Elamin Ibrahim Elamin Abdelgadir

Comparison of Incidences, Hospital Stay and Precipitating Factors of Diabetic Ketoacidosis in Ramadan and the Following Month in Three Major Hospitals in United Arab Emirates. A Prospective Observational Study

1.7 billion Muslims worldwide obey religious commands of fasting for a month. This may increase morbidity in people with diabetes. Objective: Comparing the rate and duration of admissions with diabetic ketoacidosis and the leading precipitating factors during Ramadan and in the following month (Shawal) were our primary and secondary endpoints, respectively. Design and methods: This was a prospective study that included all Muslims who were admitted with DKA to three major hospitals in United Arab Emirates during Ramadan and Shawal. Demographics, clinical, and laboratory indices were collected and analyzed to assess primary and secondary end points. Results: 48 patients were admitted during the study duration, 20 were admitted during Ramadan and 28 in Shawal. All those admitted during Ramadan were people with type1 diabetes while 4 of those admitted during Shawal were people with type 2 diabetes. 75% of those admitted during Ramadan did not receive structured education program on diabetes management in Ramadan. Urinary tract infections represented the commonest cause for admission in both months. Hospital stay was longer during Ramadan compared to Shawal (p=0.04). The average HbA1c was lower in Ramadan group; moreover, frequency of DKA admissions in 6 months period before Ramadan was higher in Ramadan group (P= 0.05). Conclusion: Our study showed lower rate of DKA admissions, but longer hospital stay during Ramadan compared to the following month. The average HbA1c was lower in patients admitted during Ramadan; moreover, frequency of DKA admissions in 6 months period before Ramadan was higher in Ramadan group (P=0.05).

Liraglutide Effect on Blood Pressure, Lipids Profile, and Liver Enzymes in Arab Patients with Type 2 Diabetes Mellitus: A Prospective LIRA-BPL Study

Background: The pathogenetic mechanisms underlying type2 diabetes are quite complex and differ between different ethnic groups. This might results in different responses to medications. Data from LEAD trials showed that liraglutide was associated with significant reduction in weight HbA1c and blood pressure values. Unfortunately there are no enough data on Arab population. Objectives: We aimed to assess the changes in blood pressure, lipids profile, and liver function test upon starting liraglutide and after 6 months of therapy in Arab patients with type 2 diabetes as primary objective. Results: 365 agreed to sign an informed consent. 29% of the studied population was males (n=106) compared to 71% females (n=259). There was no significant change in systolic blood pressure, however average diastolic blood pressure improved significantly (74.4 ± 10 to 72 ± 9 mmHg at 6 months P<0.001). Significantly lower average diastolic BP was seen in Insulin users at both start and the end of the study (73+4 vs. 76+4 P=0.05, and (71+ 5 vs.73+4.6) p=0.02, respectively). Mean AST and ALT was within normal range at baseline and despite that there was a highly significant reduction between baseline and end of study 29+18 to 25.7+ 13 and 25.1 + 20 to 22.2+ 16 for ALT and AST, respectively. Both of them showed highly significant P value (0.0000). There was a significant reduction in weight and HbA1c at 6 months. However the change in weight was more significant in insulin users compared to those who did not use insulin (96+3 to 93+5 vs. 93 +5 to 98+3.5, P-value at the end of the study was 0.02). The HbA1c reduction was significant irrespective of weight loss. Conclusion: Liraglutide showed remarkable improvement in weight, HbA1c, liver enzymes, and diastolic blood pressure. Patients who used insulin at base line had better results in weight and lipids reduction.

Cystatin C and Its Role in Patients with Type 1 and Type 2 Diabetes Mellitus

Diabetes mellitus is the commonest cause of CKD. It is the leading cause of new patients requiring renal replacement therapy, accounting for 40%, 34%, and 30% of cases in United States, Germany, and Australia, respectively. Recent studies have shown that a low-molecular weight protein, cystatin C, freely filtered by the kidneys is a novel biomarker that may be used for detection of early renal dysfunction in patients with type 1 or type 2 diabetes. Cystatin C has also been shown to detect cardiovascular disease in patients with diabetes and it may also be linked with incident type 2 diabetes in obese patients. We aim to review current evidence based literature on use of cystatin C for early detection of diabetic nephropathy due to type 1 and type 2 diabetes in comparison to conventional methods and explore its association with other comorbidities.

Safety of Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2-I) During the Month of Ramadan in Muslim Patients with Type 2 Diabetes

Objectives Sodium-glucose cotransporter 2 inhibitors (SGLT2-I) are a new class of antidiabetic drugs that might increase the risk of dehydration and hypoglycemia, particularly during the month of Ramadan in which Muslims abstain from eating and drinking for 14-16 hours daily. We aimed to provide real-life evidence about the safety of SGLT2-I during Ramadan. Methods All patients over the age of 18 years on SGLT2-I before Ramadan 2016 who would be fasting during Ramadan were included. Demographic data, detailed medical history including comorbidities and medication profile, and laboratory results were collected before and after Ramadan. We also conducted a phone interview to evaluate the frequency and severity of hypoglycemia and dehydration. Results Of the total of 417 patients, 113 (27.0%) experienced hypoglycemic events, and 93 of these (82.3%) checked their blood glucose using a glucometer. Confirmed hypoglycemia (< 70 mg/dL) was observed in 78 (83.8%). The hypoglycemic events were significantly more frequent in the SGLT2-I plus insulin-treated group than in those treated with SGLT2-I plus oral hypoglycemic agents group (p < 0.001). Confirmed hypoglycemic events were more frequent in those using SGLT2-I plus intensive insulin compared to those using SGLT2-I plus basal insulin (p = 0.020). Symptoms of dehydration were seen in 9.3% (n = 39) of the total population. We observed statistically significant reductions in glycated hemoglobin and weight by the end of Ramadan (p < 0.001). There were no significant changes in lipid profile and creatinine levels by the end of the study. Conclusions The use of insulin in combination with SGLT2-I increases the risk of hypoglycemia during Ramadan. Hypoglycemic events were mild and did not require hospital admission. However, careful monitoring during prolonged fasting is warranted. No significant harmful effects on renal function result from treatment with SGLT2-I during Ramadan.

Efficacy and Safety of SGLT2 Inhibitors in Reducing Glycated Hemoglobin and Weight in Emirati Patients With Type 2 Diabetes

Background SGLT2 inhibitors are a new class of drugs that act by inhibiting glucose reabsorption in the proximal renal tubules. Many trials have demonstrated their effectiveness in reducing glycated hemoglobin (HbA1c) and weight, but they have never been examined in Arab or Emirati populations. Methods We assessed the efficacy of SGLT2 inhibitors in reducing HbA1c and weight in our population and specifically in an Emirati cohort. We also assessed the effect on fasting blood glucose, blood pressure, lipid profile, serum creatinine, and side effects. Results The total number of patients was 307. The baseline HbA1c in the Emirati cohort was 8.9±1.7%, which dropped significantly to 8±1.5% at 6 months (P = 0.0001). At 1 year, the mean HbA1c was 8±1.4%, which was significantly different from baseline (P = 0.0001). However, the change in mean HbA1c from 6 months (8±1.5%) to 1 year (8±1.4%) was not statistically significant (P = 0.88). A similar highly significant change was observed when comparing weights at baseline and 6 months in the Emirati population (85.7 ± 17.8 kg vs. 84 ± 17.2 kg, P = 0.0001). Total cholesterol dropped significantly at 6 months (P = 0.008), as did low-density lipoprotein (LDL) (P = 0.005). Conclusions The use of SGLT2 inhibitors is associated with significant reductions in HbA1c and weight. Unlike all previous trials, the inhibitors significantly reduced total cholesterol and LDL. Larger trials are needed to reassess their effects on lipid parameters.

Late Presentation of a Disorder of Sexual Development Due to Rare46XX/47XX SRY-Positive 46XX/47XX Karyotype

Genital tract differentiation and development is a complex process beginning early in embryonic life. Mutation or translocation of the sex-determining region of the Y chromosome (SRY) may lead female genotype to become a male. The absence or genetic mutation of the SRY leads to a male phenotype individual but a female genotype individual (46xx), which is labeled as a Disorder of Sex Development (DSD). We are presenting an 18-year-old male who presented to the endocrine clinic with delayed puberty. There was no apparent predisposing factor upon review of his natal, childhood, and recent history. He had a no secondary sexual characteristics; stretched penile size was 5 cm, and the volume of both testes was around 4 ml. Biochemical assessment showed Hypergonadotrophic hypogonadism, while the peripheral blood Karyotyping showed SRY-positive 46XX/47XX DSD. This is the first reported case with SRY 46XX/47XX, although the somatic changes were not different from the rest of the genetic mutation. The spectrum of the DSD presentation is increasing in the population with time, which necessitates meticulous assessment in early infancy, and genetic screening whenever we suspect this condition. The threshold of suspicion of such diseases should be lower.

Igg4-Related Disorder and Endocrine Diseases: A Review of the Literature

IgG4-related disorders (IgG4-RD) are a new entity of multi-organ disorders that share common fibro-inflammatory histopathologic characteristics and elevated IgG4 levels in serum and tissue. Autoimmune pancreatitis and Mikulicz syndrome are major entities, however many syndromes are part of IgG4-RD including eosinophilic angiocentric fibrosis, fibrosing mediastinitis, hypertrophic pachymeningitis, inflammatory pseudotumour, multifocal fibrosclerosis (commonly affecting the orbits, thyroid gland, retroperitoneum, mediastinum, and other tissues and organs), periaortitis and peri-arteritis, inflammatory aortic aneurysm, retroperitoneal fibrosis (Ormond’s disease), Riedel’s thyroiditis, and sclerosing mesenteritis. In this review we detail the link between IgG4-RD and endocrine disorders and then examine the link between diabetes and IgG4-RD. We study the increased risk of IgG4-RD after using dulaglutide. We concluded that IgG4-RD should be suspected in patients with progressive thyroiditis with mass effect and very high antibody titers. The relationship between IgG4-RD and diabetes is still controversial.

Efficacy of bariatric surgery in improving metabolic outcomes in patients with diabetes. A 24-month follow-up study from a single center in the UAE

Background Owing to its impact on weight loss, remission of diabetes mellitus and metabolic syndrome, bariatric surgery has offered hope for grossly obese individuals. In recent years, obesity has increased in the UAE and the use of bariatric surgery has increased in-line with this trend. However, data regarding bariatric surgery outcomes in diabetic Emirati people is scarce. Objective To evaluate the effect of bariatric surgery in patients with diabetes mellitus. Methods This is a retrospective analysis of diabetic patients treated with bariatric surgery with a minimal follow-up of 1 year and extended for some patients (21) to 2 years follow up. A total of 80 patients underwent bariatric surgery. Two surgical procedures were used; laparoscopic sleeve gastrectomy (n=53) or mini-gastric bypass between January 1, 2015, and July 20, 2017. Results Mean baseline weight was 119.2±31.2 kg, this has significantly dropped to 100.1±23.1, 91.2±22.3, 82.3±17.5, and 81.3±15.3 kg at 3, 6, 12, and 24 months respectively, and this change was statistically significant P<0.001 at each time point. Mean baseline HbA1c was 8.6% ± 2.3% and this dropped significantly to 6.5±1.7, 5.9±1.2, 5.6±0.8, and 5.4±0.7 at 3, 6, 12, and 24 months respectively (P<0.000). In 49 (61.3%) we considered fatty liver based on ultrasound features either with or without elevation in alanine aminotransferase (ALT). We noticed a significant decrease in ALT at 3, 6, and 12 months after surgery. Furthermore, 11 patients (22.4%) showed sonographic features of improvement in fatty liver in addition to normalization of ALT. Conclusions Bariatric surgery was effective over a follow-up period of 2 years in achieving significant weight loss as well as resulting in improvements in glycemic control, blood pressure, and fatty liver.

Survey of the knowledge and attitude of physicians toward the management of diabetes mellitus during Ramadan

Ramadan fasting has been a major concern among researchers considering the theoretically imposed risk on patients with diabetes mellitus due to prolonged fasting. Studies indicate that the knowledge and practices of physicians do not comply with the proposed recommendations in this regard in many cases. This study aimed to explore the viewpoints and attitudes of physicians toward the management of diabetes mellitus regarding to Ramadan fasting. In addition, we assessed the knowledge and compliance of physicians with available recommendations regarding the management of diabetes mellitus in Ramadan. According to the results, Ninety five present of the physicians (n=862) believed the type of diabetes to be “important” or “very important” in decision-making for Ramadan fasting. Control of diabetes before Ramadan was noted as “important” or “very important” by 95 of the physicians (n=848). Moreover, the majority of respondents emphasized on the pivotal role of self-monitoring of blood glucose in the management of patients receiving insulin or sulphonylureas (SUs), and to a lesser extend in cases treated with other oral hypoglycemic agents than SUs. Among the participants, 63.8 (n=397) confirmed the availability of Ramadan-focused educational programs for their patients, whereas thirty six present (n=225) mentioned the absence of such programs. According to the results of this study, it is crucial to raise the awareness of patients and physicians about the importance of Ramadan fasting through structured educational interventions in order to reduce the health risks associated with fasting in diabetic patients. Therefore, it is recommended that simplified guidelines and educational materials be dispensed for healthcare providers for related training programs before Ramadan.

An Unusual Dermatological Manifestation of Gravesâ Disease

Abstract Introduction Pityriasis Rubra Pilaris (PRP) is a chronic inflammatory dermatological disease, the cause of it is not yet clear. Researchers have linked it to autoimmune disease, infections like HIV and streptococcal diseases. There was an established link hypothyroidism. This was significant in the view of some researchers to recommend thyroid function test (TFT) as part of PRP assessment. Case presentation We are presenting a 24-year old lady with a full picture of thyrotoxicosis (Grave’s disease). At the time of she started appreciating the symptoms of the thyrotoxicosis; she started feeling extensive skin dryness, scaling and skin breaks at the joints and the extensor surfaces. She sought dermatological advice in many centres, with no response. With the thyrotoxicosis treatment the skin jeopardy started to improve while she was only on emollients. The skin findings completely vanished after the radioactive iodine (RAI). Conclusions This was the first report of PRP in association with Grave’s disease. This link needs to be confirmed with more case reports. Vanishing skin changes with the thyroid settlement could make it part of the treatment of the PRP. This might strengthen the recommendation of the previous papers of adopting TFT as part of the PRP workup.