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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Introduction: Treatment of adrenal insufficiency (AI) requires correct lifelong use of glucocorticoids (GCs) with early dose adjustments to cover the increased demand in stress to avoid life-threatening emergencies. Objectives: We determine the current specific knowledge of physicians in a convenience sample on the pathophysiological and clinical aspects of AI in the two regions of North Africa and the Middle East. Materials and Methods: Participants (n = 96) were invited to complete an electronic questionnaire with various possible answers on the subject of multiple-choice questions covering physiology, pharmacology, and clinical management and define respondents' professional profiles. Results: The present study suggests that in the investigated settings, physicians' knowledge of physiology and pharmacology GCs, medical replacement strategies in AI, and prevention of adrenal crisis may be insufficient. Great knowledge gaps were demonstrated. Conclusions: There is a need for continuous structured education and training on AI in both general medical and endocrine forums.

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Objective: We sought to scope the practices in managing thyroid nodules in the Middle East and Africa (MEA). Materials and Methods: Survey of a convenience sample of physicians concerned with the management of thyroid disease. Results: Two hundred and twelve responses are included. Fine needle aspiration (FNA) is performed chiefly using ultrasound guidance (74.9%), generally by radiologists (47.1%). Respondents have a lower threshold for FNA than recommended. Management depends on the FNA cytology, with the follicular lesion of undetermined significance/atypia of undetermined significance resulting in repeat FNA for cytology (40.7%), immediate referral for thyroid surgery (32.9%), or molecular testing (13.2%). Follicular neoplasms are referred for lobectomy or total thyroidectomy by 81.6% of respondents. Nodules suspicious for malignancy are referred for thyroid surgery by 76.6% and for molecular testing by 20.1%. Respondents are less likely to perform FNA in an octogenarian than a younger patient with a comparable nodule. For a multinodular goiter, 29.9%, 25.9%, or 17.8% of respondents would, respectively, sample the largest 2–3 nodules, single largest nodule, or all nodules >1 cm in size. During pregnancy, respondents would perform FNA with nodular growth (27.1%) in the absence of nodular growth (25.6%), but more respondents (35.2%) would defer FNA until after pregnancy. Conclusions: The physicians' survey revealed a practice pattern in managing thyroid nodules in the MEA region, including both agreements and deviations from current guidelines. Focused quality assurance exercises, education, and research are needed.

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Triple-A syndrome, also known as Allgrove syndrome, is an uncommon disorder which is inherited as an autosomal recessive disorder. About 100 cases have been described in literature. The three AAA comprises adrenal insufficiency secondary to adrenocorticotropic hormone (ACTH) resistance, achalasia cardia, and alacramia. We are reporting a case of a 10-year-old boy diagnosed as triple-A syndrome with ACTHresistant adrenal insufficiency, achalasia cardia, and alacrimia. He has alacramia since birth, and at the age of 7 years, he was diagnosed to have achalasia cardia. He developed the symptoms of adrenal insufficiency at the age of 9 years. Allgrove syndrome might be underreported in literature as the diagnosis requires high index of suspicion. In our patient, there was a delay of 3 years after the initial diagnosis of achalasia cardia. The diagnosis of Allgrove syndrrome should be considered in every child presenting with alacremia or achalasia cardia.

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Objectives: Our aim was to assess the clinical profiles and determine the precipitating factors for diabetic ketoacidosis (DKA) in adult patients admitted to a tertiary care center in United Arab Emirates (UAE). Materials and Methods: We conducted a retrospective analysis of all patients admitted with DKA at a tertiary care hospital in UAE during June 2014–December 2017. Variables recorded included gender, type of diabetes, and HbA1c on presentation and identified precipitating factors. Results: Data from a total of 255 patients with DKA were analyzed. One hundred and fifty-seven of these patients had type 1 diabetes (61.6%) whereas 69 patients were diagnosed with type 2 diabetes mellitus (T2DM) (27.1%), and 22 patients could not be classified as type 1 or type 2. A small number of patients (2.7%) were found to have secondary diabetes as their DKA was precipitated by acute pancreatitis. Around 12% of cases occurred in the setting of newly diagnosed diabetes. The most common precipitating factor for DKA was noncompliance to treatment (31.4%), followed by infections (22.7%). Pancreatitis was another important precipitating factor which accounted for 6.3% of the cases. Conclusions: DKA is not limited to patients with T1DM, and there seems to be a steady increase in its occurrence in patients with T2DM. Noncompliance to therapy is a major precipitating factor which needs to be addressed by offering better education programs to prevent hospitalization of these cases.

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The aim of this study was to determine, using meta-analysis, the prevalence of diabetes mellitus (DM) and to explore the influence of method of diagnosis, DM types, and study year on the prevalence of DM with the view to evaluating the trend and the burden of DM in KSA. Prevalence estimates were derived using a random effect model on carefully selected population-based studies in KSA. The derived estimates were applied to the total populations in the country to give an estimated burden of DM. Twenty-one studies, with 376,998 participants out of whom 54,837 had DM, were selected. The prevalence of DM was 20.9%, 0.9%, and 12.6% for T2DM, T1DM, and combined T1/T2DM, respectively. Subgroup analysis using the method of DM diagnosis showed that the prevalence of DM was 14.2% (95% confidence interval [CI]: 9.3% to 19.0%) in the fasting plasma glucose group, 6.8% (95% CI: 2.6% to 11%) in oral glucose tolerance group, and 12.5% (6.2%–18.9%) in glycated hemoglobin group. Meta-regression revealed 4.6 × 10⁻³ increase in prevalence per year. The prevalence of DM in Saudi Arabia is high. There is a rising trend in the prevalence of DM in KSA and it is accompanied by a proportionate increase in the burden of DM.

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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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Background: Despite the increasing demand for continuous subcutaneous insulin infusion (CSII) or insulin pump therapy in preschool children with Type 1 diabetes (T1D), reports on its advantages over conventional methods, particularly multiple dose injection (MDI) therapy, are scant. Objectives: We aimed to investigate the effectiveness, safety, and parental satisfaction of using CSII compared to MDI in preschool children with T1D. This study also seeks to establish criteria to help clinicians choose patients most suitable for CSII. Methods: Relevant terms based on the study outcomes were used to search electronic databases and manual search for the literature. Selected articles were then thoroughly reviewed and evaluated. Results: The effect in the meta-analysis showed a small, nonsignificant positive effect on HbA1c of the CSII compared to the MDI insulin intervention method (mean Cohen's d effect size = 0.25, Standard Error = 0.18, P = 0.16 (n = 127)) and a small, nonsignificant negative effect on safety of the CSII compared to the MDI insulin intervention method (mean Cohen's d effect size = −0.26, SE = 0.36, P = 0.47 [n = 70]). For parental satisfaction, data were small and therefore inappropriate for meta-analysis. Conclusion: For preschool children, the effectiveness and safety of insulin pump therapy compared with MDI therapy was considered statistically nonsignificant. All preschool children with T1D can be considered potentially eligible candidates for insulin pump therapy. Suggested selection criteria to apply when considering preschool children for insulin pump therapy were presented.

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Introduction: The coronavirus disease-2019 (COVID-19) pandemic was associated with international obligations that modified lifestyles and clinical practice. These changes are worrisome for patients with diabetes, as disruption from a routine can have devastating effects on glucose control. This retrospective study aims to assess the impact of lockdown and the efficacy of the instituted changes in patient management on blood sugar control. Methods: Patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) who received management through telemedicine at the National Diabetes Center over a lockdown period of 3 months were included. The blood investigations that were done for them as part of standard care were reviewed. Results: A total of 509 patients were included. HbA1c slightly decreased in 49.5% of the patients after the lockdown (P = 0.42). Patients who were not hypertensive experienced a significant reduction in HbA1c (adjusted odds ratios [ORa]: 0.59, 95% confidence interval [CI]: 0.39–0.91, P = 0.018) during the lockdown. A significant association between body mass index (BMI) and lower HbA1c level postlockdown was also determined (ORa: 0.95, (95% CI: 0.92–0.98, P = 0.001). A significant HbA1c reduction was only noted in the BMI group of normal weight (mean: 0.46 ± 0.3, P = 0.03). Conclusion: The imposed lockdown due to COVID-19 did not adversely impact the HbA1c level and glycemic control in T1DM and T2DM patients. Inversely, HbA1c improvements were determined in patients with normal weight and blood pressure after the lockdown period.

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Context: Diabetic foot ulcer (DFU) is one of the most dreaded complication of diabetes which often affects the morbidity and mortality of a diabetic. Biomarkers are required for follow-up of these patients to prevent further complications to the affected limb. Aim: The aim of this study is to evaluate ischemia-modified albumin (IMA), fibrinogen in relation with high sensitive-C-reactive protein (hs-CRP) in patients with DFUs. Methods: a hospital-based cross-sectional study was carried out among 30 patients with DFU admitted in the surgery department of tertiary care teaching hospital. The duration of the study was 2 months. Serum IMA, hs-CRP, and plasma fibrinogen levels were measured. Results: The present study has demonstrated that IMA levels (P < 0.05) and fibrinogen levels (P < 0.05) are statistically significantly elevated in patients with DFU and had significant correlation with albumin and hs-CRP (P < 0.05). Conclusions: The use of IMA, hs-CRP, and fibrinogen may be incorporated during the follow-up of type 2 diabetes mellitus patients and may probably prevent the development of DFU and also possibly prevent lower limb amputation. Further studies with a larger number of patients with DFU are necessary to reach a definitive judgment.

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Background: Admission hyperglycemia is known to cause increase in in-hospital mortality, increased length of intensive care unit (ICU) stay, increased morbidity across critically ill patients. In patients with vascular disease (myocardial infarction, stroke, etc.), this has been extensively studied. We planned to study the prevalence of admission hyperglycemia and its association with adverse outcomes in all critically ill patients. Methods: In an observational, prospective study, 200 critically ill inpatients admitted to the medicine ICU were included. The patients were stratified into known diabetes, newly detected diabetes, and stress hyperglycemia. Baseline clinical and laboratory parameters were collected, and Acute Physiology and Chronic Health Evaluation (APACHE)-II, Sequential Organ Failure Assessment (SOFA), and Simplified Acute Physiology (SAP II) scores were calculated. Data regarding clinical outcomes (discharge or in-hospital death) were also collected. Results:   The prevalence of admission hyperglycemia and of stress hyperglycemia was found to be 11.99% and 1.51%, respectively. The newly detected diabetes had higher admission hyperglycemia and glycosylated hemoglobin. The prognostic scores – APACHE-II, SAP II, and SOFA scores – were worse among patients who died in the newly detected diabetes and the stress hyperglycemia group but not in the known diabetes group.   The odds of death increased by 3.5 times with 1-day increase in the ICU. Conclusion: Our study concluded that the patients with newly detected diabetes and stress hyperglycemia had more severe illness as compared to the known diabetics.

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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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Until now, injectable glucagon was the only available treatment used in the management of severe hypoglycemia wherein glucagon had to be prepared in several steps before administration. This method of delivery of injectable glucagon being cumbersome and unappealing for wide majority of the patients had led to a search for an alternative route of drug delivery. nasal glucagon (NG) now serves an efficient, safe, easy-to-administer, and a favorable substitute to glucagon injections. This ready to use device stand in clear contrast to overcome the limitations associated with the currently available glucagon preparations has emerged a key advancement in the management of severe hypoglycemia in adolescents and children with type 1 diabetes. NG is now being developed and studied in other countries as well to meet the unmet need for an easy and convenient glucagon administration. This review covers the basic information of nasal glucagon, trials on nasal glucagon in children and adults and its potential uses, limitations, and future scope in practice.

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