, 0.018, and 0.015, resp.). None of the publication year, gender, sample size, NOS score, and SAHS diagnosis was source of heterogeneity ( > 0.05). The metaregression analysis results are shown in Table 2.

Publication Bias.
To assess bias across studies, Begg's test with funnel plot asymmetry was used to identify small study effects for the association between SAHS and the risk of AF. We were unable to detect the presence of publication bias in the analyses ( = 0.833), indicating a low probability of publication bias (Figure 4).

Discussion
To our knowledge, this is the first meta-analysis that evaluated the possible effect of sleep apnea hypopnea syndrome and the risk of atrial fibrillation using the results of previous published studies. In this study, we found that the current evidence in the meta-analysis of cohort study suggests that sleep apnea hypopnea syndrome could increase the risk of AF, and there is a dose-response relationship between SAHS severity and rates of incident AF. SAHS has been shown to contribute to the increased AF burden [21,22]. Previous studies have reported a strong association between SAHS and AF, with an increased risk of 2-to 4-fold than that of those without SAHS [7]. A prospective cohort study found that patients with SAHS had the risk of AF with OR of 4.02 after adjustment for sex, age, BMI, and coronary heart disease. No dose-response relationship was found between the risk for AF and severe SAHS [7]. On the other hand, another study found that the risk of AF was linearly associated with severity of SAHS; mild SAHS increased AF risk 2.47-fold, and moderate to severe SAHS increased AF risk 5.66-fold [9]. Not all studies, however, have shown a positive association between SAHS and AF. A case-control study failed to confirm the prevalence of obstructive sleep apnea in AF patients and common population (32% versus 29%, = 0.67) [23]. However, the number of subjects in this study was relatively small and the statistical power to detect an association was therefore limited.
There is emerging evidence from animal and human studies that the physiologic changes of sleep apnea, including hypoxia, hypercapnia, and intrathoracic pressure swing, precipitate electrical and structural changes. The exact mechanisms for the association between sleep apnea hypopnea syndrome and atrial fibrillation remain unclear, as the two conditions share many of the same risk factors; however, emerging evidence from animal and human studies indicated that the physiologic changes of sleep apnea including hypoxia, hypercapnia, and activation of sympathetic nervous function may be involved in this process [24]. On the other hand, AF usually reduces cardiac output, which leads to central apnea during sleep, mainly because of the chemoreflex enhancement and prolonged lag to ventilatory response [25]. Previous study reported that obstructive events during sleep promote reductions in the intrathoracic pressure, intermittent hypoxia, and sleep fragmentation [26], which may result in structural cardiac changes, including atrial enlargement and fibrosis [27]. Chronic atrial dilation caused by changes in intrathoracic pressure and surges in blood pressure may facilitate atrial remodeling in SAHS. Besides, SAHS has been reported to increase aorta stiffness that in turn resulted in increased heart afterload and atrial and ventricular remodeling [28,29]. The increased risk of recurrence of AF has been also reported in patients who performed catheter ablation [30]. Another observational study showed that patients with untreated SAHS have a higher recurrence of AF after catheter ablation. Continuous positive airway pressure treatment was associated with a lower recurrence of AF [31]. SAHS induces repeated episodes of hypoxia which trigger chemoreflex and enhance sympathetic nerve activity, leading to tachycardia and blood pressure elevation. The above changes result in repeated myocardial and subsequently atrial ischemia during sleep, thereby promoting AF [32]. Autonomic nervous system dysfunction may be one of the mechanisms by which SAHS increases the incidence of atrial fibrillation [33]. Collapse of upper airway in patients with OSA may result in increased intrathoracic negative pressure. Upper airway collapse in patients with OSA may cause increased chest negative pressure. Sleep-breathing events can also lead to intermittent apnea, hypoxemia, hypercapnia, and other changes in blood gas, as well as sympathetic activation and subsequent hemodynamic changes, which all contribute to the development of atrial fibrillation [34].
In this meta-analysis, we confirmed that sleep apnea hypopnea syndrome could increase the risk of atrial fibrillation. However, our meta-analysis also has limitations. Although we perform a metaregression analysis to evaluate the influence of variables such as history of cardiovascular disease and BMI on the risk of atrial fibrillation, there was significant heterogeneity among dose-response and subgroup studies; we failed to conduct metaregression analysis in these studies because these variables were always unavailable.
In conclusion, our results indicated that sleep apnea hypopnea syndrome could increase the risk of atrial fibrillation. There is a dose-response relationship between sleep apnea hypopnea syndrome severity and rates of incident atrial fibrillation, and the higher the severity of sleep apnea hypopnea syndrome, the higher the risk of atrial fibrillation.

Conflicts of Interest
The authors have declared that no conflicts of interest exist.It is a bad time to be an artist. In recent times, a cartoonist has been arrested for doodling, an essay has been banned from colleges, a Bangladeshi writer lives in exile and a renowned Indian artist died in a country not his own.
Artists are in the dock for their expression. But the fallout swings from the tragic to the trite. A US Ambassador has been killed and all religion has been charged with his murder.
Last night, in CNN-IBN’s interview with Salman Rushdie, one atheist told another that he was tired of religion demanding special privileges. It was judgment without a jury.
For the record, I think Salman Rushdie has been dealt with unfairly. But the debate between free speech and fundamentalist religious belief is incomplete. It is missing people who value their own religion so much they will defend the right of their critics to speak freely, because they are convinced that their faith can stand up to scrutiny.
To be fair, God is more offensive than Salman Rushdie. If the Bible wasn’t the Bible, it would be targeted by angry religious protesters for its sexually explicit poetry and its brutally honest biographies.
Lot’s daughters get him drunk in a cave, sleep with him and bear his children. Jacob’s wages for his work are women. He marries two sisters and a couple of servants. Judah’s daughter-in-law pretends to be a prostitute and sleeps with him. David murders a man to cover up an affair with his wife. The Song of Solomon walks a thin line between art and obscenity.
God speaks through the prophets to His people, with graphic sexual imagery. His speech is intended to shock the sensibilities of people indifferent to injustice. Throughout the Bible, it is astonishing how writers are given the freedom to express themselves—under divine inspiration—in ways that would seem offensive to contemporary readers. But it remains revered because it is true.
True spirituality inspires free speech. But free speech has a responsibility to be truthful. The Da Vinci Code wasn’t offensive because it hinted that Christ had taken a lover. It was offensive because it wasn’t true.
As it turns out, truth is more offensive than insult. In a strange sense, Jesus Himself violated the rules of free speech in Jerusalem. He confronted hypocrisy and subverted authorities. He spoke the truth openly and it was taken to be offensive. Religious forces pulled every political string in their power to have him executed. By that standard, artists in exile seem to have fared better than Him.
God is not insecure. Genuine faith shouldn’t be intimidated by its critics, even if they resort to the obscene and the irreverent. As a Christian, I will defend your God-given right to disagree with me.
But if critics have the right to speak against false religion, shouldn’t true religion have the right to speak for itself? But the champions of free speech appear to be calling for a fatwa on religious belief in the public sphere. Believe what you will, but keep it in the closet. Leave it at home when you come to the city square.
The Bible has never been a book for children. It is written for grown-ups who are expected to read it like grown-ups. But there’s a childishness to the way it is read by its adversaries. They seem to miss its obvious affinity with the arts and its deep concern with reasonable thinking.
The Bible is a friend to the artist who wants to tell the truth, even if it is disturbing. Its ears are open to listen to the complaints of honest critics. It is committed to being truthful, even if it is offensive. For that reason, it is a first rate work of art and God remains the first offensive artist. Everyone else is a follower in His offensive footsteps.
Should I remove Virus Removal Tool 1?
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