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Chan YH, Teo CB, Tay JK, Cheong CS. The association between obstructive sleep apnea and osteoporosis: A systematic review and meta-analysis. Sleep Med Rev 2024; 78:102006. [PMID: 39298877 DOI: 10.1016/j.smrv.2024.102006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 09/02/2024] [Accepted: 09/04/2024] [Indexed: 09/22/2024]
Abstract
Obstructive sleep apnea (OSA) is a sleep disorder with well-known metabolic consequences. The relationship between OSA and bone health, especially osteoporosis, remains poorly understood. Given that both OSA and osteoporosis are highly prevalent chronic conditions with significant public health implications, this study aims to investigate the association of OSA with bone health and osteoporosis. A systematic search of PubMed, Embase and Cochrane Library was conducted from inception to November 22, 2022. Fifteen studies comprising 158,273 individuals were included. The presence of OSA correlated negatively with bone mineral density on meta-analysis (pooled correlation = -0.30; 95 % CI, -0.42 to -0.17; N = 8). Individuals with OSA had poorer bone mineral density scores (mean difference = -0.58, 95 % CI, -1.15 to -0.01; N = 8), and significantly higher risk of developing osteoporosis (adjusted odds ratio = 2.18; 95 % CI, 1.14 to 4.16; N = 4). Notably, both body mass index (BMI) and age were not significant effect modulators in the correlation of OSA and bone density. These findings suggest that OSA is associated with diminished bone health, and it is severity-dependent. Further studies are required to determine if treatment of OSA may have the potential to mitigate these risks.
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Affiliation(s)
- Yong Hoe Chan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Chong Boon Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Joshua K Tay
- Department of Otolaryngology - Head and Neck Surgery, National University Hospital, Singapore.
| | - Crystal S Cheong
- Department of Otolaryngology - Head and Neck Surgery, National University Hospital, Singapore.
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2
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Lavalle S, Masiello E, Iannella G, Magliulo G, Pace A, Lechien JR, Calvo-Henriquez C, Cocuzza S, Parisi FM, Favier V, Bahgat AY, Cammaroto G, La Via L, Gagliano C, Caranti A, Vicini C, Maniaci A. Unraveling the Complexities of Oxidative Stress and Inflammation Biomarkers in Obstructive Sleep Apnea Syndrome: A Comprehensive Review. Life (Basel) 2024; 14:425. [PMID: 38672697 PMCID: PMC11050908 DOI: 10.3390/life14040425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/03/2024] [Accepted: 03/18/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Obstructive sleep apnea syndrome (OSAS), affecting approximately 1 billion adults globally, is characterized by recurrent airway obstruction during sleep, leading to oxygen desaturation, elevated carbon dioxide levels, and disrupted sleep architecture. OSAS significantly impacts quality of life and is associated with increased morbidity and mortality, particularly in the cardiovascular and cognitive domains. The cyclic pattern of intermittent hypoxia in OSAS triggers oxidative stress, contributing to cellular damage. This review explores the intricate relationship between OSAS and oxidative stress, shedding light on molecular mechanisms and potential therapeutic interventions. METHODS A comprehensive review spanning from 2000 to 2023 was conducted using the PubMed, Cochrane, and EMBASE databases. Inclusion criteria encompassed English articles focusing on adults or animals and reporting values for oxidative stress and inflammation biomarkers. RESULTS The review delineates the imbalance between pro-inflammatory and anti-inflammatory factors in OSAS, leading to heightened oxidative stress. Reactive oxygen species biomarkers, nitric oxide, inflammatory cytokines, endothelial dysfunction, and antioxidant defense mechanisms are explored in the context of OSAS. OSAS-related complications include cardiovascular disorders, neurological impairments, metabolic dysfunction, and a potential link to cancer. This review emphasizes the potential of antioxidant therapy as a complementary treatment strategy. CONCLUSIONS Understanding the molecular intricacies of oxidative stress in OSAS is crucial for developing targeted therapeutic interventions. The comprehensive analysis of biomarkers provides insights into the complex interplay between OSAS and systemic complications, offering avenues for future research and therapeutic advancements in this multifaceted sleep disorder.
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Affiliation(s)
- Salvatore Lavalle
- Faculty of Medicine and Surgery, University of Enna Kore, 94100 Enna, Italy; (S.L.); (C.G.)
| | - Edoardo Masiello
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy;
| | - Giannicola Iannella
- Department of ‘Organi di Senso’, University “Sapienza”, Viale dell’Università, 33, 00185 Rome, Italy; (G.I.); (G.M.); (A.P.)
| | - Giuseppe Magliulo
- Department of ‘Organi di Senso’, University “Sapienza”, Viale dell’Università, 33, 00185 Rome, Italy; (G.I.); (G.M.); (A.P.)
| | - Annalisa Pace
- Department of ‘Organi di Senso’, University “Sapienza”, Viale dell’Università, 33, 00185 Rome, Italy; (G.I.); (G.M.); (A.P.)
| | - Jerome Rene Lechien
- Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons, 7022 Mons, Belgium;
| | - Christian Calvo-Henriquez
- Service of Otolaryngology, Hospital Complex of Santiago de Compostela, 15705 Santiago de Compostela, Spain;
| | - Salvatore Cocuzza
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, Via S. Sofia, 78, 95125 Catania, Italy; (S.C.); (F.M.P.)
| | - Federica Maria Parisi
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, Via S. Sofia, 78, 95125 Catania, Italy; (S.C.); (F.M.P.)
| | - Valentin Favier
- Service d’ORL et de Chirurgie Cervico-Faciale, Centre Hospitalo-Universitaire de Montpellier, 80 Avenue Augustin Fliche, 34000 Montpellier, France
| | - Ahmed Yassin Bahgat
- Department of Otorhinolaryngology, Alexandria University, Alexandria 21577, Egypt;
| | - Giovanni Cammaroto
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Via Carlo Forlanini, 34, 47121 Forlì, Italy;
| | - Luigi La Via
- Department of Anaesthesia and Intensive Care, University Hospital Policlinico-San Marco, 95125 Catania, Italy;
| | - Caterina Gagliano
- Faculty of Medicine and Surgery, University of Enna Kore, 94100 Enna, Italy; (S.L.); (C.G.)
| | - Alberto Caranti
- ENT and Audiology Department, University of Ferrara, 44121 Ferrara, Italy; (A.C.); (C.V.)
| | - Claudio Vicini
- ENT and Audiology Department, University of Ferrara, 44121 Ferrara, Italy; (A.C.); (C.V.)
| | - Antonino Maniaci
- Faculty of Medicine and Surgery, University of Enna Kore, 94100 Enna, Italy; (S.L.); (C.G.)
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Qiao Y, Guo J, Luo J, Huang R, Wang X, Su L, Xia W, Xiao Y. Early bone loss in patients with obstructive sleep apnea: a cross-sectional study. BMC Pulm Med 2024; 24:28. [PMID: 38200497 PMCID: PMC10782667 DOI: 10.1186/s12890-024-02848-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/04/2024] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) and osteoporosis are both prevalent diseases with shared pathophysiological mechanisms and risk factors. However, the association between the two diseases is seldom studied. This study aimed to identify the link between OSA and bone metabolism. METHODS Male participants aged 30-59-years who visited the sleep clinic were continuously recruited. Polysomnography was used to evaluate sleep and respiratory conditions. Blood samples were collected to detect metabolic, inflammatory and bone turnover indicators. High-resolution peripheral quantitative computer tomography was used to measure the non-dominant lateral radius and tibia. RESULTS Ninety subjects were recruited. The cortical area (Ct.Ar) of tibia of the severe OSA group was significantly higher than that of the mild and moderate OSA groups (P = 0.06 and P = 0.048). There were significant differences between the four groups in terms of total volumetric bone mineral density (vBMD) (F = 2.990, P = 0.035), meta trabecular vBMD (F = 3.696, P = 0.015), trabecular thickness (Tb.Th) (F = 7.060, P = 0.000) and cortical thickness (Ct.Th) (F = 4.959, P = 0.003). The mean values of the OSA groups were lower than control group. Hypopnea index and percentage of total sleep time with SpO2 < 90% were both positively correlated with alkaline phosphatase (R = 0.213, P = 0.044; R = 0.212, P = 0.045). Sleep efficiency was correlated with multiple indicators of the radius. CONCLUSIONS In non-elderly male populations, OSA patients tended to have lower vBMD, Tb.Th and Ct.Th than non-OSA patients. The negative effect of OSA may mainly affect the osteogenesis process, and is presumed to be related to sleep-related hypoxemia and sleep efficiency.
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Affiliation(s)
- Yixian Qiao
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, China
| | - Junwei Guo
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jinmei Luo
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Rong Huang
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Xiaona Wang
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Linfan Su
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Weibo Xia
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Yi Xiao
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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Wang XY, Wang XY, Liao ZX, Zhao YA, Wei C, Gong LJ. Association between obstructive sleep apnea and low bone mass in adults: a systematic review and meta-analysis. Sleep Biol Rhythms 2024; 22:65-73. [PMID: 38476856 PMCID: PMC10899924 DOI: 10.1007/s41105-023-00481-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/30/2023] [Indexed: 03/14/2024]
Abstract
Introduction This study aimed to synthesize existing evidence on the potential association between obstructive sleep apnea (OSA) and low bone mass in adults. Methods Electronic searches of four main databases were performed. The inclusion criteria consisted of observational studies investigating the relationship between OSA and bone mass, osteoporosis, fractures, or bone metabolism markers in adult population. Bone mineral density (BMD) and T score of lumbar and femur neck, incidence of osteoporosis and fractures, bone metabolism marker levels were extracted as primary outcomes. Results Among the 693 relevant publications, 10 studies consisting of 158,427 participants met with the inclusion and exclusion criteria. Meta-analysis showed a significant lower BMD of lumbar (mean difference (MD) = - 0.03; 95% CI - 0.05, - 0.01; I2 = 46%), femur neck (MD = - 0.06; 95% CI - 0.12, 0.00; I2 = 71%), and a significant lower T score of lumbar (MD = - 0.42; 95% CI - 0.79, - 0.05; I2 = 63%) in the OSA group. The results suggested that both male (odds ratio (OR) = 2.03; 95% CI 1.23, 3.35; I2 = 38%) and female (OR = 2.56; 95% CI 1.96, 3.34; I2 = 0%) had higher risk of osteoporosis in the OSA group. Besides, meta-analysis also showed that bone-specific alkaline phosphatase was significantly lower in OSA patients (MD = - 1.90; 95% CI - 3.48, - 0.32; I2 = 48%). Conclusions A potential association between OSA and lower bone mass in adults is preliminarily proved. It also seems plausible that both male and female with OSA have a higher risk of osteoporosis. Supplementary Information The online version contains supplementary material available at 10.1007/s41105-023-00481-1.
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Affiliation(s)
- Xin-Yuan Wang
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 Sichuan China
| | - Xin-Yu Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 Sichuan China
| | - Zhi-Xin Liao
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 Sichuan China
| | - Yue-An Zhao
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 Sichuan China
| | - Chang Wei
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 Sichuan China
| | - Lin-Jing Gong
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 Sichuan China
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Lv R, Liu X, Zhang Y, Dong N, Wang X, He Y, Yue H, Yin Q. Pathophysiological mechanisms and therapeutic approaches in obstructive sleep apnea syndrome. Signal Transduct Target Ther 2023; 8:218. [PMID: 37230968 DOI: 10.1038/s41392-023-01496-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/27/2023] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is a common breathing disorder in sleep in which the airways narrow or collapse during sleep, causing obstructive sleep apnea. The prevalence of OSAS continues to rise worldwide, particularly in middle-aged and elderly individuals. The mechanism of upper airway collapse is incompletely understood but is associated with several factors, including obesity, craniofacial changes, altered muscle function in the upper airway, pharyngeal neuropathy, and fluid shifts to the neck. The main characteristics of OSAS are recurrent pauses in respiration, which lead to intermittent hypoxia (IH) and hypercapnia, accompanied by blood oxygen desaturation and arousal during sleep, which sharply increases the risk of several diseases. This paper first briefly describes the epidemiology, incidence, and pathophysiological mechanisms of OSAS. Next, the alterations in relevant signaling pathways induced by IH are systematically reviewed and discussed. For example, IH can induce gut microbiota (GM) dysbiosis, impair the intestinal barrier, and alter intestinal metabolites. These mechanisms ultimately lead to secondary oxidative stress, systemic inflammation, and sympathetic activation. We then summarize the effects of IH on disease pathogenesis, including cardiocerebrovascular disorders, neurological disorders, metabolic diseases, cancer, reproductive disorders, and COVID-19. Finally, different therapeutic strategies for OSAS caused by different causes are proposed. Multidisciplinary approaches and shared decision-making are necessary for the successful treatment of OSAS in the future, but more randomized controlled trials are needed for further evaluation to define what treatments are best for specific OSAS patients.
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Affiliation(s)
- Renjun Lv
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xueying Liu
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
| | - Yue Zhang
- Department of Geriatrics, the 2nd Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Na Dong
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xiao Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Yao He
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Hongmei Yue
- Department of Pulmonary and Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, 730000, China.
| | - Qingqing Yin
- Department of Geriatric Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
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Zhao JM, Wang BY, Huang JF, Xie HS, Chen ML, Chen GP. Assessment of bone mineral density and bone metabolism in young men with obstructive sleep apnea: a cross-sectional study. BMC Musculoskelet Disord 2022; 23:682. [PMID: 35842641 PMCID: PMC9287988 DOI: 10.1186/s12891-022-05644-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypoxia in obstructive sleep apnea (OSA) patients during sleep may have an effect on bone metabolism. Few data regarding evaluation of bone metabolism in young individuals diagnosed with OSA. In this study, we aim to identify the association between bone mineral density and OSA in young men (≤ 40 years old of age). METHODS Consecutive male subjects who underwent polysomnography were enrolled. Serum calcium, 25-hydroxyvitamin-D3, β-isomerized form C-terminal telopeptide of type I collagen, osteocalcin and procollagen type 1 N-propeptide were measured in all participants, and bone mineral density (BMD) at lumbar spine (L1-L4), femoral neck and hip total were determined by dual energy X-ray absorption (DXA). RESULTS The population consisted of 85 subjects (mean age 35.53 years). The BMD at lumbar spine (L1-L4) in moderate OSA patients was higher than control and severe OSA group significantly (p = 0.036). After adjustment for confounding factors, stepwise multiple linear regression analyses showed LaSO2 (β = 0.340, p = 0.008) as an independent explanatory variable for Lumbar L1-L4 BMD, LaSO2 (β = 0.304, p = 0.037), BMI (β = 0.393, p = 0.008) for femur neck BMD and BMI (β = 0.720, p = 0.002) for hip total BMD. CONCLUSIONS Our finding indicated that there was a relationship between OSA and bone metabolism in younger men, and moderate OSA-related hypoxia positively related with BMD. This study also showed that different degrees of recurrent hypoxia had different effects on bone metabolism, a finding that required further investigation.
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Affiliation(s)
- Jian-Ming Zhao
- Department of Respiratory and Critical Care Medicine, Fujian Province, the First Affiliated Hospital of Fujian Medical University, NO 20, Chazhong road, Taijiang district, Fuzhou, 350005, People's Republic of China.,Fujian Provincial Sleep-Disordered Breathing Clinic Center, Fujian, China.,Institute of Respiratory Disease, Fujian Medical University, Fujian, China
| | - Bi-Ying Wang
- Department of Respiratory and Critical Care Medicine, Fujian Province, the First Affiliated Hospital of Fujian Medical University, NO 20, Chazhong road, Taijiang district, Fuzhou, 350005, People's Republic of China.,Fujian Provincial Sleep-Disordered Breathing Clinic Center, Fujian, China.,Institute of Respiratory Disease, Fujian Medical University, Fujian, China
| | - Jie-Feng Huang
- Department of Respiratory and Critical Care Medicine, Fujian Province, the First Affiliated Hospital of Fujian Medical University, NO 20, Chazhong road, Taijiang district, Fuzhou, 350005, People's Republic of China.,Fujian Provincial Sleep-Disordered Breathing Clinic Center, Fujian, China.,Institute of Respiratory Disease, Fujian Medical University, Fujian, China
| | - Han-Sheng Xie
- Department of Respiratory and Critical Care Medicine, Fujian Province, the First Affiliated Hospital of Fujian Medical University, NO 20, Chazhong road, Taijiang district, Fuzhou, 350005, People's Republic of China.,Fujian Provincial Sleep-Disordered Breathing Clinic Center, Fujian, China.,Institute of Respiratory Disease, Fujian Medical University, Fujian, China
| | - Meng-Lan Chen
- Department of Respiratory and Critical Care Medicine, Fujian Province, the First Affiliated Hospital of Fujian Medical University, NO 20, Chazhong road, Taijiang district, Fuzhou, 350005, People's Republic of China.,Fujian Provincial Sleep-Disordered Breathing Clinic Center, Fujian, China.,Institute of Respiratory Disease, Fujian Medical University, Fujian, China
| | - Gong-Ping Chen
- Department of Respiratory and Critical Care Medicine, Fujian Province, the First Affiliated Hospital of Fujian Medical University, NO 20, Chazhong road, Taijiang district, Fuzhou, 350005, People's Republic of China. .,Fujian Provincial Sleep-Disordered Breathing Clinic Center, Fujian, China. .,Institute of Respiratory Disease, Fujian Medical University, Fujian, China.
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Najafi A, Mohammadi I, Sadeghi M, Brühl AB, Sadeghi-Bahmani D, Brand S. Evaluation of Plasma/Serum Adiponectin (an Anti-Inflammatory Factor) Levels in Adult Patients with Obstructive Sleep Apnea Syndrome: A Systematic Review and Meta-Analysis. Life (Basel) 2022; 12:life12050738. [PMID: 35629405 PMCID: PMC9145771 DOI: 10.3390/life12050738] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/04/2022] [Accepted: 05/10/2022] [Indexed: 12/31/2022] Open
Abstract
Background and objective: A variety of diseases, including obesity, type ‖ diabetes, and cardiovascular diseases are associated with obstructive sleep apnea syndrome (OSAS), and decreased adiponectin levels have been shown to be associated with an increased risk of these diseases. However, the association of blood levels of adiponectin in OSAS patients is a challenging and unknown issue with conflicting results. Therefore, we performed a systematic review and a meta-analysis to evaluate plasma/serum adiponectin levels in adult patients with OSAS. Materials and methods: A comprehensive search in four databases (PubMed/Medline, Web of Science, Scopus, and Cochrane Library) was performed in literature dated older than 12 March 2022, to retrieve the relevant articles. Effect sizes were calculated to show the standardized mean difference (SMD) along with a 95% confidence interval (CI) of plasma/serum of adiponectin between the OSAS patients and controls. The software RevMan 5.3, NCSS 21.0.2, CMA 2.0, trial sequential analysis (TSA) 0.9.5.10 beta, and GetData Graph Digitizer 2.26 were used for data synthesis in the meta-analysis. Results: A total of 28 articles including 36 studies were entered into the meta-analysis. The results showed that pooled SMD was −0.71 (95% CI: −0.92, 0.50; p < 0.00001; I2 = 79%) for plasma/serum levels of adiponectin in OSAS cases compared to the controls. The subgroup analyses showed that the geographical region and the Apnea-Hypopnea-Index (AHI) could be confounding factors in the pooled analysis of plasma/serum adiponectin levels. The sensitivity analysis showed the stability of the results. The radial and L’Abbé plots confirmed evidence of heterogeneity. Trial sequential analysis showed sufficient cases in the meta-analysis. Conclusions: With sufficient cases and stable results, the main finding of the meta-analysis identified significantly reduced plasma/serum levels of adiponectin in OSAS cases compared with the controls. This result suggests a potential role of adiponectin in the pathogenesis of OSAS.
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Affiliation(s)
- Amir Najafi
- Oral and Maxillofacial Surgery Department, School of Dentistry, Isfahan University of Medical Sciences, Isfahan 8174673461, Iran; (A.N.); (I.M.)
| | - Iman Mohammadi
- Oral and Maxillofacial Surgery Department, School of Dentistry, Isfahan University of Medical Sciences, Isfahan 8174673461, Iran; (A.N.); (I.M.)
| | - Masoud Sadeghi
- Department of Biology, Science and Research Branch, Islamic Azad University, Tehran 1477893855, Iran;
| | - Annette Beatrix Brühl
- Center for Affective, Stress and Sleep Disorders, University of Basel, Psychiatric Clinics, 4001 Basel, Switzerland; (A.B.B.); (D.S.-B.)
| | - Dena Sadeghi-Bahmani
- Center for Affective, Stress and Sleep Disorders, University of Basel, Psychiatric Clinics, 4001 Basel, Switzerland; (A.B.B.); (D.S.-B.)
- Department of Psychology, Stanford University, Stanford, CA 94305, USA
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah 6719851115, Iran
| | - Serge Brand
- Center for Affective, Stress and Sleep Disorders, University of Basel, Psychiatric Clinics, 4001 Basel, Switzerland; (A.B.B.); (D.S.-B.)
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah 6719851115, Iran
- Substance Abuse Prevention Research Center, Kermanshah University of Medical Sciences, Kermanshah 6715847141, Iran
- Department of Sport, Exercise and Health, Division of Sport Science and Psychosocial Health, University of Basel, 4052 Basel, Switzerland
- School of Medicine, Tehran University of Medical Sciences, Tehran 1416753955, Iran
- Correspondence:
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Wang C, Zhang Z, Zheng Z, Chen X, Zhang Y, Li C, Chen H, Liao H, Zhu J, Lin J, Liang H, Yu Q, Chen R, Liang J. Relationship between obstructive sleep apnea-hypopnea syndrome and osteoporosis adults: A systematic review and meta-analysis. Front Endocrinol (Lausanne) 2022; 13:1013771. [PMID: 36465605 PMCID: PMC9712780 DOI: 10.3389/fendo.2022.1013771] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/26/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This study is undertaken to explore the relationship between obstructive sleep apnea-hypopnea syndrome (OSAHS) and osteoporosis, including the relationship between OSAHS and osteoporosis incidence, lumbar spine bone mineral density (BMD), and lumbar spine T-score. METHOD Cochrane Library, PubMed, Embase, Web of Science, and other databases are searched from their establishment to April 2022. Literature published in 4 databases on the correlation between OSAHS and osteoporosis,lumbar spine BMD,lumbar spine T-score is collected. Review Manager 5.4 software is used for meta-analysis. RESULTS A total of 15 articles are selected, including 113082 subjects. Compared with the control group, the OSAHS group has a higher incidence of osteoporosis (OR = 2.03, 95% CI: 1.26~3.27, Z = 2.90, P = 0.004), the lumbar spine BMD is significantly lower (MD = -0.05, 95% CI: -0.08~-0.02, Z = 3.07, P = 0.002), and the lumbar spine T-score is significantly decreased (MD = -0.47, 95% CI: -0.79~-0.14, Z = 2.83, P = 0. 005). CONCLUSION Compared with the control group, the OSAHS group has a higher incidence of osteoporosis and decreased lumbar spine BMD and T-score. In order to reduce the risk of osteoporosis, attention should be paid to the treatment and management of adult OSAHS, and active sleep intervention should be carried out.
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Affiliation(s)
- Chaoyu Wang
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
- Department of Pulmonary and Critical Care Medicine, Taishan Hospital of Traditional Chinese Medicine, Jiangmen, Guangdong, China
| | - Zhiping Zhang
- Department of Pulmonary and Critical Care Medicine, The People's Hospital of JiangMen (Jiangmen Hospital, Southern Medical University), Jiangmen, China
| | - Zhenzhen Zheng
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Xiaojuan Chen
- Medical College, Jiaying University, Meizhou, Guangdong, China
| | - Yu Zhang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Chunhe Li
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Huimin Chen
- Department of Traditional Chinese Medicine, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Huizhao Liao
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jinru Zhu
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Junyan Lin
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Hongwei Liang
- Department of Pulmonary and Critical Care Medicine, The People's Hospital of JiangMen (Jiangmen Hospital, Southern Medical University), Jiangmen, China
| | - Qiuying Yu
- Department of Pulmonary and Critical Care Medicine, Taishan Hospital of Traditional Chinese Medicine, Jiangmen, Guangdong, China
- *Correspondence: Qiuying Yu, ; Riken Chen, ; Jinhua Liang,
| | - Riken Chen
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
- *Correspondence: Qiuying Yu, ; Riken Chen, ; Jinhua Liang,
| | - Jinhua Liang
- Department of Endocrinology, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
- *Correspondence: Qiuying Yu, ; Riken Chen, ; Jinhua Liang,
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9
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Gender differences of clinical and polysomnographic findings with obstructive sleep apnea syndrome. Sci Rep 2021; 11:5938. [PMID: 33723369 PMCID: PMC7960714 DOI: 10.1038/s41598-021-85558-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 03/03/2021] [Indexed: 11/30/2022] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is underdiagnosed in females and gender differences in clinical and polysomnographic findings have not been widely investigated in China. We examined clinical and polysomnographic differences between males and females with OSAS in order to determine the influence of gender on clinical presentation and polysomnographic features. Data were collected from 303 adult patients diagnosed with OSAS (237 males and 66 females) from 2017 to 2019. All the patients completed physical examination, Epworth sleepiness scale, and whole night polysomnography. AVONA, univariate and multivariate logistic regression analyses were conducted to assess gender differences of clinical and polysomnographic findings with OSAS. P < 0.05 was statistically significant. The average age was 48.4 ± 12.6 years for females and 43.4 ± 12.4 years for males. Compared with female patients with OSAS, male patients were taller and heavier, had higher systolic blood pressure in the morning, shorter duration of slow wave sleep, more micro-arousal events, greater AHI, and more complex sleep apnea events. There are obvious gender differences of clinical and polysomnographic characteristics with OSAS. Understanding gender differences will contribute to better clinical recognition of OSAS in females as well as the provision of proper health care and therapeutic practice.
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10
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Obstructive sleep apnea syndrome and risk of renal impairment: a systematic review and meta-analysis with trial sequential analysis. Sleep Breath 2020; 25:17-27. [PMID: 32440991 PMCID: PMC7987709 DOI: 10.1007/s11325-020-02090-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 02/11/2020] [Accepted: 04/17/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Obstructive sleep apnea syndrome (OSAS) is associated with a variety of systemic diseases. Among patients with chronic kidney diseases (CKD), the prevalence of OSAS is high. OSAS can induce progression of CKD. However, whether or not OSAS can cause renal damage in healthy people is not clear. Thus, the purpose of this meta-analysis was to elucidate whether or not there was an association between OSAS and early renal damage. METHODS PubMed, Embase Database, Cochrane Library, Web of Science, China National Knowledge Infrastructure, China Biology Medicine Database, Chinese Scientific Journals Database, and Wanfang Database were searched systematically. The relative risk (RR), weighted mean difference (WMD), and 95% confidence intervals (CI) were used to evaluate the relationship between OSAS and early renal damage. Funnel plot and Egger's test were used to evaluate publication bias, and trial sequential analysis (TSA) was employed to verify the sufficiency of the research conclusions. RESULTS A total of 18 studies were analyzed comprising 4,567 participants. Compared with the healthy control group, levels of cystatin C (MD = 0.530, 95% CI 0.423, 0.637, P < 0.01) and proteinuria in patients with OSAS were significantly increased, while the levels of estimated glomerular filtration rate (eGFR) (MD = - 0.194, 95% CI - 0.268, - 0.121, P < 0.01) were significantly decreased. Furthermore, patients with OSAS also had an increased risk of CKD. Subgroup analysis showed that compared with patients without OSAS, the level of serum cystatin C in patients with OSAS was significantly increased independent of hypertension and diabetes, and the eGFR was significantly decreased in patients with moderate to severe OSAS and comorbid hypertension and/or diabetes. CONCLUSION In this meta-analysis, OSAS was associated with a higher risk of early renal damage. Patients with OSAS and comorbid hypertension and/or diabetes appear to suffer from severe renal damage.
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11
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Vilovic M, Dogas Z, Ticinovic Kurir T, Borovac JA, Supe-Domic D, Vilovic T, Ivkovic N, Rusic D, Novak A, Bozic J. Bone metabolism parameters and inactive matrix Gla protein in patients with obstructive sleep apnea†. Sleep 2020; 43:zsz243. [PMID: 31631227 DOI: 10.1093/sleep/zsz243] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 08/15/2019] [Indexed: 12/15/2022] Open
Abstract
STUDY OBJECTIVES The aim of this study was to investigate differences in dual-energy X-ray absorptiometry (DXA) parameters, trabecular bone score (TBS), bone turnover markers and inactive matrix Gla protein (dp-ucMGP) between patients with obstructive sleep apnea (OSA) and healthy controls. METHODS This study enrolled 53 male patients diagnosed with OSA, and 50 age- and body mass index (BMI)-matched control subjects. All participants underwent DXA imaging, TBS assessment and blood sampling for biochemical analysis of bone metabolism markers. RESULTS Mean apnea-hypopnea index (AHI) score of OSA patients was 43.8 ± 18.8 events/h. OSA patients had significantly higher plasma dp-ucMGP levels in comparison to controls (512.7 ± 71.9 vs. 465.8 ± 50.9 pmol/L, p < 0.001). OSA and control group did not significantly differ regarding standard DXA results, while TBS values were significantly lower in the OSA group (1.24 ± 0.17 vs. 1.36 ± 0.15, p < 0.001). AHI score was a significant independent correlate of plasma dp-ucMGP levels (β ± SE, 1.461 ± 0.45, p = 0.002). In addition, TBS retained a significant relationship with dp-ucMGP values (β ± SE, -93.77 ± 38.1, p = 0.001). CONCLUSIONS dp-ucMGP levels are significantly higher in patients with OSA and correlate with disease severity. In addition, TBS values in OSA patients are lower in comparison with the control group and decrease with disease severity.
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Affiliation(s)
- Marino Vilovic
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia
| | - Zoran Dogas
- Sleep Medicine Centre, University of Split School of Medicine, and University Hospital of Split, Split, Croatia
- Department of Neuroscience, University of Split School of Medicine, Split, Croatia
| | - Tina Ticinovic Kurir
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia
- Department of Endocrinology and Diabetology, University Hospital of Split, Split, Croatia
| | - Josip A Borovac
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia
| | - Daniela Supe-Domic
- Department of Medical Laboratory Diagnostics, University Hospital of Split, Split, Croatia
| | - Tina Vilovic
- Health Centre of Split-Dalmatia County, Split, Croatia
| | - Natalija Ivkovic
- Sleep Medicine Centre, University of Split School of Medicine, and University Hospital of Split, Split, Croatia
| | - Doris Rusic
- Department of Pharmacy, University of Split School of Medicine, Split, Croatia
| | - Anela Novak
- Department of Endocrinology and Diabetology, University Hospital of Split, Split, Croatia
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia
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12
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Lu M, Fang F, Wang Z, Wei P, Hu C, Wei Y. Association between serum/plasma levels of adiponectin and obstructive sleep apnea hypopnea syndrome: a meta-analysis. Lipids Health Dis 2019; 18:30. [PMID: 30684961 PMCID: PMC6347767 DOI: 10.1186/s12944-019-0973-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 01/14/2019] [Indexed: 02/01/2023] Open
Abstract
Background The relationship between obstructive sleep apnea hypopnea syndrome (OSAHS) and a variety of disease from obesity, type 2 diabetes mellitus and cardiovascular disease has been investigated previously. Reduced adiponectin levels are also associated with increased risk of these disease. However, whether serum/plasma adiponectin levels in OSAHS patients are lower than their counterparts remain controversial. Therefore, this study evaluated the association between serum/plasma adiponectin levels and OSAHS. Methods We performed a comprehensive literature search to locate eligible articles published on electronic databases including PubMed, EMBASE, Cochrane Library, WANFANG (Chinese database), VIP (Chinese Database) and Chinese National Knowledge Infrastructure (CNKI). The methodological quality of included studies was evaluated using the Newcastle-Ottawa scale (NOS). Pooled standard mean difference (SMD) with 95% confidence interval (CI) was calculated as effect size. Heterogeneity test was performed by Cochrane Q test and I2 test. Subgroup analysis and meta-regression analysis were employed to detect the sources of the heterogeneity. RevMan 5.3 and Stata 12.0 software were used in this meta-analysis for data synthesis. Results A total of 20 eligible studies with 28 databases involving 1356 participants were included in this meta-analysis. Results revealed that serum/plasma adiponectin levels in OSAHS patients were significantly lower than that in controls [SMD = − 0.71, 95% CI = − 0.92 to − 0.49, p < 0.001]. Subgroup analysis indicated that the heterogeneity would decreased when subgroup analysis was stratified by race. In addition, meta-regression analysis also suggested that the adiponectin levels were only significantly correlated with race. The removal of any independent study did not affect the pooled SMD in the sensitivity analysis. Conclusion The serum/plasma adiponectin levels were significantly lower in OSAHS patients than that in control subjects, suggesting a possible role of adiponectin in OSAHS pathogenesis, deserves further studies as a potential marker of OSAHS.
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Affiliation(s)
- Mi Lu
- The Key Laboratory of Upper Airway Dysfunction-Related Cardiovascular Diseases, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No. 2 Anzhen Road, Beijing, 100029, China.,Department of Sleep Medical Center, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China.,Department of Otolaryngology Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No. 2 Anzhen Road, Beijing, 100029, China
| | - Fang Fang
- The Key Laboratory of Upper Airway Dysfunction-Related Cardiovascular Diseases, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No. 2 Anzhen Road, Beijing, 100029, China.,Department of Sleep Medical Center, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China.,Department of Otolaryngology Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No. 2 Anzhen Road, Beijing, 100029, China
| | - Zhenjia Wang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China
| | - Peng Wei
- Department of Sleep Medical Center, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China
| | - Chunhua Hu
- Department of Otolaryngology Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No. 2 Anzhen Road, Beijing, 100029, China
| | - Yongxiang Wei
- The Key Laboratory of Upper Airway Dysfunction-Related Cardiovascular Diseases, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No. 2 Anzhen Road, Beijing, 100029, China. .,Department of Sleep Medical Center, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Beijing, 100029, China. .,Department of Otolaryngology Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No. 2 Anzhen Road, Beijing, 100029, China.
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13
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Li M, Li X, Lu Y. Obstructive Sleep Apnea Syndrome and Metabolic Diseases. Endocrinology 2018; 159:2670-2675. [PMID: 29788220 DOI: 10.1210/en.2018-00248] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 05/14/2018] [Indexed: 12/24/2022]
Abstract
With the rapid changes in lifestyle in modern society, including the high nutritional intake and reduced physical activity, the incidence of metabolic diseases has been increasing year by year. Obstructive sleep apnea syndrome (OSAS) is a sleep disorder, usually characterized by sudden pauses of breathing during sleep and an interrupted sleep rhythm. Although the pathological mechanism remains poorly understood, it has been strongly associated with metabolic diseases, including obesity, insulin resistance, type 2 diabetes mellitus (T2DM), and nonalcoholic fatty liver disease (NAFLD). In the present mini-review, we briefly summarize the connections between OSAS, obesity, T2DM, and NAFLD, which might help us to better understand the pathogenesis of human diseases.
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Affiliation(s)
- Min Li
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Xiaoying Li
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Yan Lu
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
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14
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Abdel-Fadeil MR, Abedelhaffez AS, Makhlouf HA, Al Qirshi GA. Obstructive sleep apnea: Influence of hypertension on adiponectin, inflammatory markers and dyslipidemia. ACTA ACUST UNITED AC 2017; 24:305-315. [PMID: 28890147 DOI: 10.1016/j.pathophys.2017.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 08/11/2017] [Accepted: 08/22/2017] [Indexed: 12/14/2022]
Abstract
Obstructive sleep apnea (OSA) is a common but often unrecognized condition with potentially serious complications. The aim of this study was to explore the possible mechanisms linking hypertension (HT), a common cardiovascular disease (CVD), with obstructive sleep apnea (OSA) by investigating the levels of morning and evening serum adiponectin, inflammatory markers (TNF-α, IL-6), and lipid profiles in OSA patients with and without HT. Four groups were enrolled in this case-control analytic study: control, OSA, OSA+HT, and HT groups, each of which included 22 subjects. The results revealed low morning and evening serum adiponectin levels in patients with OSA and OSA+HT compared with their control and HT counterparts. Serum adiponectin levels declined progressively with increasing severity of OSA. Also, morning adiponectin levels were significantly decreased at the same time that a loss of the normal diurnal rhythm was observed in the OSA and OSA+HT groups. Both TNF-α and IL-6 levels were significantly increased in the OSA and OSA+HT groups compared with levels in the control and HT groups. Altered lipid profiles was noticed in the same groups. These findings were more pronounced in the OSA+HT than in the OSA group. In conclusion, the biochemical findings of this study demonstrate predominantly low adiponectin levels, increased levels of inflammatory markers, and atherogenic lipid profiles in OSA patients with HT compared with those of the other patients studied. This highlights the possible contributing role of these factors to the pathogenesis of HT as a common cardiovascular complication in OSA patients.
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Affiliation(s)
- Mahmoud R Abdel-Fadeil
- Department of Medical physiology, Faculty of Medicine, Assiut University, P.O. Box No. 71526, Assiut, Egypt.
| | - Azza S Abedelhaffez
- Department of Medical physiology, Faculty of Medicine, Assiut University, P.O. Box No. 71526, Assiut, Egypt.
| | - Hoda A Makhlouf
- Department of Chest Diseases and TB, Faculty of Medicine, Assiut University, P.O. Box No. 71526, Assiut, Egypt.
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