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   Table of Contents - Current issue
April-June 2021
Volume 4 | Issue 2
Page Nos. 43-85

Online since Tuesday, June 1, 2021

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COVID-19, Ramadan, diabetes, thyroid, and more p. 43
Salem A Beshyah
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Treatment of hypothyroidism in the Middle East p. 44
Hossein Gharib
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Ramadan fasting and diabetes (2020): The year in review p. 46
Khadija Hafidh, Khawla F Ali, Saira Abbas, Salem A Beshyah
The literature on health aspects of Ramadan fasting (RF) is widely spread in many journals, making it not readily accessible to those interested in the subject. We aimed to provide a narrative overview of the global literature production in 1 year (2020) on diabetes and RF. This was a narrative, nonsystematic review of the international literature from a single major medical online database (i.e., PubMed) during the year 2020. The search term “Ramadan fasting AND Diabetes” was used, and the relevant literature was narrated in a concise thematic account. The publications spanned a vast array of topics related to RF, including assessments of safety and efficacy profiles of older and newer diabetes therapies, modes of insulin delivery, evaluating the role of utilizing advanced technology for the treatment, and monitoring of blood glucose during RF. Increased interest was evident in capturing patients' perspectives and healthcare professionals' perceptions, attitudes, and practices during Ramadan. Fasting by high-risk groups was studied. Not surprisingly, some reports covered COVID-19 and Ramadan and the role of telemedicine in ramadan. The current literature review presents this year's research data on the safety of fasting practices, care models, and patients' experiences and perspectives. It emphasizes the need for more comprehensive interventions for high-risk patients, promoting newer antidiabetic medicines, and advanced technology for safer fasting practices.
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Phenotypes of high-density lipoprotein cholesterol and their relationship with glycemic status in type 2 diabetic patients p. 59
Chikezie Hart Onwukwe, Nkiru Ifeoma Chikezie, Kalu Kalu Okorie, Augustine Efedaye Ohwovoriole
Background: There are varying reports on the association of high-density lipoprotein cholesterol (HDL-C) phenotypes and glycemia in type 2 diabetes mellitus (T2D) patients. Such information is lacking in Nigerian data. Aim: The aim of this study was to determine the relationship between HDL-C phenotypes and glycemic control in T2D patients. Materials and Methods: Clinical and laboratory data were collected from consenting T2D patients. Information was managed and analyzed with appropriate software. Results: Four hundred T2D patients consisting of 235 and 165 persons with and without poor glycemic control, respectively, were recruited for this study. There was a significant negative correlation between glycosylated hemoglobin (HbA1c) and the HDL2-C phenotype (rs = −0.12, P = 0.01). The correlation between HbA1c and the HDL3-C phenotype was not statistically significant (rs = −0.06, P = 0.21). Conclusion: The HDL2 phenotype has a stronger correlation with glycemic status than the HDL3 phenotype in T2D patients.
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COVID-19 lockdown and hypoglycemia among patients with diabetes fasting the month of Ramadan 2020 p. 64
Zahra Abdulkareem Ghareeb, Zainab Al Saffar, Ghadeer Al Ghareeb, Ghalia Jassam Almaalu, Alia Alnaj
Background: Patients with diabetes are targeted with diabetes education 8–10 weeks before Ramadan to have a safe fasting experience. In 2020, this timing coincided with COVID-19 lockdown when virtual clinics were implemented to secure patient care continuity. Objectives: We evaluated hypoglycemia episodes among patients with diabetes fasting in Ramadan 2020 during COVID-19 lockdown. Patients and Methods: A cross-sectional study was conducted after the month of Ramadan 2020, using a self-administered online questionnaire and convenient sampling methods. Patients with diabetes aged 14 years and older who practiced fasting in Ramadan were included in the study. Hypoglycemia rate in total and diabetes treatment among observers of Ramadan 2019 and Ramadan 2020 were compared. Predictors of hypoglycemia during fasting Ramadan 2020 were estimated. Results: Out of 367 patients with diabetes aged 14 years and older, 326 (88.8%) participants had the ability to fast Ramadan and were included in the study. Comparing patients' experience in Ramadan 2019 and Ramadan 2020, participants reported lower hypoglycemia episodes during Ramadan 2020 than Ramadan 2019, P = 0.017. In subgroup analysis based on the type of treatment, patients on noninsulin treatment had statistically significant lower hypoglycemia episodes during Ramadan 2020 than Ramadan 2019 (P = 0.006). Patients on insulin treatment had fewer hypoglycemia episodes during Ramadan 2020 than Ramadan 2019, but the difference was not statistically significant (P = 0.405). The probability of hypoglycemia during fasting Ramadan 2020 was higher among younger age groups 14–30 years (odds ratio [OR] 7.24, 95% confidence interval [CI] 1.72–30.39), patients aged 31–45 years (OR 7.18, 95% CI 1.97–26.19), patients with longer duration of diabetes (more than 10 years) (OR 2.30, 95% CI 1.01–5.26), and patients on insulin (OR 14.14, 95% CI 1.72–30.39). Conclusions: COVID-19 pandemic and lockdown did not affect the diabetes-related experience among participants' fasting Ramadan. The hypoglycemia episodes of patients with diabetes in Saudi Arabia were improved during the pandemic era. This could be related to telemedicine services. More studies are required to support its role in improving health conditions beyond our population's pandemic era.
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The impact of hyperglycemia on stroke outcomes in patients with and without diabetes p. 69
Khadija Hafidh, Touseef Kazmi, Ayisha Alshamsi, Sarah Mukhtar, Saira Abbas
Introduction: Diabetes mellitus is a well-established independent risk factor for the development of stroke. It increases stroke risk by about fourfold. Information is scarce on the prevalence of stroke in the Gulf region. A systematic review of stroke epidemiology in the Middle East reported an increase in stroke cases over the last decade. Objectives: We aimed to examine the relationship between adverse stroke outcomes and dysglycemia. Patients and Methods: In this observational, retrospective, cross-sectional study, we recruited 496 patients with a clinical and radiological stroke diagnosis. We compared the length of hospital stay (LOS), inhospital mortality, and 30-day stroke readmission among those with no diabetes, prediabetes, and diabetes. Results: A total of 496 patients were eligible for the inclusion in the study. They were subdivided into three main categories based on their glycemic status according to the Hemoglobin A1c values at presentation. nondiabetes (190), prediabetes (117) and diabetes (189). The mean age was 57 years, with a higher proportion of males (n = 356) than females (n = 140). There were proportionally more ischemic strokes (n = 350) than hemorrhagic strokes (n = 147). The mean LOS was 5.0 days for all patients, irrespective of their glycemic status. Inhospital mortality was 4%, with slightly higher mortality (5.3%) in the group with diabetes; however, this was not statistically significant. Glycemic status did not seem to impact the stroke readmission at 3 or 6 months significantly. Furthermore, the proportion of patients readmitted within 30 days of discharge was not different between the three categories. Conclusions: Ischemic strokes occur in a much higher proportion in our patients with diabetes. Dysglycemia did not significantly impact stroke outcomes in our cohort.
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Patterns of clinical management of hypothyroidism in adults: An electronic survey of physicians from the Middle East and Africa p. 75
Salem A Beshyah, Ibrahim H Sherif, Huda E Mustafa, Hussein F Saadi
Background: Hypothyroidism is a common endocrine disorder that is managed by a wide range of physicians. There are no data on the pattern of clinical management of hypothyroidism in the Middle East and Africa (MEA) region. Objectives: We sought to document current practices in the management of primary hypothyroidism in the MEA region and compare these with international recommendations and practices elsewhere. Materials and Methods: A convenience sample of physicians practicing in the MEA in relevant disciplines were invited to take a web-based survey consisting of previously validated multiple-choice questions dealing with investigation and treatment of an index case of overt primary hypothyroidism in general and in three special situations. Results: Out of complete 397 responses, 368 were eligible for inclusion in the analysis. The majority were endocrinologists and internal medicine specialists; 82.2% of them have been in clinical practice for 10 years or more. Overt hypothyroidism would be treated using L-T4 alone by 97.2% of respondents; 1.7% would use a combination of L-T4 and liothyronine (L-T3) therapy. The rate of replacement would be gradual (66.5%), an empiric dose, adjusted to achieve target levels (14.7%); or a calculated full replacement dose (18.5%). A target thyroid-stimulating hormone (TSH) of 2.0–2.9 mU/L was favored in the index case of overt hypothyroidism (by 34.4%) followed by a target of 3.0–3.9 mU/L (by 26.0%) of respondents. However, a target of 4.0–4.9 mU/L was the most commonly selected TSH target for an octogenarian (by 33.5% of respondents). Persistent hypothyroid symptoms despite achieving a target TSH would prompt testing for other causes by 86.9% of respondents, a change to L-T4 plus L-T3 therapy by 5.8%, and an increase in the thyroid hormone dose by 4.6%. Evaluation of persistent symptoms would include measurements of complete blood count (82.4%), complete metabolic panel (68.7%), morning cortisol (65.3%), Vitamin B12 levels (54.5%), and serum T3 levels (27.9%). Subclinical disease with a TSH 7.8 mU/L would be treated without further justification by 9.0% of respondents, or in the presence of positive thyroid peroxidase antibodies (65.3%), hypothyroid symptoms (65.0%), high low-density lipoprotein (51.7%), or a goiter (36.7%). The TSH target for a newly pregnant patient was 2.0–2.4 mU/L for 28.5% of respondents, with 15.8% preferring a TSH target of 1.5–1.9 mU/L. Thyroid hormone levels would be checked every 4 weeks during pregnancy by 62.9% and every 8 weeks by an additional 17.6%. A hypothyroid patient with a TSH of 0.5 mU/L who becomes pregnant would receive an immediate L-T4 dose increase by only 28.5% of respondents. Conclusions: The survey revealed that (1) nearly exclusive preference for L-T4 alone for therapy, (2) use of age-specific TSH targets for replacement therapy, (3) a low threshold for treating mild thyroid failure, (4) complacent and variable attention to TSH targets in the pregnant and prepregnant woman, and (5) a highly variable approach to both the rate and means of restoring euthyroid status for overt disease. Both alignments with and divergence from guidelines were detected. The results should help in directing focused educational activities in the region, providing a baseline for future monitoring of practices.
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Clopidogrel induced autoimmune hypoglycemia p. 83
Abdulla Mohamed Alnuaimi, Bachar O Afandi, Yusra Othman
We report insulin autoimmune syndrome in a diet-controlled type 2 diabetes mellitus patient. She developed recurrent attacks of severe hypoglycemia 1 week after the initiation of clopidogrel. The evaluation revealed high insulin and C-peptide levels consistent with hyperinsulinemic hypoglycemia. The insulin-to-C-peptide ratio was reversed and >50. Anti-insulin antibody titers were highly positive.
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