The prevalence of Obstructive sleep apnoea syndrome

The prevalence of Obstructive sleep apnoea syndrome (OSAS) in patients with type 2 diabetes in Jordan
Ahmad MJ. Saad 1, Dana Hiyasat 1, Hashem Jaddou 1, Nathir Obeidat 1
National Center for Diabetes, Endocrinology and Genetics, Jordan University,
Amman, Jordan.

Correspondence to:
Ahmad MJ. Saad MSc.
Diabetes Care and Education Department of Nursing services,
Dubai Diabetes Center.
PO Box Dubai 215252.

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Email: [email protected] words: Diabetes, Sleep apnoea, Jordan.

Running title: Obstructive sleep apnoea syndrome in type 2 diabetes.

Conflict of interest: The authors declare no conflicting interests.

Abstract
Objective: To estimate the prevalence of obstructive sleep apnea (OSA) among patients with type 2 diabetes (T2DM) mellitus and to explore If sleep apnea is associated to clinical and demographic variables.
Method: A cross-sectional study was carried out during 1st of November 2011 to 1st of February 2012, on 1143T2DM patients (aged 30-90 years) at the National Center for Diabetes, Endocrinology and Genetics (NCDEG), University of Jordan Amman, Jordan. The NCDEG is the only referral center in the country; therefore, the patients represent the population in different parts of the country. All participants completed a Berlin Questionnaire and were classified as low- or high-risk patients for OSA. The demo
Results: A total of 1143 T2DM patients were included in this study. There were 587 (51.4%) males and 556 (48.6%) females. The findings showed that 554 (48.5%) patients were at high risk for OSA and 589 (51.5%) were low risk for OSA. Logistic regression analysis revealed that age, smoking and neck circumference were significantly correlated with high risk for OSA. The clinical and demographic variables also collected for analysis.

Conclusions: The study found that high risk for OSA was highly prevalent among Jordanian type 2 diabetics and age, smoking and neck circumference were significantly correlated with OSA. Clinicians should be aware of the high prevalence of sleep problems among their patients with diabetes and should consider screening and treatment, which may improve patients’ quality of life.

Introduction
Sleep disordered breathing is a common chronic condition in the general population characterized by repeated episodes of apnea and hypopnea during sleep. It can present as obstructive sleep apnea/hypopnea (OSAH) disorder, central sleep apnea (CSA), or mixed sleep disordered breathing. When OSAH disorder is associated with daytime sleepiness, it is called obstructive sleep apnea-hypopnea syndrome (OSAHS). ADDIN EN.CITE ;EndNote;;Cite;;Author;Sankri-Tarbichi;/Author;;Year;2012;/Year;;RecNum;1;/RecNum;;DisplayText;;style face=”superscript”;1;/style;;/DisplayText;;record;;rec-number;1;/rec-number;;foreign-keys;;key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959480″;1;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Sankri-Tarbichi, A. G.;/author;;/authors;;/contributors;;auth-address;Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University- School of Medicine, John D. Dingell VA Medical Center and Detroit Medical Center, Detroit, USA.;/auth-address;;titles;;title;Obstructive sleep apnea-hypopnea syndrome: Etiology and diagnosis;/title;;secondary-title;Avicenna J Med;/secondary-title;;/titles;;periodical;;full-title;Avicenna J Med;/full-title;;/periodical;;pages;3-8;/pages;;volume;2;/volume;;number;1;/number;;edition;2012/12/05;/edition;;dates;;year;2012;/year;;pub-dates;;date;Jan;/date;;/pub-dates;;/dates;;isbn;2231-0770 (Print) 2231-0770 (Linking);/isbn;;accession-num;23210013;/accession-num;;urls;;related-urls;;url;http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve;amp;db=PubMed;amp;dopt=Citation;amp;list_uids=23210013;/url;;/related-urls;;/urls;;custom2;3507069;/custom2;;electronic-resource-num;10.4103/2231-0770.94803 AJM-2-3 pii;/electronic-resource-num;;language;eng;/language;;/record;;/Cite;;/EndNote;1, ADDIN EN.CITE ;EndNote;;Cite;;Author;Tsai;/Author;;Year;2018;/Year;;RecNum;42;/RecNum;;DisplayText;;style face=”superscript”;2;/style;;/DisplayText;;record;;rec-number;42;/rec-number;;foreign-keys;;key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959575″;42;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Tsai, M.;/author;;author;Khayat, R.;/author;;/authors;;/contributors;;auth-address;Division of Pulmonary Critical Care and Sleep, The Ohio State University, 201 DHLRI 473 West 12th Avenue, Columbus, OH, 43210, USA. Division of Pulmonary Critical Care and Sleep, The Ohio State University, 201 DHLRI 473 West 12th Avenue, Columbus, OH, 43210, USA. [email protected] The Sleep Heart Program, The Ohio State University, Columbus, OH, USA. [email protected];/auth-address;;titles;;title;Sleep Apnea in Heart Failure;/title;;secondary-title;Curr Treat Options Cardiovasc Med;/secondary-title;;alt-title;Current treatment options in cardiovascular medicine;/alt-title;;/titles;;periodical;;full-title;Curr Treat Options Cardiovasc Med;/full-title;;abbr-1;Current treatment options in cardiovascular medicine;/abbr-1;;/periodical;;alt-periodical;;full-title;Curr Treat Options Cardiovasc Med;/full-title;;abbr-1;Current treatment options in cardiovascular medicine;/abbr-1;;/alt-periodical;;pages;33;/pages;;volume;20;/volume;;number;4;/number;;edition;2018/03/24;/edition;;dates;;year;2018;/year;;pub-dates;;date;Mar 22;/date;;/pub-dates;;/dates;;isbn;1092-8464 (Print) 1092-8464;/isbn;;accession-num;29568980;/accession-num;;urls;;/urls;;electronic-resource-num;10.1007/s11936-018-0624-0;/electronic-resource-num;;remote-database-provider;Nlm;/remote-database-provider;;language;eng;/language;;/record;;/Cite;;/EndNote;2 It is now well established that sleep problems are associated with diabetes mellitus, cardiovascular disease ADDIN EN.CITE ;EndNote;;Cite;;Author;Vitulano;/Author;;Year;2013;/Year;;RecNum;2;/RecNum;;DisplayText;;style face=”superscript”;3;/style;;/DisplayText;;record;;rec-number;2;/rec-number;;foreign-keys;;key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959480″;2;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Vitulano, N.;/author;;author;Di Marco Berardino, A.;/author;;author;Re, A.;/author;;author;Riccioni, G.;/author;;author;Perna, F.;/author;;author;Mormile, F.;/author;;author;Valente, S.;/author;;author;Bellocci, F.;/author;;/authors;;/contributors;;auth-address;Via dei Gelsi, 15, 71043 Manfredonia (FG), Italy.;/auth-address;;titles;;title;Obstructive sleep apnea and heart disease: the biomarkers point of view;/title;;secondary-title;Front Biosci (Schol Ed);/secondary-title;;/titles;;periodical;;full-title;Front Biosci (Schol Ed);/full-title;;/periodical;;pages;588-99;/pages;;volume;5;/volume;;edition;2013/01/02;/edition;;dates;;year;2013;/year;;/dates;;isbn;1945-0524 (Electronic) 1945-0516 (Linking);/isbn;;accession-num;23277071;/accession-num;;urls;;related-urls;;url;http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve;amp;db=PubMed;amp;dopt=Citation;amp;list_uids=23277071;/url;;/related-urls;;/urls;;electronic-resource-num;S392 pii;/electronic-resource-num;;language;eng;/language;;/record;;/Cite;;/EndNote;3, mental health problems PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QcmFiaGF0PC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA 6, 7 and overall poor quality of life ADDIN EN.CITE ;EndNote;;Cite;;Author;Prabhat;/Author;;Year;2012;/Year;;RecNum;3;/RecNum;;DisplayText;;style face=”superscript”;4;/style;;/DisplayText;;record;;rec-number;3;/rec-number;;foreign-keys;;key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959480″;3;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Prabhat, K. C.;/author;;author;Goyal, L.;/author;;author;Bey, A.;/author;;author;Maheshwari, S.;/author;;/authors;;/contributors;;auth-address;Department of Orthodontics and Dental Anatomy, Dr. Z. A. Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India.;/auth-address;;titles;;title;Recent advances in the management of obstructive sleep apnea: The dental perspective;/title;;secondary-title;J Nat Sci Biol Med;/secondary-title;;/titles;;periodical;;full-title;J Nat Sci Biol Med;/full-title;;/periodical;;pages;113-7;/pages;;volume;3;/volume;;number;2;/number;;edition;2012/12/12;/edition;;dates;;year;2012;/year;;pub-dates;;date;Jul;/date;;/pub-dates;;/dates;;isbn;0976-9668 (Print) 0976-9668 (Linking);/isbn;;accession-num;23225971;/accession-num;;urls;;related-urls;;url;http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve;amp;db=PubMed;amp;dopt=Citation;amp;list_uids=23225971;/url;;/related-urls;;/urls;;custom2;3510903;/custom2;;electronic-resource-num;10.4103/0976-9668.101877 JNSBM-3-113 pii;/electronic-resource-num;;language;eng;/language;;/record;;/Cite;;/EndNote;4, PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CcmFuZGFvPC9BdXRob3I+PFllYXI+MjAxODwvWWVhcj48
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ADDIN EN.CITE.DATA 11, 12, ADDIN EN.CITE ;EndNote;;Cite;;Author;Viswanathan;/Author;;Year;2017;/Year;;RecNum;7;/RecNum;;DisplayText;;style face=”superscript”;13;/style;;/DisplayText;;record;;rec-number;7;/rec-number;;foreign-keys;;key app=”EN” db-id=”0wtrzt5vlzfrd1ee90r50w5lrftrswtwpevf” timestamp=”1521960750″;7;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Viswanathan, V.;/author;;author;Ramalingam, I. P.;/author;;author;Ramakrishnan, N.;/author;;/authors;;/contributors;;auth-address;Head ;amp; Chief Diabetologist, M.V. Hospital for Diabetes ;amp; President, Prof. M. Viswanathan Diabetes Research Centre, Chennai, Tamil Nadu. Clinical Research Associate, Prof. M. Viswanathan Diabetes Research Centre, Chennai, Tamil Nadu. Senior Consultant and Director, Nithra Institute of Sleep Sciences, Chennai, Tamil Nadu.;/auth-address;;titles;;title;High Prevalence of Obstructive Sleep Apnea among People with Type 2 Diabetes Mellitus in a Tertiary Care Center;/title;;secondary-title;J Assoc Physicians India;/secondary-title;;alt-title;The Journal of the Association of Physicians of India;/alt-title;;/titles;;periodical;;full-title;J Assoc Physicians India;/full-title;;abbr-1;The Journal of the Association of Physicians of India;/abbr-1;;/periodical;;alt-periodical;;full-title;J Assoc Physicians India;/full-title;;abbr-1;The Journal of the Association of Physicians of India;/abbr-1;;/alt-periodical;;pages;38-42;/pages;;volume;65;/volume;;number;11;/number;;edition;2018/01/13;/edition;;dates;;year;2017;/year;;pub-dates;;date;Nov;/date;;/pub-dates;;/dates;;isbn;0004-5772 (Print) 0004-5772;/isbn;;accession-num;29322708;/accession-num;;urls;;/urls;;remote-database-provider;Nlm;/remote-database-provider;;language;eng;/language;;/record;;/Cite;;/EndNote;13.

Obstructive sleep apnea, is not only highly prevalent in patients with T2DM mellitus, but may contribute to the development of abnormalities in blood glucose metabolism. ADDIN EN.CITE ;EndNote;;Cite;;Author;Ioja;/Author;;Year;2012;/Year;;RecNum;11;/RecNum;;DisplayText;;style face=”superscript”;14;/style;;/DisplayText;;record;;rec-number;11;/rec-number;;foreign-keys;;key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959481″;11;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Ioja, S.;/author;;author;Weir, I. D.;/author;;author;Rennert, N. J.;/author;;/authors;;/contributors;;auth-address;Department of Medicine, Norwalk Hospital, Norwalk, CT 06856, USA. [email protected];/auth-address;;titles;;title;Relationship between sleep disorders and the risk for developing type 2 diabetes mellitus;/title;;secondary-title;Postgrad Med;/secondary-title;;/titles;;periodical;;full-title;Postgrad Med;/full-title;;/periodical;;pages;119-29;/pages;;volume;124;/volume;;number;4;/number;;edition;2012/08/24;/edition;;keywords;;keyword;Blood Glucose/*metabolism</keyword><keyword>Continuous Positive Airway Pressure</keyword><keyword>Diabetes Complications</keyword><keyword>Diabetes Mellitus, Type 2/*etiology</keyword><keyword>Humans</keyword><keyword>Prevalence</keyword><keyword>Risk</keyword><keyword>Risk Factors</keyword><keyword>Sleep Apnea, Obstructive/*complications/therapy</keyword><keyword>Sleep Disorders/*complications/metabolism/therapy</keyword></keywords><dates><year>2012</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1941-9260 (Electronic) 0032-5481 (Linking)</isbn><accession-num>22913900</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=22913900</url></related-urls></urls><electronic-resource-num>10.3810/pgm.2012.07.2573</electronic-resource-num><language>eng</language></record></Cite></EndNote>14. Additionally, diabetes-specific complications, such as neuropathy, could directly interfere with sleep problems ADDIN EN.CITE <EndNote><Cite><Author>Mossman</Author><Year>1990</Year><RecNum>12</RecNum><DisplayText><style face=”superscript”>15</style></DisplayText><record><rec-number>12</rec-number><foreign-keys><key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959482″>12</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Mossman, B. T.</author></authors></contributors><auth-address>Department of Pathology, University of Vermont College of Medicine, Burlington 05405.</auth-address><titles><title>In vitro studies on the biologic effects of fibers: correlation with in vivo bioassays</title><secondary-title>Environ Health Perspect</secondary-title></titles><periodical><full-title>Environ Health Perspect</full-title></periodical><pages>319-22</pages><volume>88</volume><edition>1990/08/01</edition><keywords><keyword>Animals</keyword><keyword>Asbestos/*toxicity</keyword><keyword>Biological Assay</keyword><keyword>Carcinogens</keyword><keyword>Cell Division/drug effects</keyword><keyword>Cell Survival/drug effects</keyword><keyword>Cell Transformation, Neoplastic</keyword><keyword>Genes/drug effects</keyword><keyword>Humans</keyword><keyword>Minerals/*toxicity</keyword></keywords><dates><year>1990</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0091-6765 (Print) 0091-6765 (Linking)</isbn><accession-num>2272329</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=2272329</url></related-urls></urls><custom2>1568030</custom2><language>eng</language></record></Cite></EndNote>15. The direct and indirect costs of sleep problems are substantial. Despite the individual and societal burden of sleep problems, most (80%-90%) remain undiagnosed PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbC1FaXRoYW48L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFy
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ADDIN EN.CITE.DATA 16-18. Screening for sleep disorders and OSA should be routinely performed in an increased number of patients, particularly those at high risk diabetic patients ADDIN EN.CITE <EndNote><Cite><Author>Hernandez</Author><Year>2012</Year><RecNum>16</RecNum><DisplayText><style face=”superscript”>19</style></DisplayText><record><rec-number>16</rec-number><foreign-keys><key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959482″>16</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Hernandez, A.</author><author>Philippe, J.</author><author>Jornayvaz, F. R.</author></authors></contributors><auth-address>Service d&apos;endocrinologie, diabetologie et nutrition HUG, 1211 Geneve 14. [email protected]</auth-address><titles><title>Sleep and diabetes</title><secondary-title>Rev Med Suisse</secondary-title></titles><periodical><full-title>Rev Med Suisse</full-title></periodical><pages>1198-200, 1202-3</pages><volume>8</volume><number>344</number><edition>2012/06/27</edition><keywords><keyword>Diabetes Mellitus, Type 2/*complications</keyword><keyword>Humans</keyword><keyword>Obesity/*complications</keyword><keyword>Sleep Deprivation/*complications</keyword><keyword>Sleep Disorders/*complications</keyword></keywords><dates><year>2012</year><pub-dates><date>Jun 6</date></pub-dates></dates><orig-pub>Sommeil et diabete.</orig-pub><isbn>1660-9379 (Print) 1660-9379 (Linking)</isbn><accession-num>22730615</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=22730615</url></related-urls></urls><language>fre</language></record></Cite></EndNote>19. Despite these independent associations between OSA and abnormal glucose metabolism and the high prevalence of OSA in patients withT2DM, data on whether the presence and severity of OSA compromises glycemic control in patients with T2DM is lacking.
In this study we aimed to estimate the prevalence of OSA among patients with T2DMandto explore if sleep apnea is associated to clinical and demographic variable.

Methods
Study design and Settings
We conducted a cross-sectional study during 1st of November 2011 to 1st of February 2012, on 1143 T2DMpatients (30-90 years) at the National Center for Diabetes, Endocrinology and Genetics (NCDEG) at the University of Jordan, Amman, Jordan. The NCDEG is the only referral center in the country; therefore, the patients represent the population in different parts of the country. All participants completed a Berlin Questionnaire and were classified as low- or high-risk patients for OSA. We also collected the data of patients ‘age, gender, level of education, smoking status, DM duration and type of DM treatment.

Inclusion criteria:
Age range between 30-90, years old, Diagnosed with T2DM mellitus according to the American Diabetes Association (ADA) and were attending the general outpatient clinic’s every 1-3 months as part of their routine follow up were included in the study.

Exclusion criteria:
Patients with type 1 diabetes, pregnant or breastfeeding women were also excluded from this study.

Ethical approval
The study was approved by the Research and Ethical Committee of NCDEG in Amman-Jordan. The participation of the diabetes patients is voluntary and the data collected during the study has been handled confidentially.

Measures
Anthropometric measurement:-
Height was measured without a shoe, to the nearest 0.5 cm using a stadiometer with shoulders in a relaxed position and the arms hanging freely. Weight was taken with the patient wearing light clothes and without shoes and was measured to the nearest 0.5 Kg. BMI was obtained by dividing the weight in kilograms on the square of height in meters ADDIN EN.CITE <EndNote><Cite><Author>Al-Jadid</Author><Year>2012</Year><RecNum>17</RecNum><DisplayText><style face=”superscript”>20</style></DisplayText><record><rec-number>17</rec-number><foreign-keys><key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959482″>17</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Al-Jadid, M. S.</author><author>Robert, A. A.</author></authors></contributors><auth-address>Department of Neurosciences, Rehabilitation Medicine Division, Riyadh Military Hospital, Riyadh, Kingdom of Saudi Arabia. [email protected]</auth-address><titles><title>Length of stay of patients in different rehabilitation programs. A hospital experience in Saudi Arabia</title><secondary-title>Saudi Med J</secondary-title></titles><periodical><full-title>Saudi Med J</full-title></periodical><pages>326-7</pages><volume>33</volume><number>3</number><edition>2012/03/20</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Female</keyword><keyword>*Hospitals</keyword><keyword>Humans</keyword><keyword>*Length of Stay</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Rehabilitation</keyword><keyword>Saudi Arabia</keyword></keywords><dates><year>2012</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0379-5284 (Print) 0379-5284 (Linking)</isbn><accession-num>22426917</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=22426917</url></related-urls></urls><electronic-resource-num>0&apos; pii</electronic-resource-num><language>eng</language></record></Cite></EndNote>20 .Waist circumference was measured to the nearest cm using non-stretchable tailors. Measuring tape was put at the level midway between the lower rib margin and iliac crest in a horizontal plane, also (Waist/Height) ratio was obtained by dividing the waist in cm on height in cm. Neck circumferences (NC) was measured to the nearest 0.5 cm using non-stretchable tailor around the neck just below the most prominent portion of the thyroid cartilage the laryngeal prominence (Adam’s apple). ADDIN EN.CITE <EndNote><Cite><Author>Al Zoman</Author><Year>2011</Year><RecNum>18</RecNum><DisplayText><style face=”superscript”>21</style></DisplayText><record><rec-number>18</rec-number><foreign-keys><key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959483″>18</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Al Zoman, H.</author><author>Al Jetaily, S.</author><author>Robert, A. A.</author><author>Baskaradoss, J. K.</author><author>Al-Suwyed, A.</author><author>Ciancio, S.</author><author>Al Mubarak, S.</author></authors></contributors><auth-address>a College of Dentistry, King Saud University, Riyadh, Saudi Arabia.</auth-address><titles><title>Flapless Dental Implant Surgery For Patients On Oral Anticoagulants – &quot;WarLess Procedure&quot; – A Report of Two Cases</title><secondary-title>J Oral Implantol</secondary-title></titles><periodical><full-title>J Oral Implantol</full-title></periodical><edition>2011/11/24</edition><dates><year>2011</year><pub-dates><date>Nov 22</date></pub-dates></dates><isbn>0160-6972 (Print) 0160-6972 (Linking)</isbn><accession-num>22107055</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=22107055</url></related-urls></urls><electronic-resource-num>10.1563/AAID-JOI-D-11-00105</electronic-resource-num><language>Eng</language></record></Cite></EndNote>21Clinical and Laboratory measurement:-
Glycosylated hemoglobin (HbA1c) was analyzed by using a high performance liquid chromatography (HPLC) method (Bio-Rad) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb2JlcnQ8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 22 and the last result was taken. Also information about medical history i.e the presence of hypertension, dyslipidemia, coronary artery disease, erectile dysfunction and the type of treatment i.e oral hypoglycemic agents, insulin or both hypoglycemic agents and insulin were collected from the medical record at time of interview.
Structured questionnaire:
The questionnaire was used to assess the symptoms and risk of OSA called Berlin questionnaire (BQ) in Arabic language. The English version was designed in 1996 and was validated as a self-report screening instrument for OSA; the questionnaire consists of ten questions, divided into three categories. The first category addresses the presence of snoring, its loudness, frequency, whether it bothers other people and the frequency of witnessed apnea. The second category addresses the frequency of feeling tired or fatigued after sleep and during wake time, and the tendency and frequency to falling asleep while driving a vehicle. The third category addresses the presence of hypertension and obesity body mass index (BMI) ?30 kg/m2. Response in categories 1 and 2 was considered positive if greater than or equal to two items of the category were positive. Category 3 was considered positive if the subject had hypertension, obesity, or both. Subjects who scored positive in two or more categories were considered as having high risk symptoms for obstructive sleep apnea (HR-OSA). ADDIN EN.CITE <EndNote><Cite><Author>Netzer</Author><Year>1999</Year><RecNum>20</RecNum><DisplayText><style face=”superscript”>23</style></DisplayText><record><rec-number>20</rec-number><foreign-keys><key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959483″>20</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Netzer, N. C.</author><author>Stoohs, R. A.</author><author>Netzer, C. M.</author><author>Clark, K.</author><author>Strohl, K. P.</author></authors></contributors><auth-address>Center for Sleep Education and Research, Case Western Reserve University, Cleveland, Ohio, USA.</auth-address><titles><title>Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome</title><secondary-title>Ann Intern Med</secondary-title></titles><periodical><full-title>Ann Intern Med</full-title></periodical><pages>485-91</pages><volume>131</volume><number>7</number><edition>1999/10/03</edition><keywords><keyword>Female</keyword><keyword>Humans</keyword><keyword>Hypertension/complications</keyword><keyword>Logistic Models</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Monitoring, Physiologic</keyword><keyword>Obesity/complications</keyword><keyword>*Questionnaires</keyword><keyword>Reproducibility of Results</keyword><keyword>Respiration Disorders/etiology</keyword><keyword>Risk Factors</keyword><keyword>Sex Factors</keyword><keyword>Sleep Apnea Syndromes/complications/*diagnosis/physiopathology</keyword><keyword>Snoring/etiology</keyword></keywords><dates><year>1999</year><pub-dates><date>Oct 5</date></pub-dates></dates><isbn>0003-4819 (Print) 0003-4819 (Linking)</isbn><accession-num>10507956</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=10507956</url></related-urls></urls><electronic-resource-num>199910050-00002 pii</electronic-resource-num><language>eng</language></record></Cite></EndNote>23 The high-risk pre-test probability for OSA was found previously to predict an respiratory disturbance index of > 5 a sensitivity of 0.86, a specificity of 0.77, a positive predictive value of 0.89 and likelihood ratio of 3.79(35).The valid translated Arabic version of Berlin questionnaire by Professor Ahmed S Bahammam was used. ADDIN EN.CITE <EndNote><Cite><Author>Bahammam</Author><Year>2009</Year><RecNum>21</RecNum><DisplayText><style face=”superscript”>24</style></DisplayText><record><rec-number>21</rec-number><foreign-keys><key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959483″>21</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Bahammam, A. S.</author><author>Al-Rajeh, M. S.</author><author>Al-Ibrahim, F. S.</author><author>Arafah, M. A.</author><author>Sharif, M. M.</author></authors></contributors><auth-address>Sleep Disorders Center, College of Medicine, Department of Medicine 38, King Saud University, PO Box 225503, Riyadh 11324, Kingdom of Saudi Arabia. [email protected]</auth-address><titles><title>Prevalence of symptoms and risk of sleep apnea in middle-aged Saudi women in primary care</title><secondary-title>Saudi Med J</secondary-title></titles><periodical><full-title>Saudi Med J</full-title></periodical><pages>1572-6</pages><volume>30</volume><number>12</number><edition>2009/11/26</edition><keywords><keyword>Adult</keyword><keyword>Body Mass Index</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Middle Aged</keyword><keyword>Prevalence</keyword><keyword>Primary Health Care</keyword><keyword>Risk Factors</keyword><keyword>Saudi Arabia/epidemiology</keyword><keyword>Sleep Apnea Syndromes/*epidemiology/physiopathology</keyword></keywords><dates><year>2009</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0379-5284 (Print) 0379-5284 (Linking)</isbn><accession-num>19936423</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=19936423</url></related-urls></urls><electronic-resource-num>0&apos; pii</electronic-resource-num><language>eng</language></record></Cite></EndNote>24Waist and neck circumference:-
Waist and neck circumference was considered normal in women if less than 88cm, and in men if less than 102 cm according to ATP III criteria (37).Neck circumference was considered normal (for men if < 43 cm, and for women if < 38 cm) ADDIN EN.CITE <EndNote><Cite><Author>Medeiros</Author><Year>2011</Year><RecNum>22</RecNum><DisplayText><style face=”superscript”>25</style></DisplayText><record><rec-number>22</rec-number><foreign-keys><key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959483″>22</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Medeiros, C. A.</author><author>Bruin, V. M.</author><author>Castro-Silva, Cd</author><author>Araujo, S. M.</author><author>Chaves Junior, C. M.</author><author>Bruin, P. F.</author></authors></contributors><auth-address>Universidade Federal do Ceara, Fortaleza, CE, Brazil.</auth-address><titles><title>Neck circumference, a bedside clinical feature related to mortality of acute ischemic stroke</title><secondary-title>Rev Assoc Med Bras</secondary-title></titles><periodical><full-title>Rev Assoc Med Bras</full-title></periodical><pages>559-64</pages><volume>57</volume><number>5</number><edition>2011/10/21</edition><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Body Mass Index</keyword><keyword>Disorders of Excessive Somnolence/*complications</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neck/*anatomy &amp; histology</keyword><keyword>Polysomnography</keyword><keyword>Prospective Studies</keyword><keyword>Risk Factors</keyword><keyword>Severity of Illness Index</keyword><keyword>Sleep Apnea, Obstructive/*complications</keyword><keyword>Stroke/etiology/*mortality</keyword></keywords><dates><year>2011</year><pub-dates><date>Sep-Oct</date></pub-dates></dates><isbn>0104-4230 (Print) 0104-4230 (Linking)</isbn><accession-num>22012291</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=22012291</url></related-urls></urls><electronic-resource-num>S0104-42302011000500015 pii</electronic-resource-num><language>eng</language></record></Cite></EndNote>25.

Glycosylated hemoglobin (HBA1C):-
HbA1c divided into three groups: group1 good glycemic control if HbA1c < 7%, group2 fairly controlled if HbA1c 7 – 8.5%, group3 poor glycemic control if HbA1c >8.5%.

Dyslipidemia: –
According to ADA criteria 2011 ADDIN EN.CITE <EndNote><Cite><Author>Al-Eithan</Author><Year>2011</Year><RecNum>23</RecNum><DisplayText><style face=”superscript”>26</style></DisplayText><record><rec-number>23</rec-number><foreign-keys><key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959483″>23</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Al-Eithan, M. H.</author><author>Amin, M.</author><author>Robert, A. A.</author></authors></contributors><auth-address>Department of Psychology, Sultan Bin Abdulaziz Humanitarian City, Riyadh, Kingdom of Saudi Arabia. [email protected]</auth-address><titles><title>The effect of hemiplegia/hemiparesis, diabetes mellitus, and hypertension on hospital length of stay after stroke</title><secondary-title>Neurosciences (Riyadh)</secondary-title></titles><periodical><full-title>Neurosciences (Riyadh)</full-title></periodical><pages>253-6</pages><volume>16</volume><number>3</number><edition>2011/06/17</edition><keywords><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Comorbidity</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Diabetes Mellitus/epidemiology/*rehabilitation</keyword><keyword>Female</keyword><keyword>Functional Laterality</keyword><keyword>Hemiplegia/epidemiology/*rehabilitation</keyword><keyword>Humans</keyword><keyword>Hypertension/epidemiology/*rehabilitation</keyword><keyword>*Length of Stay</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Retrospective Studies</keyword><keyword>Stroke/*rehabilitation</keyword></keywords><dates><year>2011</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1319-6138 (Print) 1319-6138 (Linking)</isbn><accession-num>21677617</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=21677617</url></related-urls></urls><language>eng</language></record></Cite></EndNote>26, lipid levels were considered abnormal if: LDL level ? 100 mg / dl, HDL level ? 50 mg / dl in women and ? 40 mg / dl in men and triglyceride ?150 mg / dl.

Hypertension:
Hypertension was considered if systolic blood pressure > 130 or diastolic blood pressure > 80 mmHg. Also patients were considered as hypertensive if they were on antihypertensive therapy at the time of presentation to the diabetic clinic at the NCDEG. ADDIN EN.CITE <EndNote><Cite><Author>Al-Eithan</Author><Year>2011</Year><RecNum>23</RecNum><DisplayText><style face=”superscript”>26</style></DisplayText><record><rec-number>23</rec-number><foreign-keys><key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959483″>23</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Al-Eithan, M. H.</author><author>Amin, M.</author><author>Robert, A. A.</author></authors></contributors><auth-address>Department of Psychology, Sultan Bin Abdulaziz Humanitarian City, Riyadh, Kingdom of Saudi Arabia. [email protected]</auth-address><titles><title>The effect of hemiplegia/hemiparesis, diabetes mellitus, and hypertension on hospital length of stay after stroke</title><secondary-title>Neurosciences (Riyadh)</secondary-title></titles><periodical><full-title>Neurosciences (Riyadh)</full-title></periodical><pages>253-6</pages><volume>16</volume><number>3</number><edition>2011/06/17</edition><keywords><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Comorbidity</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Diabetes Mellitus/epidemiology/*rehabilitation</keyword><keyword>Female</keyword><keyword>Functional Laterality</keyword><keyword>Hemiplegia/epidemiology/*rehabilitation</keyword><keyword>Humans</keyword><keyword>Hypertension/epidemiology/*rehabilitation</keyword><keyword>*Length of Stay</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Retrospective Studies</keyword><keyword>Stroke/*rehabilitation</keyword></keywords><dates><year>2011</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1319-6138 (Print) 1319-6138 (Linking)</isbn><accession-num>21677617</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=21677617</url></related-urls></urls><language>eng</language></record></Cite></EndNote>26
Smoking status: –
According to the world health organization guidelines the smokers were classified to three groups Current smokers: a person who smokes cigarettes daily or occasionally. Past smoker (Ex-smoker): a person who was formerly a daily or occasionally smoker, but currently did not smoke at all. Nonsmoker: a person who has never smoked before or has smoked very little in the past. ADDIN EN.CITE <EndNote><Cite><Author>Al-Jadid</Author><Year>2010</Year><RecNum>24</RecNum><DisplayText><style face=”superscript”>27</style></DisplayText><record><rec-number>24</rec-number><foreign-keys><key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959483″>24</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Al-Jadid, M. S.</author><author>Robert, A. A.</author></authors></contributors><auth-address>Department of Neurosciences, Rehabilitation Medicine Dividison, Riyadh Military Hospital, PO Box 14126, Riyadh 11424, Kingdom of Saudi Arabia. [email protected]</auth-address><titles><title>A comparative analysis of length of stay of traumatic and non-traumatic brain injured patients in Saudi Arabia</title><secondary-title>Saudi Med J</secondary-title></titles><periodical><full-title>Saudi Med J</full-title></periodical><pages>1172-3</pages><volume>31</volume><number>10</number><edition>2010/10/19</edition><keywords><keyword>Adult</keyword><keyword>*Brain Injuries</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>*Length of Stay</keyword><keyword>Male</keyword><keyword>Wounds and Injuries</keyword></keywords><dates><year>2010</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0379-5284 (Print) 0379-5284 (Linking)</isbn><accession-num>20953538</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=20953538</url></related-urls></urls><electronic-resource-num>20102573&apos; pii</electronic-resource-num><language>eng</language></record></Cite></EndNote>27Statistical analysis:-
Statistical analysis was carried out using Statistical Package for Social Science (SPSS, version 16). Initially, the data were examined for data entry errors and outlying values. Descriptive statistics were obtained, such as the mean value and standerd deviation for continuous variables and frequency distribution for categorical variables.

The prevalence of high risk for OSA was expressed as percentage. Bivariate association between HR-OSA and a number of independent variables were assessed for statistical significance using Chi-Square. AP-value less than 0.05 were considered statistically significant. Multivariate logistic regression was used to examine the net effect for each of the independent variables on dependent variable.

Results
The mean age of the patients was 58.6±10 years. Out of 1143 patients, 587 were (51.4%) males and 556 (48.6%) were females (age range between 30-90 years). The socio-demographic and clinical characteristics are presented in table 1 and 2. The comparisons of high risk OSA and low risk of OSA on socio-demographic and clinical parameters are shown in (Table 3). The analysis showed that there were no significant correlation between high risk OSA and low risk OSA on the patients’ gender, age, level of education, smoking status, duration of diabetes, dyslipidemia or HbA1c level. However, significant difference was found between high risk OSA and low risk OSA on neck circumference (P<0.0001).

Socio-demographic, laboratory and clinical factors affecting high for obstructive sleep apnea (table 4). The results showed the patients who aged > 40 years were at high risk for OSA. Patients who aged between 40 to 59 years were 2.26 times more likely to had high risk for OSA than those who aged less than 40, also people who aged > 60 were 2.3 times more likely to had high risk for OSA than those less than 40 years of age.

The current smoker were 1.45 times more likely to have high risk for OSA than patients who never smoked and this association was statistically significant (P< 0.025).Those who had elevated neck circumference were found to be 2.8 times more likely to have high risk for OSA than those with normal neck circumference (P<0.0001).

Discussion
Type 2 diabetes is a major public health concern with high morbidity, mortality, and health-care costs and the prevalence of T2DM is high in Jordan population PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LaGF0dGFiPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48
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ADDIN EN.CITE.DATA 28, 29 ADDIN EN.CITE <EndNote><Cite><Author>Jarab</Author><Year>2018</Year><RecNum>6</RecNum><DisplayText><style face=”superscript”>30</style></DisplayText><record><rec-number>6</rec-number><foreign-keys><key app=”EN” db-id=”0wtrzt5vlzfrd1ee90r50w5lrftrswtwpevf” timestamp=”1521960491″>6</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Jarab, A. S.</author><author>Mukattash, T. L.</author><author>Al-Azayzih, A.</author><author>Khdour, M.</author></authors></contributors><auth-address>Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan. Faculty of Pharmacy, Al-Quds University, Palestinian Territories, Israel.</auth-address><titles><title>A focus group study of patient&apos;s perspective and experiences of type 2 diabetes and its management in Jordan</title><secondary-title>Saudi Pharm J</secondary-title><alt-title>Saudi pharmaceutical journal : SPJ : the official publication of the Saudi Pharmaceutical Society</alt-title></titles><periodical><full-title>Saudi Pharm J</full-title><abbr-1>Saudi pharmaceutical journal : SPJ : the official publication of the Saudi Pharmaceutical Society</abbr-1></periodical><alt-periodical><full-title>Saudi Pharm J</full-title><abbr-1>Saudi pharmaceutical journal : SPJ : the official publication of the Saudi Pharmaceutical Society</abbr-1></alt-periodical><pages>301-305</pages><volume>26</volume><number>3</number><edition>2018/03/21</edition><dates><year>2018</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1319-0164 (Print) 1319-0164</isbn><accession-num>29556120</accession-num><urls></urls><custom2>Pmc5856954</custom2><electronic-resource-num>10.1016/j.jsps.2018.01.013</electronic-resource-num><remote-database-provider>Nlm</remote-database-provider><language>eng</language></record></Cite></EndNote>30. Recent reports have indicated that the majority of patients with T2DMalso have OSA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UYXNhbGk8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 29. The prevalence of OSA is increasing because of a worldwide increase in obesity and the ageing of populations ADDIN EN.CITE <EndNote><Cite><Author>Usmani</Author><Year>2012</Year><RecNum>4</RecNum><DisplayText><style face=”superscript”>5</style></DisplayText><record><rec-number>4</rec-number><foreign-keys><key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959480″>4</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Usmani, Z. A.</author><author>Chai-Coetzer, C. L.</author><author>Antic, N. A.</author><author>McEvoy, R. D.</author></authors></contributors><auth-address>Adelaide Institute for Sleep Health, Repatriation General Hospital, Adelaide, South Australia, Australia.</auth-address><titles><title>Obstructive sleep apnoea in adults</title><secondary-title>Postgrad Med J</secondary-title></titles><periodical><full-title>Postgrad Med J</full-title></periodical><edition>2012/11/20</edition><dates><year>2012</year><pub-dates><date>Nov 17</date></pub-dates></dates><isbn>1469-0756 (Electronic) 0032-5473 (Linking)</isbn><accession-num>23161914</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=23161914</url></related-urls></urls><electronic-resource-num>postgradmedj-2012-131340 pii 10.1136/postgradmedj-2012-131340</electronic-resource-num><language>Eng</language></record></Cite></EndNote>5. In this study we also found that OSA is a highly prevalent (48.5%) in the diabetes population and this is in agreement with previous studies, which show that OSA has been identified as a highly prevalent comorbidity of T2DM patients PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FaW5ob3JuPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48
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ADDIN EN.CITE.DATA 31-33. A recent study from United States also found that sleep problems are highly prevalent and more than 90% of patients reported any examined sleep problem and 10% to 40% reported any given problem ADDIN EN.CITE <EndNote><Cite><Author>Plantinga</Author><Year>2012</Year><RecNum>30</RecNum><DisplayText><style face=”superscript”>34</style></DisplayText><record><rec-number>30</rec-number><foreign-keys><key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959484″>30</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Plantinga, L.</author><author>Rao, M. N.</author><author>Schillinger, D.</author></authors></contributors><auth-address>Department of Epidemiology, Rollins School of Public Health, Emory University, Claudia Nance Rollins Building, Floor 3, 1518 Clifton Rd NE, Atlanta, GA 30322, USA. [email protected]</auth-address><titles><title>Prevalence of self-reported sleep problems among people with diabetes in the United States, 2005-2008</title><secondary-title>Prev Chronic Dis</secondary-title></titles><periodical><full-title>Prev Chronic Dis</full-title></periodical><pages>E76</pages><volume>9</volume><edition>2012/03/24</edition><keywords><keyword>Diabetes Mellitus/*epidemiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Logistic Models</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nutrition Surveys</keyword><keyword>Prevalence</keyword><keyword>Self Report</keyword><keyword>Sleep Disorders/*epidemiology</keyword><keyword>United States</keyword></keywords><dates><year>2012</year></dates><isbn>1545-1151 (Electronic)</isbn><accession-num>22440550</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=22440550</url></related-urls></urls><custom2>3392086</custom2><electronic-resource-num>E76 pii</electronic-resource-num><language>eng</language></record></Cite></EndNote>34. Shim et al also found that patients with T2DM using Berlin Questionnaire showed higher (50.8%) rick of OSA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGltPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 5, 36, 37. In our study we found that 60% of our participants were obese while 32.4% were overweight with a mean body mass index of 32 and 75.2% were hypertensive patients. In addition 73% of the study population had elevated waist circumference and 28% of them had elevated neck circumference. Our results also showed when compared to low risk the neck circumference was significantly correlated with OSA.
Several studies have attempted to address the cause of age-related impact on OSA. Mechanisms proposed for the increased prevalence of OSA in the elderly include increased deposition of fat in the parapharyngeal area, lengthening of the soft palate, and changes in body structures surrounding the pharynx PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FaWtlcm1hbm48L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFy
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ADDIN EN.CITE.DATA 38, 39. In our study we also found OSA risk significantly increased with age, for age group <30 years had 5.4%, 30-59 years had 28.4% and > 60 years had 45.9%. Due to sequence of weight gain, after middle age upper respiratory tract becomes narrower, and it worsens obstructive sleep apnea syndrome (OSAS). Since mastication is to provoke and maintain arousal, OSAS patients, who especially feel strong sleepiness, tend to encourage them to be obesity by frequent mastication that leads them to the tendency to overeat ADDIN EN.CITE <EndNote><Cite><Author>Sasanabe</Author><Year>2012</Year><RecNum>36</RecNum><DisplayText><style face=”superscript”>40</style></DisplayText><record><rec-number>36</rec-number><foreign-keys><key app=”EN” db-id=”d0rd5pezgsaadyeddfnxaxfk5p2dvwefsf9a” timestamp=”1521959485″>36</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Sasanabe, R.</author><author>Watanabe, Y.</author><author>Shiomi, T.</author></authors></contributors><auth-address>Department of Sleep Medicine, Aichi Medical University School of Medicine.</auth-address><titles><title>A sleep disordered breathing as the lifestyle-related diseases</title><secondary-title>Nihon Rinsho</secondary-title></titles><periodical><full-title>Nihon Rinsho</full-title></periodical><pages>1211-5</pages><volume>70</volume><number>7</number><edition>2012/08/01</edition><keywords><keyword>Diabetes Mellitus/*etiology</keyword><keyword>Glucose Intolerance/complications</keyword><keyword>Humans</keyword><keyword>Hypertension/*complications</keyword><keyword>*Life Style</keyword><keyword>Obesity/*complications</keyword><keyword>Sleep Apnea Syndromes/*complications/therapy</keyword></keywords><dates><year>2012</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>0047-1852 (Print) 0047-1852 (Linking)</isbn><accession-num>22844807</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=22844807</url></related-urls></urls><language>jpn</language></record></Cite></EndNote>40.

Many studies reported that OSA is associated with higher HbA1c levels in patients with and without diabetes. The severity of hypoxemia in patients with sleep apnea correlates with HbA1C levels ranging from normal to pre-diabetes and diabetes PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaHBpcmVyPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA 41. In contrast, in our study we found there were no significant results were found between normal to pre-diabetes and diabetes.

Cigarette smoking has been shown to be risk factors for OSA. Smoking is associated with a higher prevalence of snoring and sleep-disordered breathing PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Fa2ljaTwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 45The major limitation of this study was the limited number of risk factor examined, single center and its cross sectional nature. Further research is needed to address these limitations. In conclusion, the study found that high risk for OSA was highly prevalent among Jordanian type 2 diabetics and age, smoking and neck circumference were significantly correlated with OSA. Our findings suggest that more attention must be paid to Jordanian diabetes and clinicians should be aware of the high prevalence of sleep problems among their patients with diabetes in Jordan and should consider screening and treatment, which may improve patients’ quality of life and to prevent or minimize complications of diabetes mellitus including the OSA.

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22860000
Groups compared with total population, Fisher’s exact test ***P <0.001
Table 1: Socio-demographic characteristics of study participants
Variable N %
Sex Male 587 51.4
Female 556 48.6
Age(year) <40 36 3.2
40-59 559 48.9
?60 548 47.9
Level of education < high school 343 30.0
= high school 192 16.8
> high school 608 53.2
Smoking Nonsmoker 725 63.4
Ex-smoker 190 16.6
Smoker 228 20
Duration of diabetes(year) <5 378 33.1
5-9 262 22.9
>10 503 44
Body mass index(kgm2) <25 90 7.8
25-29.9 370 32.4
?30 683 59.8
Waist circumference(cm) Normal 301 26.3
Abnormal 842 73.7
Neck circumference(cm)* Normal 829 72.5
Elevated 314 27.5
Table 2: Clinical and laboratory characteristics of study participants
Variable N %
Hypertension Yes 860 75.2
No 283 24.8
Dyslipidemia Yes 929 81.3
No 214 18.7
HbA1c (%) <7 355 31.0
7-8.5 505 44.2
>8.5 283 24.8
Table 3: Prevalence of high and low risk for OSA in study population according to the socio-demographic, clinical and laboratory characteristics
Variable HR-OSA,n %) LR-OSA, n (%) P value
Sex Male 273(46.5%) 314(53.5%) .173
Female 281(50.5%) 275(49.5%) Age (year) <40 12(33.3%) 24(66.7%) .178
40-59 272(48.7%) 287(51.3%) >60 270(49.3%) 278(50.7%) Level of education < high school 180(52.5%) 163(47.5%) .101
= high school 97(50.5%) 95(49.5%) > high school 277(45.6%) 331(54.4%) Smoking Nonsmoker 338(46.6%) 387(53.4%) .254
EX-smoker 99(52.1%) 91(47.9%) Smoker 117(51.3%) 111(48.7%) Duration of Diabetes <5 183(48.4%) 195(51.6%) .753
5-9 132(50.4%) 130(49.6%) ?10 239(47.5%) 264(52.5%) Neck circumference(cm) Normal 347 (41.9%) 482 (58.1%) .000
Elevated 207 (65.9%) 107 (34.1%) Dyslipidemia Yes 462(49.7%) 467(50.3%) .075
No 92(43.0%) 122(57.0%) HbA1c (%) <7 167(47.0%) 188(53.0%) .614
7-8.5 243(48.1%) 262(51.9%) >8.5 144(50.9%) 139(49.1%) HR-OSA: high risks of obstructive sleep apnoea
LR-OSA: low risks of obstructive sleep apnoea
Table (4) Logistic regression analysis for socio-demographic, laboratory and clinical factors affecting high for obstructive sleep apnea
Variable OR P-value
Smoking
Nonsmoker
Ex-smoker
Current smoker 1
1.348
1.454 .100
.025
Neck circumference
Normal
Elevated 1
2.75 .000
Age groups <40 1 40-59 2.257 .03
> 60 2.318 .03
Sex Male 1 Female 1.0 .980
HbA1c < 7 1 7-8.5 1.010 .947
>8.5 1.001 .995
Duration of DM < 5 1 5-9 .906 .568
> 10 .815 .202
Dyslipidemia No 1 Yes 1.200 .256
Level of education < high school 1 = high school .920 .662
> high school .810 .184

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