiong-Lan Zhou
- Department of Endocrinology, People's Hospital of Yilong County, 637676, Yilong, P.R. China
| | - Min Zhang
- Center of Diabetes Mellitus, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, 610072, Chengdu, P. R. China.
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12
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Smith JP, Cyr LG, Dowd LK, Duchin KS, Lenihan PA, Sprague J. The Veterans Affairs Continuous Positive Airway Pressure Use and Diabetic Retinopathy Study. Optom Vis Sci 2019; 96:874-878. [PMID: 31664013 PMCID: PMC6855331 DOI: 10.1097/opx.0000000000001446] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/08/2019] [Accepted: 08/20/2019] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE Obstructive sleep apnea has been linked to the development and progression of diabetic retinopathy. In this study, diabetic patients compliant with continuous positive airway pressure therapy (CPAP) for sleep apnea were less likely to have retinopathy, emphasizing the benefits and potential therapeutic role of CPAP in individuals with both conditions. PURPOSE The aim of this study was to compare the prevalence of diabetic retinopathy in type 2 diabetic patients with obstructive sleep apnea who were compliant with CPAP therapy with those who were not compliant with CPAP therapy. METHODS A retrospective cross-sectional review of type 2 diabetic patients using CPAP for obstructive sleep apnea was conducted. The prevalence of retinopathy was identified, and groups with and without retinopathy were compared using univariate analyses and multivariate logistic regression. RESULTS The prevalence of retinopathy was 19.6% (n = 321). Retinopathy was significantly less prevalent in those compliant with CPAP (odds ratio, 0.54; 95% confidence interval, 0.31 to 0.94; P = .04). The relationship remained statistically significant when adjusting for other factors known to impact the course of diabetic eye disease. CONCLUSIONS Increased CPAP compliance may mitigate the risk of developing diabetic retinopathy in type 2 diabetic patients with obstructive sleep apnea.
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13
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Kahal H, Kyrou I, Uthman OA, Brown A, Johnson S, Wall PDH, Metcalfe A, Parr DG, Tahrani AA, Randeva HS. The prevalence of obstructive sleep apnoea in women with polycystic ovary syndrome: a systematic review and meta-analysis. Sleep Breath 2019; 24:339-350. [PMID: 31111411 PMCID: PMC7127997 DOI: 10.1007/s11325-019-01835-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 02/28/2019] [Accepted: 03/22/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Obesity is a common risk factor for polycystic ovary syndrome (PCOS) and obstructive sleep apnoea (OSA). Both PCOS and OSA are associated with increased risk of type 2 diabetes and cardiovascular disease. Hence, it is important to determine the burden of OSA in women with PCOS. METHODS We searched electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, OpenGrey, CENTRAL), conference abstracts, and reference lists of relevant articles, up to January 2019. No restriction for language or publication status. Studies that examined the presence of OSA in women with PCOS using polysomnography and/or level III devices were eligible for inclusion. RESULTS Seventeen studies involving 648 participants were included. Our meta-analysis showed that 35.0% (95% CI 22.2-48.9%) of women with PCOS had OSA. This prevalence was not affected by variation in PCOS definition between studies. Approximately one-tenth of the variation in OSA prevalence was related to differences in study population (higher in adults than adolescents and mixed populations), and around one-tenth was related to sample size (higher in smaller studies). OSA prevalence was markedly higher in obese versus lean women with PCOS, and in women with PCOS compared to controls (odds ratio = 3.83, 95% CI 1.43-10.24, eight studies, 957 participants (349 PCOS and 608 controls)). However, most of the studies were at high risk of selection bias, did not account for important confounders, included predominantly women with class II obesity, and were conducted in one country (USA). CONCLUSIONS Future studies need to examine the true prevalence of OSA in a more representative sample of women with PCOS. Nevertheless, our results suggest that the prevalence of OSA in women with PCOS and obesity is high and clinicians should have a high index of suspicion of OSA in these women.
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Affiliation(s)
- Hassan Kahal
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| | - Ioannis Kyrou
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK.,Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, B4 7ET, UK.,Centre of Applied Biological and Exercise Sciences (ABES), Faculty of Health and Life Sciences, Coventry University, Coventry, CV1 5FB, UK
| | - Olalekan A Uthman
- Warwick - Centre for Applied Health Research and Delivery (WCAHRD), Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Anna Brown
- Library and Knowledge Services, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| | - Samantha Johnson
- University of Warwick Library, University of Warwick, Coventry, CV4 7AL, UK
| | - Peter D H Wall
- Department of Warwick Orthopaedics, Warwick Medical School, University of Warwick, Coventry, CV2 2DX, UK
| | - Andrew Metcalfe
- Department of Warwick Orthopaedics, Warwick Medical School, University of Warwick, Coventry, CV2 2DX, UK
| | - David G Parr
- Department of Respiratory Medicine, Cardio-Respiratory Division, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Centre of Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham, UK.,Department of Diabetes and Endocrinology, Birmingham Heartlands Hospital, Birmingham, UK
| | - Harpal S Randeva
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK. .,Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK. .,Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, B4 7ET, UK. .,Centre of Applied Biological and Exercise Sciences (ABES), Faculty of Health and Life Sciences, Coventry University, Coventry, CV1 5FB, UK.
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14
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Subramanian A, Adderley NJ, Tracy A, Taverner T, Hanif W, Toulis KA, Thomas GN, Tahrani AA, Nirantharakumar K. Risk of Incident Obstructive Sleep Apnea Among Patients With Type 2 Diabetes. Diabetes Care 2019; 42:954-963. [PMID: 30862657 DOI: 10.2337/dc18-2004] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/27/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This study compared the incidence of obstructive sleep apnea (OSA) in patients with and without type 2 diabetes and investigated risk factors for OSA in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A retrospective cohort study was performed to compare OSA incidence between adult patients with and without type 2 diabetes matched for age, sex, and BMI. Patients with a prevalent OSA diagnosis were excluded. The study cohort was derived from The Health Improvement Network (THIN), a U.K. primary care database, from 1 January 2005 to 31 December 2017. RESULTS There were 3,110 (0.88%) and 5,968 (0.46%) incident OSA cases identified in the 360,250 exposed and 1,296,489 unexposed patient cohorts, respectively. Adjusted incidence rate ratio (aIRR) of OSA in patients with type 2 diabetes compared with those without was 1.48 (95% CI 1.42-1.55; P < 0.001). In a multivariate regression analysis of patients with type 2 diabetes, significant predictors of OSA were diabetes-related foot disease (1.23 [1.06-1.42]; P = 0.005), being prescribed insulin in the last 60 days (1.58 [1.42-1.75]; P < 0.001), male sex (2.27 [2.09-2.46]; P < 0.001), being overweight (2.02 [1.54-2.64]; P < 0.001) or obese (8.29 [6.42-10.69]; P < 0.001), heart failure (1.41 [1.18-1.70]; P < 0.001), ischemic heart disease (1.22 [1.11-1.34]; P < 0.001), atrial fibrillation (1.23 [1.04-1.46]; P = 0.015), hypertension (1.32 [1.23-1.43]; P < 0.001), and depression (1.75 [1.61-1.91]; P < 0.001). CONCLUSIONS When considered alongside previous evidence, this study indicates that the association between type 2 diabetes and OSA is bidirectional. In addition to known predictors of OSA, diabetes-related foot disease and insulin treatment were identified as risk factors in patients with type 2 diabetes.
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Affiliation(s)
| | - Nicola J Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, U.K
| | - Alexander Tracy
- Institute of Clinical Sciences, Centre for Translational Inflammation Research, University of Birmingham, Birmingham, U.K
| | - Tom Taverner
- Institute of Applied Health Research, University of Birmingham, Birmingham, U.K
| | - Wasim Hanif
- University Hospital Birmingham, Birmingham, U.K
| | | | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, U.K.
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, U.K.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, U.K
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, U.K.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, U.K.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, U.K.,Health Data Research UK Midlands, Birmingham, U.K
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15
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Kahal H, Kyrou I, Uthman O, Brown A, Johnson S, Wall P, Metcalfe A, Tahrani AA, Randeva HS. The association between obstructive sleep apnea and metabolic abnormalities in women with polycystic ovary syndrome: a systematic review and meta-analysis. Sleep 2019; 41:4990841. [PMID: 29722890 DOI: 10.1093/sleep/zsy085] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Indexed: 12/18/2022] Open
Abstract
Study Objectives In this systematic review and meta-analysis, we aimed to examine the relationship between obstructive sleep apnea (OSA) and metabolic abnormalities in women with polycystic ovary syndrome (PCOS). Methods Electronic databases (Medline, Embase, Cinahl, PsycInfo, Scopus, Web of Science, Opengrey, and CENTRAL), conference abstracts, and reference lists of relevant articles were searched. No restriction was applied for language or publication status. Results Six studies involving 252 participants were included. Women with PCOS and OSA had significantly higher body mass index (mean difference [MD]: 6.01 kg/m2, 95% confidence intervals [CI]: 4.69-7.33), waist circumference (MD: 10.93 cm, 95% CI: 8.03-13.83), insulin resistance, systolic and diastolic blood pressure, and worse lipids' profile and impaired glucose regulation compared with women with PCOS without OSA. Most studies did not adjust for weight in their between-groups analysis. Total and free testosterone levels were not significantly different between the two groups. The majority of studies were found to be at high risk of selection bias, did not account for important confounders, were conducted in one country (United States), and used different methodologies to assess testosterone levels (preventing a meta-analysis for this specific outcome). Conclusions OSA is associated with obesity and worse metabolic profiles in women with PCOS. However, whether the effects of OSA are independent of obesity remain unclear. As OSA is a treatable condition, research focused on the independent effects of OSA on key clinical outcomes in women with PCOS, including fertility, psychological health, type 2 diabetes, and cardiovascular risk, is lacking and needed. PROSPERO registration number: CRD42016048587.
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Affiliation(s)
- Hassan Kahal
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom.,Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, United Kingdom
| | - Ioannis Kyrou
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom.,Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, United Kingdom.,Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham B4 7ET, United Kingdom.,Centre of Applied Biological and Exercise Sciences, Faculty of Health and Life Sciences, Coventry University, Coventry CV1 5FB, United Kingdom
| | - Olalekan Uthman
- Division of Health Sciences, Warwick - Centre for Applied Health Research and Delivery (WCAHRD), Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Anna Brown
- Library and Knowledge Services, University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, United Kingdom
| | - Samantha Johnson
- University of Warwick Library, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Peter Wall
- Department of Warwick Orthopaedics, Warwick Medical School, University of Warwick, Coventry CV2 2DX, United Kingdom
| | - Andrew Metcalfe
- Department of Warwick Orthopaedics, Warwick Medical School, University of Warwick, Coventry CV2 2DX, United Kingdom
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom.,Centre of Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham United Kingdom.,Department of Diabetes and Endocrinology, Birmingham Heartlands Hospital, Birmingham, United Kingdom
| | - Harpal S Randeva
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom.,Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, United Kingdom.,Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham B4 7ET, United Kingdom.,Centre of Applied Biological and Exercise Sciences, Faculty of Health and Life Sciences, Coventry University, Coventry CV1 5FB, United Kingdom
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16
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Chattu VK, Chattu SK, Burman D, Spence DW, Pandi-Perumal SR. The Interlinked Rising Epidemic of Insufficient Sleep and Diabetes Mellitus. Healthcare (Basel) 2019; 7:E37. [PMID: 30841553 PMCID: PMC6473416 DOI: 10.3390/healthcare7010037] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 12/15/2022] Open
Abstract
For healthy existence, humans need to spend one-third of their time sleeping. Any qualitative or quantitative disturbances in sleep would result in an increased prevalence of obesity, metabolic disorders, diabetes, cardiovascular diseases, and hypertension. The paper aims to highlight the growing global problem of insufficient sleep and its significant impact on the rising incidence of diabetes mellitus. An extensive literature search was done in all major databases for "insufficient sleep" and "Diabetes Mellitus" for this review. Shorter (<6 h) and longer (>9 h) durations of sleep have been adversely related to insulin resistance. Though the relation between insufficient sleep and diabetes mellitus is more or less understood, little is known about how oversleeping or hypersomnia (10⁻12 h) increases the risk of diabetes. The relationship between sleep disturbances and diabetes is dual-sided, as chronic sleep disturbances would elevate the risk of developing insulin resistance, while diabetes would worsen the quality of sleep. Both the qualitative and quantitative disturbances in sleep significantly increase the risk of developing diabetes, which is supported by numerous community-based and hospital-based epidemiological studies discussed in this review. Obstructive sleep apnea is one of the most common sleep disorders and is characterized by chronic intermittent hypoxia and increased sympathetic activity, thus leading to a higher prevalence of diabetes. Sleep therapy may serve as a low-cost method for fighting against the rising epidemic of diabetes.
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Affiliation(s)
- Vijay Kumar Chattu
- Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago.
- Global Institute of Public Health, Thiruvananthapuram, Kerala 695024, India.
| | - Soosanna Kumary Chattu
- Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago.
| | - Deepa Burman
- School of Medicine, University of Pittsburgh, 4200 Fifth Ave, Pittsburgh, PA 15260, USA.
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17
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Neumann K, Arzt M, Heid I, Böger C, Stadler S. Sleep-Disordered Breathing Is Associated with Metabolic Syndrome in Outpatients with Diabetes Mellitus Type 2. J Diabetes Res 2019; 2019:8417575. [PMID: 31179343 PMCID: PMC6501158 DOI: 10.1155/2019/8417575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/19/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Metabolic syndrome (MS) and sleep-disordered breathing (SDB) are highly prevalent in patients with diabetes mellitus type 2 (DM2). The present study examined whether there is an independent association between SDB and MS in a sample of outpatients with DM2. METHODS MS was determined in 679 patients of the DIACORE-SDB substudy, a study of outpatients with DM2. According to the National Cholesterol Education Program (NCEP) criteria, MS is defined by at least three of the following five criteria: waist circumference of >102 cm (men)/>88 cm (women), blood pressure of ≥130/85 mmHg, a fasting triglyceride level of >150 mg/dl, high-density lipoprotein (HDL) of <40 mg/dl (men)/<50 mg/dl (women), and a fasting glucose level of ≥110 mg/dl. The apnea-hypopnea index (AHI) was assessed with a 2-channel ambulatory monitoring device and used to define the severity of SDB (AHI < 15.0: no/mild SDB; AHI 15.0-29.9: moderate SDB; AHI ≥ 30.0: severe SDB). RESULTS 228 (34%) of the 679 participants (mean age 66 years, mean body mass index (BMI) 31.2 kg/m2, and mean AHI 14/hour) had SDB. MS was significantly more frequent in patients with more severe SDB (no/mild SDB vs. moderate SDB vs. severe SDB: 72% vs. 79% vs. 85%, respectively, p = 0.038). Logistic regression analysis adjusted for sex, age, obesity (BMI ≥ 30 kg/m2), and the HOMA index showed a significant association between the AHI and the presence of MS (OR (95%CI) = 1.039 (1.011; 1.068); p = 0.007). Further, male sex, obesity, and the HOMA index were significantly associated with MS. CONCLUSION SDB is significantly and independently associated with MS in outpatients with DM2.
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Affiliation(s)
- K. Neumann
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - M. Arzt
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - I. Heid
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
| | - C. Böger
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - S. Stadler
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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18
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Association of usual sleep quality and glycemic control in type 2 diabetes in Japanese: A cross sectional study. Sleep and Food Registry in Kanagawa (SOREKA). PLoS One 2018; 13:e0191771. [PMID: 29364963 PMCID: PMC5783416 DOI: 10.1371/journal.pone.0191771] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 12/13/2017] [Indexed: 12/16/2022] Open
Abstract
Objectives Excessively short and long sleep durations are associated with type 2 diabetes, but there is limited information about the association between sleep quality and diabetes. Accordingly, the present study was performed to investigate this relationship. Materials and methods The subjects were 3249 patients with type 2 diabetes aged 20 years or older. Sleep quality was assessed by using the Pittsburgh Sleep Quality Index (PSQI). A higher global PSQI score indicates worse sleep quality, and a global PSQI score >5 differentiates poor sleepers from good sleepers. Results The mean global PSQI score was 5.94 ± 3.33, and 47.6% of the patients had a score of 6 or higher. Regarding the components of the PSQI, the score was highest for sleep duration, followed by subjective sleep quality and then sleep latency in decreasing order. When the patients were assigned to HbA1c quartiles (≤ 6.5%, 6.6–7.0%, 7.1–7.8%, and ≥ 7.9%), the top quartile had a significantly higher global PSQI score than the other quartiles. The top HbA1c quartile had a sleep duration of only 6.23 ± 1.42 hours, which was significantly shorter than in the other quartiles. Also, sleep latency was 25.3 ± 31.8 minutes in the top quartile, which was significantly longer (by approximately 20 minutes) than in the other quartiles. When analysis was performed with adjustment for age, gender, BMI, smoking, and other confounders, the global PSQI score was still significantly higher and sleep duration was shorter in the top HbA1c quartile (HbA1c ≥ 7.9%). Conclusions Japanese patients with type 2 diabetes were found to have poor subjective sleep quality independently of potential confounders, especially those with inadequate glycemic control. Impairment of sleep quality was associated with both increased sleep latency and a shorter duration of sleep.
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19
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Shen H, Zhao J, Liu Y, Sun G. Interactions between and Shared Molecular Mechanisms of Diabetic Peripheral Neuropathy and Obstructive Sleep Apnea in Type 2 Diabetes Patients. J Diabetes Res 2018; 2018:3458615. [PMID: 30116739 PMCID: PMC6079583 DOI: 10.1155/2018/3458615] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 06/26/2018] [Indexed: 02/07/2023] Open
Abstract
Type 2 diabetes (T2D) accounts for about 90% of all diabetes patients and incurs a heavy global public health burden. Up to 50% of T2D patients will eventually develop neuropathy as T2D progresses. Diabetic peripheral neuropathy (DPN) is a common diabetic complication and one of the main causes of increased morbidity and mortality of T2D patients. Obstructive sleep apnea (OSA) affects over 15% of the general population and is associated with a higher prevalence of T2D. Growing evidence also indicates that OSA is highly prevalent in T2D patients probably due to diabetic peripheral neuropathy. However, the interrelations among diabetic peripheral neuropathy, OSA, and T2D hitherto have not been clearly elucidated. Numerous molecular mechanisms have been documented that underlie diabetic peripheral neuropathy and OSA, including oxidative stress, inflammation, endothelin-1, vascular endothelial growth factor (VEGF), accumulation of advanced glycation end products, protein kinase C (PKC) signaling, poly ADP ribose polymerase (PARP), nitrosative stress, plasminogen activator inhibitor-1, and vitamin D deficiency. In this review, we seek to illuminate the relationships among T2D, diabetic peripheral neuropathy, and OSA and how they interact with one another. In addition, we summarize and explain the shared molecular mechanisms involved in diabetic peripheral neuropathy and OSA for further mechanistic investigations and novel therapeutic strategies for attenuating and preventing the development and progression of diabetic peripheral neuropathy and OSA in T2D.
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Affiliation(s)
- Hong Shen
- Department of Endocrinology, The Second Hospital of Jilin University, Changchun 130041, China
| | - Junrong Zhao
- Department of Nephrology, The Second Hospital of Jilin University, Changchun 130041, China
| | - Ying Liu
- Department of Nephrology, The Second Hospital of Jilin University, Changchun 130041, China
| | - Guangdong Sun
- Department of Nephrology, The Second Hospital of Jilin University, Changchun 130041, China
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20
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Kahal H, Kyrou I, Tahrani AA, Randeva HS. Obstructive sleep apnoea and polycystic ovary syndrome: A comprehensive review of clinical interactions and underlying pathophysiology. Clin Endocrinol (Oxf) 2017. [PMID: 28640938 DOI: 10.1111/cen.13392] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Polycystic ovary syndrome (PCOS) is the most prevalent endocrine disorder in women of reproductive age. PCOS is associated with multiple comorbidities including, obesity, insulin resistance and type 2 diabetes, as well as mood disorders and impaired quality of life (QoL). Obstructive sleep apnoea (OSA) is also a common medical condition that is often undiagnosed, particularly in women. OSA is associated with a similar spectrum of comorbidities to that observed in PCOS, including manifestations of the metabolic syndrome and impaired QoL, whilst obesity frequently constitutes a common denominator in the pathophysiology of both OSA and PCOS. Hence, it is not surprising that OSA and PCOS may coexist in women of reproductive age, and the current clinical guidelines on the management of PCOS recommend screening for OSA symptoms in overweight/obese women with PCOS. In this review, we examine the relationship between OSA and PCOS and explore the potential underlying mechanisms that link these two conditions.
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Affiliation(s)
- Hassan Kahal
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Ioannis Kyrou
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, UK
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre of Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham, UK
- Department of Diabetes and Endocrinology, Birmingham Heartlands Hospital, Birmingham, UK
| | - Harpal S Randeva
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, UK
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Abstract
Obstructive sleep apnoea (OSA) is very common in patients with Type 2 diabetes (T2D), which is not surprising considering that obesity is a common risk factor for both conditions. In general population studies, OSA has been shown to be associated with several comorbidities including increased risk of road traffic accidents, T2D, hypertension and lack of nocturnal dipping of blood pressure, hyperlipidaemia, increased inflammation, increased risk of cardiovascular disease and mortality, increased risk of atrial fibrillation, worse quality of life, and erectile dysfunction. However, the impact of OSA on diabetes-related vascular and metabolic outcomes remains unclear. Furthermore, the impact of continuous positive airway pressure (CPAP) treatment in patients with T2D is also unclear. This unclarity regarding the impact of OSA and CPAP in patients with T2D has possibly contributed to the lack of screening for OSA in patients with T2D in the UK despite the high prevalence of OSA in patients with T2D. In this commentary, I provide an overview about OSA with a particular focus on its role and impact in patients with T2D.
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Affiliation(s)
- Abd A Tahrani
- 1 Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- 2 Department of Diabetes & Endocrinology, Birmingham Heartlands Hospital, Birmingham, UK
- 3 Centre of Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
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22
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Khalyfa A, Kheirandish-Gozal L, Gozal D. Circulating exosomes in obstructive sleep apnea as phenotypic biomarkers and mechanistic messengers of end-organ morbidity. Respir Physiol Neurobiol 2017; 256:143-156. [PMID: 28676332 DOI: 10.1016/j.resp.2017.06.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/13/2017] [Accepted: 06/19/2017] [Indexed: 02/08/2023]
Abstract
Obstructive sleep apnea (OSA), the most severe form of sleep disordered breathing, is characterized by intermittent hypoxia during sleep (IH), sleep fragmentation, and episodic hypercapnia. OSA is associated with increased risk for morbidity and mortality affecting cardiovascular, metabolic, and neurocognitive systems, and more recently with non-alcoholic fatty liver disease (NAFLD) and cancer-related deaths. Substantial variability in OSA outcomes suggests that genetically-determined and environmental and lifestyle factors affect the phenotypic susceptibility to OSA. Furthermore, OSA and obesity often co-exist and manifest activation of shared molecular end-organ injury mechanisms that if properly identified may represent potential therapeutic targets. A challenge in the development of non-invasive diagnostic assays in body fluids is the ability to identify clinically relevant biomarkers. Circulating extracellular vesicles (EVs) include a heterogeneous population of vesicular structures including exosomes, prostasomes, microvesicles (MVs), ectosomes and oncosomes, and are classified based on their size, shape and membrane surface composition. Of these, exosomes (30-100nm) are very small membrane vesicles derived from multi-vesicular bodies or from the plasma membrane and play important roles in mediating cell-cell communication via cargo that includes lipids, proteins, mRNAs, miRNAs and DNA. We have recently identified a unique cluster of exosomal miRNAs in both humans and rodents exposed to intermittent hypoxia as well as in patients with OSA with divergent morbid phenotypes. Here we summarize such recent findings, and will focus on exosomal miRNAs in both adult and children which mediate intercellular communication relevant to OSA and endothelial dysfunction, and their potential value as diagnostic and prognostic biomarkers.
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Affiliation(s)
- Abdelnaby Khalyfa
- Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, IL, USA.
| | - Leila Kheirandish-Gozal
- Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, IL, USA
| | - David Gozal
- Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, IL, USA
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23
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Affiliation(s)
- Abd A Tahrani
- Institute of Metabolism and Systems Research; University of Birmingham; Birmingham UK
- Centre of Endocrinology, Diabetes and Metabolism; Birmingham Health Partners; Birmingham UK
- Department of Diabetes and Endocrinology; Birmingham Heartlands Hospital; Birmingham UK
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24
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Güneri P, İlhan B, Çal E, Epstein JB, Klasser GD. Obstructive sleep apnoea and the need for its introduction into dental curricula. EUROPEAN JOURNAL OF DENTAL EDUCATION : OFFICIAL JOURNAL OF THE ASSOCIATION FOR DENTAL EDUCATION IN EUROPE 2017; 21:121-129. [PMID: 26895614 DOI: 10.1111/eje.12190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/26/2016] [Indexed: 06/05/2023]
Abstract
Obstructive sleep apnoea (OSA) is a major health problem which causes blood oxygen desaturation that may initiate a cascade of events via inflammatory cytokines and adrenocorticotrophic hormone that may have impact upon quality of life and lead to potential life-threatening events. Even though OSA affects an increasing number of individuals, the role of dental practitioners in recognition, screening and management has not developed accordingly. The goal of this article was to provide updated information to dental practitioners on pathophysiology, consequences and treatment options of OSA with a focused discussion on oral appliance (OA) therapy, as this topic is not routinely included in current dental curricula of many dental schools. Additionally, we present a template dental curriculum for predoctoral and/or postdoctoral students in education regarding sleep disordered breathing.
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Affiliation(s)
- P Güneri
- Department of Oral and Maxillofacial Radiology, Ege University School of Dentistry, Izmir, Turkey
| | - B İlhan
- Department of Oral and Maxillofacial Radiology, Ege University School of Dentistry, Izmir, Turkey
| | - E Çal
- Department of Prosthetic Dentistry, Ege University School of Dentistry, Izmir, Turkey
| | - J B Epstein
- Division of Otolaryngology and Head and Neck Surgery City of Hope National Medical Center, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - G D Klasser
- Department of Diagnostic Sciences, School of Dentistry, Louisiana State University, New Orleans, LA, USA
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25
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Tahrani AA. Ethnic differences in the pathogenesis of obstructive sleep apnoea: Exploring non-anatomical factors. Respirology 2017; 22:847-848. [DOI: 10.1111/resp.13057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 03/28/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Abd A. Tahrani
- Institute of Metabolism and Systems Research; University of Birmingham; Birmingham UK
- Centre of Endocrinology, Diabetes and Metabolism; Birmingham Health Partners; Birmingham UK
- Department of Diabetes and Endocrinology; Birmingham Heartlands Hospital; Birmingham UK
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26
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Amin A, Ali A, Altaf QA, Piya MK, Barnett AH, Raymond NT, Tahrani AA. Prevalence and Associations of Obstructive Sleep Apnea in South Asians and White Europeans with Type 2 Diabetes: A Cross-Sectional Study. J Clin Sleep Med 2017; 13:583-589. [PMID: 28162147 DOI: 10.5664/jcsm.6548] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/02/2017] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVES To assess and compare obstructive sleep apnea (OSA) prevalence in South Asians and White Europeans with type 2 diabetes mellitus (T2DM). Secondary aims included exploring possible causes for observed ethnic differences. METHODS A cross-sectional study of patients with T2DM recruited from secondary care diabetes clinics. OSA was defined as an apnea-hypopnea index (AHI) ≥ 5 events/h using home-based, multi-channel respiratory monitoring. RESULTS Two hundred thirty-four patients (105 South Asian and 129 White Europeans) were studied. The prevalence of mild, moderate, and severe OSA in South Asians was 36.2% (n = 38/105), 9.5% (n = 10/105), and 5.7% (n = 6/105) respectively. After adjustment, OSA was associated with a higher body mass index in South Asians. OSA was significantly less common in South Asians compared to White Europeans (51.4% [54/105] versus 75.2% [97/129], P < .001). OSA was also less severe in South Asians compared to White Europeans (median [interquartile range]: AHI 5.1 [1.4-11.5] versus 8.5 [5.0-20.7] events/h, P < .001; time spent with oxygen saturations < 90% 0.5 [0.0-2.9]% versus 4.0 [0.7-14.4]%, P < .001). Logistic regression showed that only obesity measures explained the ethnic differences in OSA. CONCLUSIONS South Asians with T2DM are at considerable risk of OSA. OSA in South Asians was associated with obesity. However, OSA prevalence was lower in South Asians than in White Europeans. Obesity measures accounted for the observed ethnic differences. Examining factors contributing to ethnic differences will be important to inform screening and treatment strategies.
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Affiliation(s)
- Amin Amin
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Asad Ali
- Department of Respiratory Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Quratul A Altaf
- Department of Diabetes and Endocrinology, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Milan K Piya
- Department of Diabetes, Derby Teaching Hospitals NHS Foundation NHS Trust, Derby, United Kingdom.,Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Anthony H Barnett
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Department of Diabetes and Endocrinology, Heart of England NHS Foundation Trust, Birmingham, United Kingdom.,Centre of Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Neil T Raymond
- Independent Epidemiology and Statistical Consultant, Epidemiology, Research Design and Statistical Consulting (ERDASC), Leicestershire, United Kingdom
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Department of Diabetes and Endocrinology, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
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27
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Jokubauskas L, Baltrušaitytė A. Relationship between obstructive sleep apnoea syndrome and sleep bruxism: a systematic review. J Oral Rehabil 2017; 44:144-153. [DOI: 10.1111/joor.12468] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2016] [Indexed: 12/26/2022]
Affiliation(s)
- L. Jokubauskas
- Faculty of Odontology; Lithuanian University of Health Sciences; Kaunas Lithuania
| | - A. Baltrušaitytė
- Department of Prosthodontics; Faculty of Odontology; Lithuanian University of Health Sciences; Kaunas Lithuania
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28
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Bozic J, Galic T, Supe-Domic D, Ivkovic N, Ticinovic Kurir T, Valic Z, Lesko J, Dogas Z. Morning cortisol levels and glucose metabolism parameters in moderate and severe obstructive sleep apnea patients. Endocrine 2016; 53:730-9. [PMID: 27000083 DOI: 10.1007/s12020-016-0925-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/11/2016] [Indexed: 12/26/2022]
Abstract
Obstructive sleep apnea (OSA) has been associated with dysregulation of the hypothalamic-pituitary-adrenal axis and alterations in glucose metabolism with increased risk for type 2 diabetes. The aim of the current study was to compare morning plasma cortisol levels and glucose metabolism parameters between moderate (apnea-hypopnea index (AHI): 15-30 events/h) and severe OSA patients (AHI >30 events/h), with respective controls. A total of 56 male OSA patients, 24 moderate (AHI = 21.1 ± 5.3) and 32 severe (AHI = 49.7 ± 18.1), underwent a full-night polysomnography, oral glucose tolerance test (OGTT), and measurement of morning plasma cortisol levels. These groups were compared to 20 matched subjects in a control group. Morning plasma cortisol levels were statistically lower in severe OSA group than in moderate OSA and control groups (303.7 ± 93.5 vs. 423.9 ± 145.1 vs. 417.5 ± 99.8 pmol/L, P < 0.001). Significant negative correlations were found between morning plasma cortisol levels and AHI (r = -0.444, P = 0.002), as well as oxygen desaturation index (r = -0.381, P = 0.011). Fasting plasma glucose (5.0 ± 0.5 vs. 5.4 ± 0.7 vs. 4.9 ± 0.6 mmol/L, P = 0.009) was higher in the severe OSA group compared to moderate OSA and controls. Homeostasis model assessment insulin resistance (HOMA-IR) was higher in the severe OSA group compared to moderate OSA and controls (4.6 ± 3.7 vs. 2.7 ± 2.0 and 2.2 ± 1.8, respectively, P = 0.006). In conclusion, our study showed that morning plasma cortisol levels measured at 8 a.m. were significantly lower in severe OSA patients than those in moderate OSA group and controls. Morning plasma cortisol levels showed a negative correlation with AHI and oxygen desaturation index. Additionally, this study confirmed the evidence of glucose metabolism impairment in moderate and severe OSA patients, with more pronounced effect in the severe OSA patients group.
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Affiliation(s)
- Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, Soltanska 2, Split, Croatia
| | - Tea Galic
- Study of Dental Medicine, University of Split School of Medicine, Soltanska 2, Split, Croatia
| | - Daniela Supe-Domic
- Department of Medical Laboratory Diagnostics, University Hospital Split, Spinciceva 1, Split, Croatia
| | - Natalija Ivkovic
- Split Sleep Medicine Center, University of Split School of Medicine, Soltanska 2, Split, Croatia
| | - Tina Ticinovic Kurir
- Department of Pathophysiology, University of Split School of Medicine, Soltanska 2, Split, Croatia
| | - Zoran Valic
- Department of Physiology, University of Split School of Medicine, Soltanska 2, Split, Croatia
| | - Josip Lesko
- Departments of Anatomy and Neuroscience, University of Mostar School of Medicine, Bijeli brijeg bb, Mostar, Bosnia and Herzegovina
| | - Zoran Dogas
- Split Sleep Medicine Center, University of Split School of Medicine, Soltanska 2, Split, Croatia.
- Department of Neuroscience, University of Split School of Medicine, Soltanska 2, Split, 21000, Croatia.
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29
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Altaf QAA, Ali A, Piya MK, Raymond NT, Tahrani AA. The relationship between obstructive sleep apnea and intra-epidermal nerve fiber density, PARP activation and foot ulceration in patients with type 2 diabetes. J Diabetes Complications 2016; 30:1315-20. [PMID: 27324704 DOI: 10.1016/j.jdiacomp.2016.05.025] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/03/2016] [Accepted: 05/28/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is associated with increased nitrosative stress, endothelial dysfunction, and peripheral neuropathy in patients with type 2 diabetes. We hypothesized that OSA is associated with Poly ADP ribose polymerase (PARP) activation, lower intra-epidermal nerve fiber density (IENFD), and diabetic foot ulceration (DFU). METHODS A cross-sectional study of adults with type 2 diabetes recruited from a secondary care hospital in the UK. OSA was assessed by multi-channel home-based cardio-respiratory device (Alice PDX, Philips Respironics). DPN was assessed using the Michigan Neuropathy Screening Instrument (MNSI). IENFD and % PAR stained nuclei were assessed using immunohistochemistry staining on skin biopsies. DFU was assessed based on MNSI. RESULTS Skin biopsies and DFU data were available from 52 and 234 patients respectively. OSA was associated with lower IENFD (12.75±1.93 vs. 10.55±1.62 vs. 9.42±1.16 fibers/mm of epidermis for no OSA, mild OSA and moderate to severe OSA respectively, p<0.001). Following adjustment, mild (B=-2.19, p=0.002) and moderate to severe OSA (B=-3.45, p<0.001) were independently associated with IENFD. The apnea hypopnea index (AHI) was associated with IENFD following adjustment (B=-2.45, p<0.001). AHI was associated with percentage of PAR stained nuclei following adjustment (B=13.67, p=0.025). DFU prevalence was greater in patients with OSA (7.1% vs. 28.1% vs. 26.2% for patients with no OSA, mild OSA and moderate to severe OSA respectively, p=0.001). Following adjustment, OSA was associated with DFU (OR 3.34, 95% CI 1.19-9.38, p=0.022). CONCLUSIONS OSA is associated with lower IENFD, PARP activation and DFU in patients with type 2 diabetes. Our findings suggest that OSA is associated with small fiber neuropathy. PARP activation is a potential mechanisms linking OSA to DPN and endothelial dysfunction in patients with type 2 diabetes. Whether OSA treatment will have a favorable impact on these parameters and DFU requires interventional studies.
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Affiliation(s)
- Quratul-Ain Altaf Altaf
- Department of Diabetes and Endocrinology, Heart of England NHS Foundation Trust, Birmingham, UK; Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Asad Ali
- Department of Respiratory Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Milan K Piya
- Department of Diabetes and Endocrinology, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Neil T Raymond
- Independent Epidemiology and Statistical Consultant, Epidemiology, Research Design and Statistical Consulting (ERDASC), Leicestershire, UK
| | - Abd A Tahrani
- Department of Diabetes and Endocrinology, Heart of England NHS Foundation Trust, Birmingham, UK; Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Song TJ, Park JH, Choi KH, Chang Y, Moon J, Kim JH, Choi Y, Kim YJ, Lee HW. Moderate-to-severe obstructive sleep apnea is associated with cerebral small vessel disease. Sleep Med 2016; 30:36-42. [PMID: 28215260 DOI: 10.1016/j.sleep.2016.03.006] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 02/03/2016] [Accepted: 03/08/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cerebral small vessel disease (SVD) is associated with increased risk of cerebral infarction and hemorrhage. Obstructive sleep apnea (OSA) is known to increase the risk of cerebrovascular disease. This study aimed to investigate the association between cerebral SVD and severity of OSA. METHODS A total of 170 patients were included from the patient registry at the present Sleep Center; these patients underwent both magnetic resonance imaging (MRI) of the brain and polysomnography (PSG) for suspected OSA. The presence and burden of white matter hyperintensities (WMHs), asymptomatic lacunar infarctions (ALIs), cerebral microbleeds (CMBs), and perivascular spaces (PVSs) were determined by MRI, and their relationships with the apnea-hypopnea index (AHI), as determined by PSG, were investigated. RESULTS Among the 170 patients, 25 (14.7%) had high-grade WMHs, 21 (12.4%) had ALIs, 21 (12.4%) had CMBs, and 34 (20.0%) had high-grade PVSs. In the multivariable analysis, after adjusting for factors including age, sex, and other variables for which p <0.1 in univariable analysis (hypertension, diabetes mellitus, previous stroke, minimal SaO2 and arousal index), moderate-to-severe OSA was associated with high-grade WMHs (odds ratio [OR] 4.72; 95% confidence interval [CI] 1.14-19.47), CMBs (OR 3.47; 95% CI 0.89-15.18), or high-grade PVSs (OR 3.64; 95% CI 1.02-13.01), but not with ALIs. The total SVD score was independently associated with increased AHI (p = 0.017), particularly in patients with moderate-to-severe OSA (β [standard error] = 0.448 (0.204), p = 0.030]. CONCLUSION Moderate-to-severe OSA is positively associated with multiple indicators of cerebral SVD, including WMHs, CMBs, and PVSs.
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Affiliation(s)
- Tae-Jin Song
- Department of Neurology, Ewha Womans University School of Medicine, Seoul, Republic of Korea; Department of Medical Science, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Jung-Hyun Park
- Department of Neurology, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Kang Hyun Choi
- Department of Medical Science, Ewha Womans University School of Medicine, Seoul, Republic of Korea; Ewha Medical Research Institute, Seoul, Republic of Korea
| | - Yoonkyung Chang
- Department of Neurology, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Jangsup Moon
- Department of Neurology, Ewha Womans University School of Medicine, Seoul, Republic of Korea; Department of Medical Science, Ewha Womans University School of Medicine, Seoul, Republic of Korea; Ewha Medical Research Institute, Seoul, Republic of Korea
| | - Ju-Hee Kim
- Department of Medical Science, Ewha Womans University School of Medicine, Seoul, Republic of Korea; Ewha Medical Research Institute, Seoul, Republic of Korea
| | - Yunseo Choi
- Department of Medical Science, Ewha Womans University School of Medicine, Seoul, Republic of Korea; Ewha Medical Research Institute, Seoul, Republic of Korea
| | - Yong-Jae Kim
- Department of Neurology, Ewha Womans University School of Medicine, Seoul, Republic of Korea; Department of Medical Science, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Hyang Woon Lee
- Department of Neurology, Ewha Womans University School of Medicine, Seoul, Republic of Korea; Department of Medical Science, Ewha Womans University School of Medicine, Seoul, Republic of Korea; Ewha Medical Research Institute, Seoul, Republic of Korea.
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31
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Bayır Ö, Acar M, Yüksel E, Yüceege M, Saylam G, Tatar EÇ, Özdek A, Firat H, Gürdal C, Korkmaz MH. The effects of anterior palatoplasty on floppy eyelid syndrome patients with obstructive sleep apnea. Laryngoscope 2016; 126:2171-5. [DOI: 10.1002/lary.25905] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 12/18/2015] [Accepted: 01/11/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Ömer Bayır
- Department of Otolaryngology; Head & Neck Surgery, Ministry of Health Diskapi Yildirim Beyazit Training and Research Hospital; Ankara Turkey
| | - Mutlu Acar
- Department of Ophthalmology; Ministry of Health Diskapi Yildirim Beyazit Training and Research Hospital; Ankara Turkey
| | - Elvan Yüksel
- Department of Otolaryngology; Head & Neck Surgery, Ministry of Health Diskapi Yildirim Beyazit Training and Research Hospital; Ankara Turkey
| | - Melike Yüceege
- Department of Respiratory Medicine; Ministry of Health Diskapi Yildirim Beyazit Training and Research Hospital; Ankara Turkey
| | - Güleser Saylam
- Department of Otolaryngology; Head & Neck Surgery, Ministry of Health Diskapi Yildirim Beyazit Training and Research Hospital; Ankara Turkey
| | - Emel Çadalli Tatar
- Department of Otolaryngology; Head & Neck Surgery, Ministry of Health Diskapi Yildirim Beyazit Training and Research Hospital; Ankara Turkey
| | - Ali Özdek
- Department of Otolaryngology; Head & Neck Surgery, Ministry of Health Diskapi Yildirim Beyazit Training and Research Hospital; Ankara Turkey
| | - Hikmet Firat
- Department of Respiratory Medicine; Ministry of Health Diskapi Yildirim Beyazit Training and Research Hospital; Ankara Turkey
| | - Canan Gürdal
- Department of Ophthalmology; Ministry of Health Diskapi Yildirim Beyazit Training and Research Hospital; Ankara Turkey
| | - Mehmet Hakan Korkmaz
- Department of Otolaryngology; Head & Neck Surgery, Faculty of Medicine, Yildirim Beyazit University; Ankara Turkey
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Le syndrome d’apnée de sommeil. Est-il un facteur de risque de rétinopathie diabétique ? J Fr Ophtalmol 2016; 39:139-42. [DOI: 10.1016/j.jfo.2015.08.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 08/05/2015] [Accepted: 08/24/2015] [Indexed: 11/15/2022]
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33
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Tahrani AA. Obstructive sleep apnea in patients with diabetes: implications for clinical practice. ACTA ACUST UNITED AC 2015. [DOI: 10.2217/dmt.15.34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Ceccato F, Bernkopf E, Scaroni C. Sleep apnea syndrome in endocrine clinics. J Endocrinol Invest 2015; 38:827-34. [PMID: 26122486 DOI: 10.1007/s40618-015-0338-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 06/10/2015] [Indexed: 12/19/2022]
Abstract
Obstructive sleep apnea syndrome (OSAS) is a chronic condition with a high prevalence (up to 7 % of the general population) characterized by frequent episodes of upper airway collapse while sleeping. Left untreated, OSAS can cause severe complications, including systemic hypertension, cardiovascular disease, stroke, and abnormal glucose metabolism. This review aims to summarize the close links between OSAS, endocrinology, and metabolism. In patients with metabolic syndrome, OSAS is an independent risk factor for the onset of type 2 diabetes and a worsening glycemic control. The accumulation of adipose tissue in the neck and limited chest wall dynamics, hypoxia, and local micro-inflammation link visceral obesity closely with OSAS. There is now an abundance of convincing data indicating that promoting lifestyle changes, improving sleep hygiene, and adjusting diet can ameliorate both metabolic syndrome and OSAS, especially in obese patients. The incidence of OSAS in acromegaly is high, though GH treatments seem to be unrelated to the onset of apnea in GH-deficient individuals. Prospective studies have suggested an association between hypertension and OSAS because intermittent nocturnal hypoxia prompts an increase in sympathetic tone, endothelial dysfunction, and vascular inflammation: aldosterone excess may have a pathophysiological role, and some authors have reported that treating OSAS leads to a modest, but significant, reduction in blood pressure.
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Affiliation(s)
- F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy,
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A Tahrani A. Obstructive Sleep Apnoea and Vascular Disease in Patients with Type 2 Diabetes. EUROPEAN ENDOCRINOLOGY 2015; 11:81-89. [PMID: 29632575 PMCID: PMC5819072 DOI: 10.17925/ee.2015.11.02.81] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 07/10/2015] [Indexed: 12/21/2022]
Abstract
Obstructive sleep apnoea (OSA) is common and is associated with many vascular risk factors, such as hypertension, insulin resistance, albuminuria, dyslipidaemia, increased inflammation and endothelial dysfunction. Epidemiological studies have shown that OSA is associated with increased cardiovascular disease (CVD) and that continuous positive airway pressure (CPAP) might reduce CVD events in patients with OSA. In addition, OSA has also been shown to be associated with albuminuria, chronic kidney disease, a wide range of ocular diseases and peripheral neuropathy. Considering that CVD and microvascular complications are major contributors to the morbidity, mortality and the economic burden of diabetes and that OSA is common in patients with type 2 diabetes (T2D), it is important to understand the role of OSA in the development and/or progression of vascular disease in patients with T2D and to explore the impact of CPAP on diabetes-related vascular outcomes. The purpose of this article is to review the evidence for the relationship and impact of OSA on vascular disease and vascular risk factors particularly in patients with T2D.
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Affiliation(s)
- Abd A Tahrani
- Centre of Endocrinology, Diabetes and Metabolism, University of Birmingham; Birmingham, UK; Department of Diabetes and Endocrinology, Birmingham Heartlands Hospital, Birmingham, UK
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Effects of mandibular advancement device treatment on arterial stiffness and glucose metabolism in patients with mild to moderate obstructive sleep apnea: a prospective 1 year study. Sleep Breath 2015; 20:69-77. [DOI: 10.1007/s11325-015-1186-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 03/18/2015] [Accepted: 04/15/2015] [Indexed: 11/26/2022]
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Daulatzai MA. “Boomerang Neuropathology” of Late-Onset Alzheimer’s Disease is Shrouded in Harmful “BDDS”: Breathing, Diet, Drinking, and Sleep During Aging. Neurotox Res 2015; 28:55-93. [DOI: 10.1007/s12640-015-9528-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 04/03/2015] [Accepted: 04/03/2015] [Indexed: 12/12/2022]
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Tahrani AA. Diabetes and sleep apnea. INTERNATIONAL TEXTBOOK OF DIABETES MELLITUS 2015:316-336. [DOI: 10.1002/9781118387658.ch22] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Altaf QA, Barnett AH, Tahrani AA. Novel therapeutics for type 2 diabetes: insulin resistance. Diabetes Obes Metab 2015; 17:319-34. [PMID: 25308775 DOI: 10.1111/dom.12400] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 09/23/2014] [Accepted: 10/04/2014] [Indexed: 12/19/2022]
Abstract
Insulin resistance (IR) plays an important role in the pathogenesis of type 2 diabetes (T2D) and cardiovascular disease. Hence improving IR is a major target of treatment in patients with T2D. Obesity and lack of exercise are major causes of IR. However, recent evidence implicates sleep disorders and disorders of the circadian rhythm in the pathogenesis of IR. Weight loss and lifestyle changes are the cornerstone and most effective treatments of IR, but adherence and patient's acceptability are poor. Bariatric surgery results in significant and sustainable long-term weight loss associated with beneficial impact on IR and glucose metabolism, making this an attractive treatment option for patients with T2D. Currently available pharmacological options targeting IR (such as metformin and thiazolidinediones) do not maintain glycaemic measures within targets long term and can be associated with significant side effects. Over the last two decades, many pharmacological agents targeting different aspects of the insulin signalling pathway were developed to improve IR, but only a minority reached clinical trials. Such treatments need to be specific and reversible as many of the components of the insulin signalling pathway are involved in other cellular functions such as apoptosis. Recent evidence highlighted the role of circadian rhythm and sleep-related disorders in the pathogenesis of IR. In this article, we review the latest developments in the pharmacological and non-pharmacological interventions targeting IR including bariatric surgery. We will also review the role of circadian rhythm and sleep-related disorders in the development and treatment of IR.
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Affiliation(s)
- Q-A Altaf
- Department of Diabetes and Endocrinology, Heart of England NHS Foundation Trust, Birmingham, UK; Centre of Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, UK
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Altaf Q, Tahrani AA. Obstructive Sleep Apnea and Diabetic Microvascular Complications. MODULATION OF SLEEP BY OBESITY, DIABETES, AGE, AND DIET 2015:213-224. [DOI: 10.1016/b978-0-12-420168-2.00023-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Tahrani AA. Comment on Guest et al. Clinical outcomes and cost-effectiveness of continuous positive airway pressure to manage obstructive sleep apnea in patients with type 2 diabetes in the U.K. Diabetes Care 2014;37:1263-1271. Diabetes Care 2014; 37:e200-1. [PMID: 25147263 DOI: 10.2337/dc14-1000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Abd A Tahrani
- Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, U.K., and Department of Diabetes and Endocrinology, Heart of England National Health Service Foundation Trust, Birmingham, U.K.
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Surani SR. Diabetes, sleep apnea, obesity and cardiovascular disease: Why not address them together? World J Diabetes 2014; 5:381-384. [PMID: 24936259 PMCID: PMC4058742 DOI: 10.4239/wjd.v5.i3.381] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 03/01/2014] [Accepted: 05/16/2014] [Indexed: 02/05/2023] Open
Abstract
Obesity, sleep apnea, diabetes and cardiovascular diseases are some of the most common diseases encountered by the worldwide population, with high social and economic burdens. Significant emphasis has been placed on obtaining blood pressure, body mass index, and placing importance on screening for signs and symptoms pointing towards cardiovascular disease. Symptoms related to sleep, or screening for sleep apnea has been overlooked by cardiac, diabetic, pulmonary and general medicine clinics despite recommendations for screening by several societies. In recent years, there is mounting data where obesity and obstructive sleep apnea sit at the epicenter and its control can lead to improvement and prevention of diabetes and cardiovascular complications. This editorial raises questions as to why obstructive sleep apnea screening should be included as yet another vital sign during patient initial inpatient or outpatient visit.
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