Obstructive Sleep Apnoea and Metabolic Syndrome in Mediterranean Countries

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Obstructive Sleep Apnoea and Metabolic Syndrome in Mediterranean Countries and the prognosis of anti-PL7 ASS under treatment were 3 Sato S, Hirakata M, Kuwana M, et al. Clinical characteristics of heterogeneous. Japanese patients with anti-PL-7 (anti-threonyl-tRNA synthetase) autoantibodies. Clin Exp Rheumatol 2005; 23: 609–615. 4 Yamasaki Y, Yamada H, Nozaki T, et al. Unusually high frequency " + B. Hervier*, Y. Uzunhan#, E. Hachulla , O. Benveniste , of autoantibodies to PL-7 associated with milder muscle disease in 1 e H. Nunes#, P. Delaval , L. Musset , S. Dubucquoi**, Japanese patients with polymyositis/dermatomyositis. Arthritis B. Wallaert## and M. Hamidou* Rheum 2006; 54: 2004–2009. 5 Mimori T, Imura Y, Nakashima R, et al. Autoantibodies in *Internal Medicine Dept, CHU Nantes Hotel Dieu, Nantes, idiopathic inflammatory myopathy: an update on clinical and # + Pneumology Dept, CHU Avicenne, Internal Medicine Dept, pathophysiological significance. 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DOI: 10.1183/09031936.00104310 Obstructive sleep apnoea and metabolic syndrome in Mediterranean countries To the Editors: Patients diagnosed with OSA in the period July 2007–September 2008 in Palermo, Italy (Respiratory Section, DIBIMIS, University Obstructive sleep apnoea (OSA) is often associated with of Palermo, and CNR Institute of Biomedicine and Molecular metabolic disturbances, including altered glucose metabolism Immunology), Palma de Mallorca, Spain (Hospital Son Dureta) and dyslipidaemia, which probably contribute to the increased and Alexandroupolis, Greece (Sleep Unit, Medical School, cardiovascular risk in these patients [1]. The concept of the Democritus University of Thrace), were evaluated in this study. metabolic syndrome (MetS) as a cluster of cardiometabolic risk All underwent clinical examination for clinical suspicion of factors has gained popularity in recent years, and a much OSA, and full polysomnography or nocturnal cardiorespiratory higher prevalence of the MetS has been found in OSA patients monitoring (eight channel) according to the American Academy compared with the general population in several studies [1]. of Sleep Medicine guidelines [6]. OSA was diagnosed when While the MetS largely reflects the effects of visceral obesity, the apnoea/hypopnoea index (AHI) was .5 events?h-1; mean environmental factors, i.e. the type of diet, could also play lowest arterial oxygen saturation (Sa,O2) was recorded. Daytime some role. The Mediterranean diet, rich in olive oil and fish, is sleepiness was subjectively assessed by the Epworth Sleepiness protective against the MetS [2–4], but no study has examined Score questionnaire. Body mass index (BMI) was defined as the association of MetS and OSA in Mediterranean countries. kg?m-2. Neck, waist and hip circumferences (cm) were mea- We hypothesised that prevalence of the MetS might be lower in sured. The MetS was diagnosed based on the presence of three OSA patients living in the Mediterranean area compared with or more of the following factors: waist circumference o80 cm in the prevalence values found in non-Mediterranean countries. females and o94 cm in males; serum triglycerides o150 Therefore, we retrospectively assessed the prevalence of the mg?dL-1 or lipid-lowering treatment; high-density lipoprotein MetS according to the modified National Health and Nutrition HDL cholesterol ,40 mg?dL-1 in males and ,50 mg?dL-1 in Examination Survey Adult Treatment Panel (ATP) III criteria females or statin treatment; systemic hypertension (systolic [5] in consecutive patients referred to sleep laboratories in Italy blood pressure .135 mmHg and/or diastolic blood pressure c (n5107), Spain (n5138) and Greece (n5218). .85 mmHg) or anti-hypertensive treatment; and fasting blood EUROPEAN RESPIRATORY JOURNAL VOLUME 37 NUMBER 3 717 glucose .100 mg?dL-1 or anti-diabetic treatment [5]. Plasma for hypertension (ACE inhibitors 34.2%, b-blockers 11.7% and glucose and lipids were analysed by standard laboratory diuretics 19.2%), diabetes (oral hypoglycemic drugs 15.8%), methods in venous blood withdrawn in the morning in a fasting or dyslipidaemia (29.2%) compared to Italian patients (ACE state. Treatment for hypertension (i.e. diuretics, b-blockers and inhibitors 17.2%, b-blockers 8.0%, diuretics 6.9%, oral hypo- angiotensin-converting enzyme (ACE) inhibitors, etc.), diabetes glycemic drugs 3.4% and dyslipidaemia treatment 9.2%), (i.e. oral antidiabetic drugs and insulin), or dyslipidaemia or Spanish patients (ACE inhibitors 14.2%, b-blockers 7.4%, (i.e. statins and clofibrate, etc.) was recorded in all patients. diuretics 16.8%, oral hypoglycemic drugs 7.4% and dyslipidae- mia treatment 11.9%). Waist-to-hip ratio was lowest in Italian ¡ Data are reported as mean SD for continuous variables, and patients, intermediate in Greek patients and highest in Spanish percentage of positive subjects for categorical variables. Con- patients. tinuous variables in the three patients’ samples were compared by one-way ANOVA with Bonferroni correction for multiple According to the National Cholesterol Education Program comparisons. The Chi-squared test was used to assess dif- (NCEP)-ATP III definition, MetS was present in 67.3% of the ferences in the frequency of categorical variables. Variables patients of the entire cohort (fig. 1 and table 1), with the lowest significantly associated with MetS were tested by multiple prevalence in the Italian sample (p,0.0001 by Chi-squared logistic regression. Statistical analysis was performed by using test). Significant differences in the prevalence of single MetS the SPSS version 17 software (SPSS Inc., Chicago, IL, USA) and components were found among the samples for waist significance was at p,0.05 for all tests. circumference, triglycerides and fasting blood glucose, while prevalence of hypertension or low HDL-cholesterol was A total of 463 patients were diagnosed with OSA in the study similar in the three samples. Logistic regression analysis in period (107 in Palermo, 218 in Alexandroupolis and 138 in the entire sample identified age, BMI, male sex, lowest Sa,O2 Palma de Mallorca), but 127 had to be excluded due to missing and presence of daytime sleepiness as significantly associated information (20, 98 and nine, from the respective samples), with MetS. leaving 336 patients for analysis. Excluded patients did not show any significant difference compared to included ones for The results of this retrospective study do not support the sex distribution, age, BMI or OSA severity (data not shown). hypothesis that patients with OSA from Mediterranean countries may be protected against MetS. Indeed, the preva- Table 1 summarises the anthropometric and clinical features of lence rates observed were similar to those reported by other the samples. The percentage of female patients was similar in clinical studies in Western countries ranging between 30% and Italy and Spain (between 30% and 35%), and lowest in the Greek 87% [1]. Prevalence of MetS in Mediterranean OSA patients sample (19%). Age and AHI were similar in the three groups. was at least twice as high as in the general population of the Greek patients showed a significantly lower Sa,O2 during sleep. respective countries, which is rising and currently estimated to Mean BMI and waist circumference were highest in the Greek be between 22% and 25% [7–9]. The Greek sample showed the patients, who also showed significantly higher treatment rates highest prevalence of markers of abdominal obesity, accounting TABLE 1 Characteristics of the patients All patients Palermo, Alexandroupolis, Palma de Mallorca, p-value Italy Greece Spain Patients n 336 87 120 129 Males % 72.3 65.5 80.8 69.0 ,0.05 Age yrs 55.3¡12.3 54.3¡11.1 57.3¡12.8
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