The effectiveness of an obstructive sleep apnea screening and treatment program in patients with type 2 diabetes

Effects of Positive Airway Pressure Therapy on Glycemic Variability in Patients With Type 2 Diabetes and OSA: A Randomized Controlled Trial

BACKGROUND

Glycemic variability is associated with increased risk for cardiovascular disease in patients with type 2 diabetes independent of glycosylated hemoglobin A1c (HbA1c) levels. Given the conflicting evidence on the effect of positive airway pressure (PAP) therapy for OSA on HbA1c, elucidating its effect on glycemic variability has value.

RESEARCH QUESTION

Does the use of PAP therapy for OSA improve glycemic variability in patients with type 2 diabetes?

STUDY DESIGN AND METHODS

A randomized controlled trial was conducted in 184 patients with type 2 diabetes and moderate-to-severe OSA. Participants received either 3 months of PAP therapy with lifestyle counseling or lifestyle counseling alone. End points included the SD of glucose levels along with other metrics derived from continuous glucose monitoring and self-monitoring of blood glucose.

RESULTS

No differences were noted in either primary or secondary continuous glucose monitoring end points between the two groups. Average use of PAP therapy was 5.4 h/night (SD, 1.6). Exploratory analyses by sex showed significant differences in the primary and secondary outcomes. In female participants, PAP therapy was associated with improvement in the SD of glucose levels, with a mean difference in change between intervention and control groups of 3.5 mg/dL (P = .02). PAP therapy was also associated with lower post-dinner and bedtime glucose levels: 20.1 mg/dL (P < .01) and 34.6 mg/dL (P < .01), respectively.

INTERPRETATION

PAP therapy did not improve glycemic control or variability in patients with moderate-to-severe OSA and type 2 diabetes. Exploratory analyses suggested that PAP therapy may improve glucose variability in female participants. Post-dinner and bedtime glucose levels were higher in those who did not receive PAP therapy.

TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT02454153; URL: www.

CLINICALTRIALS

gov.

Obstructive sleep apnea and its management in patients with atrial fibrillation: An International Collaboration of Sleep Apnea Cardiovascular Trialists (INCOSACT) global survey of practicing cardiologists

Background

Among international cardiologists it is unclear whether equipoise exists regarding the benefit of diagnosing and managing obstructive sleep apnea (OSA) to improve atrial fibrillation (AF) outcomes and whether clinical practice and equipoise are linked.

Methods

Between January 2019 and June 2020 we distributed a web-based 12-question survey regarding OSA and AF management to practicing cardiologists in 16 countries.

Results

The United States, Japan, Sweden, and Turkey accounted for two-thirds of responses. 863 cardiologists responded; half were general cardiologists, a quarter electrophysiologists. Responses regarding treating OSA with CPAP to improve AF endpoints were mixed. 33% of respondents referred AF patients for OSA screening. OSA was diagnosed in 48% of referred patients and continuous positive airway pressure (CPAP) was prescribed for 59% of them. Nearly 70% of respondents believed randomized controlled trials (RCTs) of OSA treatment in AF patients were necessary and indicated willingness to contribute to such trials.

Conclusions

There was no clinical equipoise among surveyed cardiologists; a majority expressed certainty that combined OSA and AF treatment is superior to AF treatment alone for improving AF outcomes. However, a minority of surveyed cardiologists referred AF patients for OSA testing, and while half of screened AF patients had OSA, CPAP was prescribed in little more than half of them, reflecting the view that better clinical trial evidence is needed to support this practice. Our results underscore the need for larger, multi-national prospective studies of OSA treatment and AF outcomes to inform more uniform society guideline recommendations.

The prevalence of obstructive sleep apnea in patients with type 2 diabetes: a systematic review and meta-analysis

Background

Obstructive Sleep Apnea (OSA) is one of the diseases related to diabetes. Considering the varying prevalence of OSA in patients with type 2 diabetes in different parts of the world, in order to aggregate the results and come to a general review about the topic mentioned, the current study performed a systematic review and meta-analysis of OSA in patients with type 2 diabetes.

Methods

In this study, the international databases (PubMed, Scopus, Web of science, and Cochran library) were searched without time limit using keywords diabetes, obstructive sleep apnea, and prevalence or epidemiology. Homogeneity was investigated among studies using Cochran Q test and I2 index. Given the heterogeneity of studies, random effect model was used to estimate the prevalence of OSA. Meta-regression was used to investigate the effect of quantitative variables on the prevalence of OSA. Comprehensive Meta-analysis (CMA) software was used for data analysis.

Results

Twenty studies were included in the meta-analysis. In these 19 studies, the total number of patients with type 2 diabetes was 10,754, with a mean age of 58.6 ± 4.1 years. Final estimation of OSA prevalence was calculated to be 56.0%. The results of meta-regression showed the prevalence of OSA increased with a rise in the mean age, the percentage of male sex, body mass index, and sample size.

Conclusion

Given the high prevalence of OSA in patients with type 2 diabetes, weight control can partly mitigate their problems and possibly reduce OSA prevalence.

Diagnosis of Obstructive Sleep Apnea in Patients with Associated Comorbidity

Obstructive sleep apnea (OSA) is a heterogeneous disease with many physiological implications. OSA is associated with a great diversity of diseases, with which it shares common and very often bidirectional pathophysiological mechanisms, leading to significantly negative implications on morbidity and mortality. In these patients, underdiagnosis of OSA is high. Concerning cardiorespiratory comorbidities, several studies have assessed the usefulness of simplified screening tests for OSA in patients with hypertension, COPD, heart failure, atrial fibrillation, stroke, morbid obesity, and in hospitalized elders.The key question is whether there is any benefit in the screening for the existence of OSA in patients with comorbidities. In this regard, there are few studies evaluating the performance of the various diagnostic procedures in patients at high risk for OSA. The purpose of this chapter is to review the existing literature about diagnosis in those diseases with a high risk for OSA, with special reference to artificial intelligence-related methods.

Validation of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnoea in patients with cardiovascular risk factors: a systematic review and meta-analysis

Introduction

Obstructive sleep apnoea (OSA) is highly prevalent in patients with cardiovascular risk factors and is associated with increased morbidity and mortality. This review presents the predictive parameters of the STOP-Bang questionnaire as a screening tool for OSA in this population.

Methods

A search of databases was performed. The inclusion criteria were: (1) use of the STOP-Bang questionnaire to screen for OSA in adults (>18 years) with cardiovascular risk factors; (2) polysomnography or home sleep apnoea testing performed as a reference standard; (3) OSA defined by either Apnoea–Hypopnoea Index (AHI) or Respiratory Disturbance Index; and (4) data on predictive parameters of the STOP-Bang questionnaire. A random-effects model was used to obtain pooled predictive parameters of the STOP-Bang questionnaire.

Results

The literature search resulted in 3888 articles, of which 9 papers met the inclusion criteria, involving 1894 patients. The average age of the included patients was 58±13 years with body mass index (BMI) of 30±6 kg/m², and 64% were male. The STOP-Bang questionnaire has a sensitivity of 89.1%, 90.7% and 93.9% to screen for all (AHI ≥5), moderate-to-severe (AHI ≥15) and severe (AHI≥30) OSA, respectively. The specificity was 32.3%, 22.5% and 18.3% and the area under the curve (AUC) was 0.86, 0.65 and 0.52 for all, moderate-to-severe and severe OSA, respectively.

Conclusion

The STOP-Bang questionnaire is an effective tool to screen for OSA (AHI≥5) with AUC of 0.86 in patients with cardiovascular risk factors.

Effect of Glucose Improvement on Nocturnal Sleep Breathing Parameters in Patients with Type 2 Diabetes: The Candy Dreams Study

Type 2 diabetes exerts a negative impact on sleep breathing. It is unknown whether a long-term improvement in glycemic control ameliorates this effect. We conducted an interventional study with 35 patients with type 2 diabetes and obstructive sleep apnea (OSA) to explore this. At home, sleep breathing parameters were assessed at baseline and after a 4-month period in which antidiabetic therapy was intensified. Patients who decreased their body mass index ≥2kg/m² were excluded. Those with an HbA1c reduction ≥0.5% were considered good responders (n = 24). After the follow-up, good responders exhibited an improvement in the apnea–hypopnea index (AHI: 26-1 (95% IC: 8.6–95.0) vs. 20.0 (4.0–62.4) events/hour, p = 0.002) and in time with oxygen saturation below 90% (CT90: 13.3 (0.4–69.0) vs. 8.1 (0.4–71.2) %, p = 0.002). No changes were observed in the group of non–responders (p = 0.722 and p = 0.138, respectively). The percentage of moderate and severe OSA decreased among good responders (p = 0.040). In the wider population, the change in HbA1c correlated positively to decreases in AHI (r = 0.358, p = 0.035) and negatively to increases in the minimum arterial oxygen saturation (r = −0.386, p = 0.039). Stepwise multivariate regression analysis showed that baseline AHI and the absolute change in HbA1c independently predicted decreased AHI (R² = 0.496). The improvement of glycemic control exerts beneficial effects on sleep breathing parameters in type 2 diabetes, which cannot be attributed merely to weight loss.

A sleep hygiene and yoga intervention conducted in affordable housing communities: Pilot study results and lessons for a future trial

BACKGROUND

and purpose: Inadequate sleep is highly prevalent among socioeconomically disadvantaged and racial/ethnic minority communities and is often related to maladaptive sleep behaviors and stress. There is scant research investigating the delivery of these interventions in underserved communities. The purpose of this study was to develop and test the feasibility and acceptability of a sleep education and yoga intervention for socioeconomically disadvantaged and racial/ethnic diverse adults.

MATERIALS AND METHODS

We present quantitative and qualitative data from a single-arm sleep education and yoga pilot study (n = 17) conducted in two affordable housing communities, and the multi-modal process we employed to refine the intervention for a future trial.

RESULTS

Participants were age 43.6 years on average (±19.3 years) and 88.2% were female. Nearly 56% identified as non-Hispanic Black and 19% as Hispanic/Latino. Results showed significant pre/post-intervention improvements in sleep duration (5.4 ± 1.2 h/night vs 6.9 ± 1.7 h/night; p < 0.01), sleep-related impairment (-8.15; p < 0.01), sleep disturbance (-5.95; p < 0.01), and sleep hygiene behaviors (-5.50; p < 0.01).

CONCLUSION

This study indicates intervention acceptability and improvements in sleep and sleep hygiene. Future randomized controlled trials are needed to assess efficacy.

Sleep disturbance and sleep-related impairment in psychotic disorders are related to both positive and negative symptoms

A large literature indicates that sleep disturbances are associated with paranoia and other positive symptoms in psychotic disorders. However, few studies have examined the potential association between sleep disturbances and negative symptoms and the results have been inconsistent. The current study examined the hypothesis that sleep problems would be associated with more severe positive and negative symptoms in a transdiagnostic sample of individuals with psychosis (N = 90). Further, we examined whether sleep would be related to negative symptoms above and beyond the contribution of paranoia, other positive symptoms, and depression-anxiety. Results replicated prior research in finding that both sleep disturbance and sleep-related impairment were related to more severe paranoia, other positive symptoms and depression-anxiety. Consistent with our hypothesis, more severe sleep disturbance and sleep-related impairment were related to greater negative symptoms; this was evident across both motivation-pleasure deficits and diminished expression. Sleep variables remained significantly related to motivation-pleasure deficits even after controlling for other non-negative symptoms. These results indicate the broad symptom impact of sleep disturbances and may suggest a novel treatment target to improve negative symptoms.

Sleep Problems and Social Impairment in Psychosis: A Transdiagnostic Study Examining Multiple Social Domains

Psychotic disorders are characterized by profound social impairment. An accumulation of research has explored the contribution of symptoms, cognitive functioning, and behavioral skills deficits to this social dysfunction. Recent research indicates that sleep disturbance has significant social implications in nonclinical populations-this research suggests that sleep problems may also be relevant to understanding social impairment in psychosis. This study adopted a symptom-oriented dimensional approach to examine how sleep disturbance and sleep-related impairment are related to multiple social domains within a transdiagnostic sample (N = 90). This sample included individuals with a variety of psychotic disorders (n = 75) along with healthy non-clinical participants (n = 15) to ensure sampling across the full range of sleep problems and social functioning. Social domains spanned self-reported perceptions of social relationships, social functioning in the community, and behavioral assessments of social competence. We hypothesized that greater sleep disturbance and sleep-related impairment would be associated with more negative or problematic perceptions of social relationships (i.e., less social support, less companionship, and greater distress), poorer social functioning in the community, smaller social networks, and poorer behavioral ratings of social competency. Results supported these hypotheses indicating that sleep disturbance and sleep-related impairment have widespread deleterious impacts on perceptions of social relationships, social functioning, and competence. Sleep disturbance retained associations with perceptions of social relationships, social functioning, and social competence even after controlling for total symptoms or cognitive functioning. These findings indicate that sleep problems may have important implications for fully understanding the causes of social impairment in psychosis.

Responsiveness of Patient-Reported Outcomes to Treatment Among Patients With Type 2 Diabetes Mellitus and OSA

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) includes two instruments to quantify sleep symptoms (sleep disturbance [SDA] and sleep-related impairment [SRI]) in diverse populations across a wide symptom spectrum. However, the responsiveness of PROMIS measures to treatment of sleep disorders is unknown. We examined the responsiveness of the PROMIS sleep scales to the treatment of OSA.

METHODS

We collected SDA, SRI, and Epworth Sleepiness Scale (ESS) before and after initiation of positive airway pressure (PAP) in patients with type 2 diabetes newly diagnosed with OSA. To compare responsiveness, we compared effect sizes and classifications of symptom improvement using both the reliable change method and thresholds of minimum important difference (MID).

RESULTS

A total of 103 patients completed assessments pre- and post-PAP. SDA, SRI, and ESS scores all declined significantly with PAP therapy. We observed the largest effect size for SDA (-0.64; 95% CI, -0.86 to -0.42), followed by SRI (-0.43; 95% CI, -0.63 to -0.23), and ESS (-0.28; 95% CI, -0.42 to -0.15). More patients experienced the reliable change category of symptom remission categorized by the PROMIS measures (SDA: 23.3%; SRI: 31.1%) relative to the ESS (5.8%) (P < .001 for both). Using the MID, SDA and SRI also classified more patients as improved (SDA: 54.4%; SRI: 49.5%) relative to the ESS (35.0%) (P < .001 for both pairwise comparisons).

CONCLUSIONS

PROMIS sleep measures were more likely than the ESS to detect an improvement with PAP therapy. Incorporating PROMIS measures into research and clinical care may provide a more sensitive assessment of symptomatic response to OSA treatment.

Factors influencing breath analysis results in patients with diabetes mellitus

Breath analysis is used to detect the composition of exhaled gas. As a quick and non-invasive detection method, breath analysis provides deep insights into the progression of various kinds of diseases, especially those with metabolism disorders. Abundant information on volatile compounds in diabetic patients has been studied in numerous articles in the literature. However, exhaled gas in diabetic patients can be altered by various complications. So far, little attention has been paid to this alteration. In our paper, we found that under air pollution conditions, diabetic patients exhale more nitric oxide. Diabetic patients with heart failure exhale more acetone than those without heart failure. After ¹³C-labeled glucose intake, patients infected with Helicobacter pylori exhaled more ¹³C and less ¹⁸O than those without infection. Exhalation with chronic kidney disease changes volatile organic compounds on a large scale. Diabetic patients with ketoacidosis exhale more acetone than those without ketoacidosis. Some specific volatile organic compounds also emanate from diabetic feet. By monitoring breath frequency, diabetic patients with obstructive sleep apnea syndrome exhibit a unique breath pattern and rhythm as compared with other diabetic patients, and sleep apnea is prevalent among diabetic patients. In addition to clinical findings, we analyzed the underlying mechanisms at the levels of molecules, cells and whole bodies, and provided suggestions for further studies.

Risk of Incident Obstructive Sleep Apnea Among Patients With Type 2 Diabetes

OBJECTIVE

This study compared the incidence of obstructive sleep apnea (OSA) in patients with and without type 2 diabetes and investigated risk factors for OSA in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A retrospective cohort study was performed to compare OSA incidence between adult patients with and without type 2 diabetes matched for age, sex, and BMI. Patients with a prevalent OSA diagnosis were excluded. The study cohort was derived from The Health Improvement Network (THIN), a U.K. primary care database, from 1 January 2005 to 31 December 2017.

RESULTS

There were 3,110 (0.88%) and 5,968 (0.46%) incident OSA cases identified in the 360,250 exposed and 1,296,489 unexposed patient cohorts, respectively. Adjusted incidence rate ratio (aIRR) of OSA in patients with type 2 diabetes compared with those without was 1.48 (95% CI 1.42-1.55; P < 0.001). In a multivariate regression analysis of patients with type 2 diabetes, significant predictors of OSA were diabetes-related foot disease (1.23 [1.06-1.42]; P = 0.005), being prescribed insulin in the last 60 days (1.58 [1.42-1.75]; P < 0.001), male sex (2.27 [2.09-2.46]; P < 0.001), being overweight (2.02 [1.54-2.64]; P < 0.001) or obese (8.29 [6.42-10.69]; P < 0.001), heart failure (1.41 [1.18-1.70]; P < 0.001), ischemic heart disease (1.22 [1.11-1.34]; P < 0.001), atrial fibrillation (1.23 [1.04-1.46]; P = 0.015), hypertension (1.32 [1.23-1.43]; P < 0.001), and depression (1.75 [1.61-1.91]; P < 0.001).

CONCLUSIONS

When considered alongside previous evidence, this study indicates that the association between type 2 diabetes and OSA is bidirectional. In addition to known predictors of OSA, diabetes-related foot disease and insulin treatment were identified as risk factors in patients with type 2 diabetes.

Implementing protocol for obstructive sleep apnea screening in the primary care setting

AIM

1) To implement obstructive sleep apnea (OSA) screening of at -risk patients in a primary care setting; 2) to evaluate and refer screened participants to sleep studies since early identification of OSA symptoms is an important initial step in reducing the burden of undiagnosed OSA disease.

METHOD

Participants completed the STOP-Bang questionnaire and those considered to be at risk were referred for sleep studies for disease identification, categorization, and treatment.

RESULTS

Prevalent OSA screening and referral rates at the clinic prior to project implementation was 3% and 0% respectively, compared to the corresponding rates of 43% and 39% post project implementation. Out of 187 participants screened between January and April 2018, 61% had scores of 3 and higher on the STOP-Bang questionnaire, however, only 39% of the at-risk participants agreed to undergo sleep studies. Those who declined sleep study referrals were mostly participants who were not experiencing higher burden of sleep deprivation. Out of 45 participants who underwent sleep studies, 67% were diagnoses with moderate to severe OSA with recommendations to initiate continuous positive airway pressure (CPAP) machine therapy.

CONCLUSION

Most primary care providers do not routinely screen at-risk patients for OSA despite existing clinical practice guideline recommending early and accurate diagnosis of OSA for this population. The Stop -Bang screening tool can reliably predict the presence of moderate to severe OSA. Early identification of OSA risks in the primary care setting through routing screening is very imperative in order to minimize its effects on cardiovascular morbidity and mortality. The obtained results highlight the potentially high unmet need for screening and treatment of OSA in the primary care setting.

Electronic Systems for Patients to Report and Manage Side Effects of Cancer Treatment: Systematic Review

BACKGROUND

There has been a dramatic increase in the development of electronic systems to support cancer patients to report and manage side effects of treatment from home. Systems vary in the features they offer to patients, which may affect how patients engage with them and how they improve patient-centered outcomes.

OBJECTIVE

This review aimed to (1) describe the features and functions of existing electronic symptom reporting systems (eg, symptom monitoring, tailored self-management advice), and (2) explore which features may be associated with patient engagement and patient-centered outcomes.

METHODS

The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and followed guidelines from the Centre for Reviews and Dissemination (University of York, United Kingdom). Primary searches were undertaken of MEDLINE, Embase, PsycInfo, Web of Science, Cochrane Central Register of Controlled Trials, and the Health Technology Assessment databases. Secondary searches were undertaken by screening reference lists and citations. Two researchers applied broad inclusion criteria to identify and select relevant records. Data were extracted and summarized using Microsoft Excel. In order to meet the aims, the study selection, data extraction, and data synthesis comprised two stages: (1) identifying and characterizing available systems and (2) summarizing data on patient engagement and patient-centered outcomes.

RESULTS

We identified 77 publications relating to 41 distinct systems. In Stage 1, all publications were included (N=77). The features identified that supported clinicians and care were facility for health professionals to remotely access and monitor patient-reported data (24/41, 58%) and function to send alerts to health professionals for severe symptoms (17/41, 41%). Features that supported patients were facility for patients to monitor/review their symptom reports over time (eg, graphs) (19/41, 46%), general patient information about cancer treatment and side effects (17/41, 41%), tailored automated patient advice on symptom management (12/41, 29%), feature for patients to communicate with the health care team (6/41, 15%), and a forum for patients to communicate with one another (4/41, 10%). In Stage 2, only publications that included some data on patient engagement or patient-centered outcomes were included (N=29). A lack of consistency between studies in how engagement was defined, measured, or reported, and a wide range of methods chosen to evaluate systems meant that it was not possible to compare across studies or make conclusions on relationships with system features.

CONCLUSIONS

Electronic systems have the potential to help patients manage side effects of cancer treatment, with some evidence to suggest a positive effect on patient-centered outcomes. However, comparison across studies is difficult due to the wide range of assessment tools used. There is a need to develop guidelines for assessing and reporting engagement with systems, and a set of core outcomes for evaluation. We hope that this review will contribute to the field by introducing a taxonomy for characterizing system features.

TRIAL REGISTRATION

PROSPERO CRD42016035915; www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016035915.

Erickson health coaching: An innovative approach for weight management in obese patients with obstructive sleep apnoea?

Obstructive sleep apnoea (OSA) is a highly prevalent medical condition and amajor cardiovascular risk factor. Obesity is present in ∼70% of patients with OSA, nevertheless, continuous positive airway pressure (CPAP) ventilation - the gold standard therapy for moderate and severe OSA - has no appreciable long-term beneficial effects on obesity, body composition, energy metabolism, physical activities or the incidence of major cardiovascular events. Therefore, effective weight loss strategies in conjunction with CPAP therapy in OSA are critically needed. Since lifestyle interventions may positively impact body weight, there is a strong rationale to testing the hypothesis that Erikson coaching intervention as a form of lifestyle intervention to obese patients with OSA may increase their adherence to healthy lifestyle behaviour and thus result in weight reduction, improved body composition (reduction in %body fat) and improvements in glucose and lipid metabolism. There are three lines of evidence to justify testing this hypothesis: First, health coaching significantly facilitates uptake of healthy behaviours across a broad variety of chronic conditions; second, several randomized clinical trials suggested positive impact of health coaching on weight management and on cardiometabolic risk factors in overweight/obese otherwise healthy persons; third, Erickson coaching approach empowers the three key elements of health coaching (patient-centeredness, patient-determined goals, use of a self-discovery process) further, namely by introducing two other specific core elements into the coaching process: a) solution-focus and outcome frame, b) orientation at the patient-formulated positive outcomes (i.e., positive values resulting from behavioural change). Importantly, results of our recent pilot observational cohort study suggested that Erickson coaching is a powerful tool to address behavioural modification in obesity. In conclusion, testing our hypothesis may have significant clinical implications: if clinical randomized trials indicate that Erickson health coaching is an efficient approach to behavioural change and weight management in OSA then combining Erickson coaching with CPAP therapy may result in reductions in cardiovascular morbidity and mortality in these high-risk patients.

Clinical usefulness of the body muscle-to-fat ratio for screening obstructive sleep apnea syndrome in patients with inadequately controlled type 2 diabetes mellitus

AIMS

To investigate whether body composition measures can be used for screening obstructive sleep apnea syndrome (OSAS) in patients with type 2 diabetes mellitus (T2DM) suspected of having OSAS.

METHODS

Subjects were 186 hospital inpatients with inadequately controlled T2DM. We measured the respiratory disturbance index (RDI) as an indicator of OSAS using a sheet-type breath detection monitor, defining OSAS as an RDI ≥ 19 events/hour. Elementary body composition was measured by bioelectrical impedance analysis using InBody770.

RESULTS

Simple logistic regression analysis identified body weight, body mass index (BMI), waist circumference, total body fat mass, body fat percentage, and body muscle-to-fat ratio (BMFR) as significantly associated with OSAS. The Nagelkerke R² test showed that the BMFR was the most suitable measure for screening OSAS. Multivariate logistic regression analysis demonstrated that BMFR was significantly and independently associated with OSAS. In receiver operating characteristic curve analysis, the area under the BMFR curve was 0.70 (P < 0.001), indicating that BMFR was significantly predictive of OSAS. Furthermore, BMFR was the most suitable measure for screening OSAS in a sub-group analysis of non-obese patients with relatively low BMI (<27.5 kg/m²).

CONCLUSIONS

In patients with T2DM, the BMFR is useful for screening OSAS in daily clinical practice.

The Epidemiology of Sleep and Diabetes

PURPOSE OF REVIEW

To provide an overview of the mechanistic and epidemiologic evidence linking sleep-related exposures, such as short sleep duration, obstructive sleep apnea, shift work, and insomnia, with type 2 diabetes risk in adults.

RECENT FINDINGS

Both poor sleep habits and sleep disorders are highly prevalent among adults with type 2 diabetes. In observational studies, short sleep duration, obstructive sleep apnea, shift work, and insomnia are all associated with higher risk of incident type 2 diabetes and may predict worse outcomes in those with existing diabetes. However, interventional studies addressing sleep abnormalities in populations with or at high risk for type 2 diabetes are scarce. Although common sleep abnormalities are associated with risk of incident type 2 diabetes and worse prognosis in those with established diabetes, there are few randomized trials evaluating the impact of sleep-focused interventions on diabetes, making it difficult to determine whether the relationship is causal.

"Mind" in Betel-quid Use and Related Disorders

Oral squamous cell carcinoma is characterized by a unique predisposing state called oral potentially malignant disorders (OPMDs). Wide variety of carcinogenic insult in the form of detrimental habits can contribute to the causation of variety of OPMDs.1,2.

The Clinical Impact of Systematic Screening for Obstructive Sleep Apnea in a Type 2 Diabetes Population-Adherence to the Screening-Diagnostic Process and the Acceptance and Adherence to the CPAP Therapy Compared to Regular Sleep Clinic Patients

Obstructive sleep apnea (OSA) is a common disorder in Type 2 diabetes (T2D) patients further increasing their already high cardiovascular risk. As T2D patients typically not report OSA symptoms, systematic screening for OSA in this population is warranted. We aimed to determine the readiness of T2D patients to undergo screening and to compare their adherence to continuous positive airway pressure (CPAP) therapy with "regular" sleep clinic patients who typically seek medical advice on their own initiative. We therefore recruited 494 consecutive T2D patients and offered them OSA screening using home sleep monitoring (type IV device). All participants in high risk of moderate-to-severe OSA were recommended home sleep apnea testing (HSAT) followed by CPAP therapy. Patients were followed-up for 12 months and outcomes compared to 228 consecutive sleep clinic patients undergoing HSAT. Among 307 screened T2D patients, 94 (31%) were identified at high risk of moderate-to-severe OSA. Subsequently, 54 patients underwent HSAT, 51 were recommended, and 38 patients initiated CPAP (acceptance 75%). Among 228 sleep clinic patients, 92 (40%) were recommended and 74 patients initiated CPAP (acceptance 80%). After 1 year, 15 (39%) T2D and 29 (39%) sleep clinic patients showed good CPAP adherence (use ≥ 4 h/night ≥ 70% nights). In conclusion, 20 T2D patients needed to be screened in order to obtain one successfully treated patient. OSA screening in T2D patients identified 31% with moderate-to-severe OSA. Once diagnosed, their CPAP acceptance and adherence did not differ from sleep clinic patients. However, the reasons for the high dropout during the screening-diagnostic process impacting the overall success of the screening program need to be identified and addressed.