Mussa H. Almalki

Vitamin D: Light side and best time of sunshine in Riyadh, Saudi Arabia.

Low levels of 25-hydroxyvitamin D have been documented among inhabitants of the wider Middle East and North African countries. Sunlight has long been recognized as a major provider of vitamin D. In this study we aimed to determine the optimum time for sun exposure in the Central region of Riyadh, Saudi Arabia. Ampoules containing 7-dehydrocholesterol in ethanol were exposed to sunlight every hour starting from sunrise until sunset in July and December. Our results demonstrated that the time of the day has a major influence in vitamin D production. In this study, summer production of previtamin D3 was observed to occur between 8:00 PM to 4:00 PM with peak hours between 10:00 AM to 12:00 PM. During wintertime however, the conversion began later at around 9:30 AM and ended sooner at 2:00 PM, with peak hours at 10:00 AM to 12 noon. In conclusion, the optimum time to get sun exposure for vitamin D3 production in Riyadh, during summer is from 9:00 AM and before 10:30 AM, as well as after 2:00 PM until 3:00 PM, while during winter it’s from 10:00 AM until 2:00 PM. These times are important on a public health perspective, as it’s free, relatively safe and the most enjoyable. This strategy is a highly efficacious way for improving the vitamin D status for children and adults and preventing vitamin D deficiency.

Managing Prolactinomas during Pregnancy.

Prolactinomas are the most prevalent functional benign pituitary tumors due to a pituitary micro- or macroadenoma. The majority of patients presents with infertility and gonadal dysfunction. A dopamine agonist (DA) (bromocriptine or cabergoline) is the treatment of choice that can normalize prolactin levels, reduce tumor size, and restore ovulation and fertility. Cabergoline generally preferred over bromocriptine because of its higher efficacy and tolerability. Managing prolactinomas during pregnancy may be challenging. During pregnancy, the pituitary gland undergoes global hyperplasia due to a progressive increase in serum estrogens level that may lead to increase of the tumor volume with potential mass effect and visual loss. The risk of tumor enlargement may occur in 3% of those with microadenomas, 32% in those with macroadenomas that were not previously operated on, and 4.8% of those with macroadenomas with prior ablative treatment. Though both drugs appear to be safe during pregnancy, the data on fetal exposure to DAs during pregnancy have been reported with bromocriptine far exceeds that of cabergoline with no association of increased risk of pregnancy loss and premature delivery. It is advisable to stop the use of DAs immediately once pregnancy is confirmed, except in the case of women with invasive macroprolactinomas or pressure symptoms. This review outlines the therapeutic approach to prolactinoma during pregnancy, with emphasis on the safety of available DA therapy.

Metformin induced acute pancreatitis

Acute pancreatitis frequently presents with abdomen pain but may presents with various skin manifestations as rash and rarely, pancreatic panniculitis. Metformin, one of the most effective and valuable oral hypoglycemic agents in the biguanide class was linked to acute pancreatitis in few cases. Here, we report a case of metformin induce acute pancreatitis in young healthy man with normal renal function.

Differences and associations of metabolic and vitamin D status among patients with and without sub-clinical hypothyroid dysfunction

BackgroundSub-clinical hypothyroid dysfunction, a relatively understudied disorder in the Kingdom of Saudi Arabia (KSA), has significant clinical implications if not properly monitored. Also from KSA, more than 50% of the population suffer from hypovitaminosis D (<50 nmol/l). In this cross-sectional case-control study, we described the differences and associations in the metabolic patterns of adult Saudis with and without hypothyroid dysfunction in relation to their vitamin D status, PTH, calcium and lipid profile.MethodsA total of 94 consenting adult Saudis [52 controls (without subclinical hypothyroidism), 42 cases (previously diagnosed subjects)] were included in this cross-sectional study. Anthropometrics were obtained and fasting blood samples were taken for ascertaining lipid and thyroid profile, as well as measuring PTH, 25(OH) vitamin D and calcium.ResultsCases had a significantly higher body mass index than the controls (p < 0.001). Circulating triglycerides was also significantly higher in cases than the controls (p = 0.001). A significant positive association between HDL-cholesterol and PTH (R = 0.56; p = 0.001), as well as a negative and modestly significant negative association between LDL-cholesterol and PTH (R = - 20.0; p = 0.04) were observed. FT3 was inversely associated with circulating 25 (OH) vitamin D (R = -0.25; p = 0.01).ConclusionsPatients with hypothyroid dysfunction possess several cardiometabolic risk factors that include obesity and dyslipidemia. The association between PTH and cholesterol levels as well as the inverse association between vitamin D status and FT3 needs to be reassessed prospectively on a larger scale to confirm these findings.

Intrathyroidal Parathyroid Cyst: An Unusual Neck Mass

Parathyroid cyst (PC) is a very rare condition. A case of intrathyroidal PC is being reported here in a 53-year-old woman who presented to the endocrine clinic with slowly progressive painless left anterior neck swelling for 1 year with no symptoms of thyroid or parathyroid dysfunction and no compressive symptoms. Ultrasound of the thyroid showed a well-defined cystic lesion measuring 4.7 × 3.6 cm in maximum diameter with internal echoes within the cyst located in the left lobe of the thyroid gland. Fine needle aspiration revealed colorless clear fluid with a high concentration of parathyroid hormone. The patient underwent left hemithyroidectomy at her request. Histopathology revealed parathyroid tissue with unilocular cyst and thyroid tissue with goitrous changes. She was in remission, and there was no evidence of thyroid or parathyroid dysfunction after surgery.

Glycemic control and pregnancy outcomes in patients with diabetes in pregnancy: A retrospective study

Context: Diabetes in pregnancy (DIP) is either pregestational or gestational. Aims: To determine the relationship between glycemic control and pregnancy outcomes in a cohort of DIP patients. Settings and Design: In this 12-month retrospective study, a total of 325 Saudi women with DIP who attended the outpatient clinics at a tertiary center Riyadh, Saudi Arabia, were included. Subjects and Methods: The patients were divided into two groups, those with glycated hemoglobin (HbA1c) ≤6.5% (48 mmol/mol) and those with glycated hemoglobin (HbA1c) above 6.5%. The two groups were compared for differences in maternal and fetal outcomes. Statistical Analysis Used: Independent Students t-test and analysis of variance were performed for comparison of continuous variables and Chi-square test for frequencies. Odds ratio and 95% confidence intervals were calculated using logistic regression. Results: Patients with higher HbA1c were older (P = 0.0077), had significantly higher blood pressure, proteinuria (P < 0.0001), and were multiparous (P = 0.0269). They had significantly shorter gestational periods (P = 0.0002), more preterm labor (P < 0.0001), more perineal tears (P = 0.0406), more miscarriages (P < 0.0001), and more operative deliveries (P < 0.0001). Their babies were significantly of greater weight, had more Neonatal Intensive Care Unit (NICU) admissions, hypoglycemia, and macrosomia. Conclusions: Poor glycemic control during pregnancy is associated with adverse maternal and fetal outcomes (shortened gestational period, greater risk of miscarriage, increased likelihood of operative delivery, hypoglycemia, macrosomia, and increased NICU admission). Especially at risk are those with preexisting diabetes, who would benefit from earlier diabetes consultation and tighter glycemic control before conception.

Options for Controlling Type 2 Diabetes during Ramadan

The Muslim population is about 1.5 billion worldwide. Based on a global diabetes prevalence of 4.6%, it is estimated that there are about 50 million Muslims with diabetes around the world who observe fasting during the month of Ramadan each year. Ramadan, one of the five pillars of Islam, and which takes place during the ninth month of the Islamic calendar, involves fasting from sunrise to sunset. During the fast, Muslims are required to refrain from eating food, drinking, using medications, and smoking from dawn until after sunset, with no restrictions on food or fluid intake between sunset and dawn. Islam exempts people from the duty of fasting if they are sick, or if fasting may affect their health, as fasting for patients with diabetes carries a risk of an assortment of complications, including hypoglycemia, postprandial hyperglycemia, and metabolic complications, associated with dehydration. Nevertheless, a large number of people with diabetes who still choose to fast during Ramadan despite the advice of their doctor, and the permission received from religious authorities thus create medical challenges for themselves and their health-care providers. It is thus important for patients with diabetes who wish to fast during Ramadan to make the necessary preparations to engage in fasting as safely as possible. This review presents a guide to the care of diabetic patients during Ramadan to help them fast safely if they wish to do so.

Clinical and Biochemical Characteristics of Diabetes Ketoacidosis in a Tertiary Hospital in Riyadh

Diabetes is the fifth leading cause of death worldwide. Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes. The aim of this study is to investigate the clinical and biochemical characteristics of DKA among 400 patients admitted to hospital, most of whom had type 1 diabetes (n = 372; 93%). Vomiting (n = 319; 79.8%), nausea (n = 282; 70.5%), and abdominal pain (n = 303; 75.8%) were the presenting symptoms most commonly experienced by the patients. Tachycardia was the most common clinical sign noted in the patients on admission (n = 243; 61.8%). The predominant precipitating cause of DKA was noncompliance to an insulin regimen (n = 215; 54.2%). Recurrent DKA admissions in type 1 diabetes patients was higher than those with type 2 diabetes (n = 232 versus n = 9, respectively; P = 0.002). Recurrent DKA admissions in female patients were higher than in male patients (n = 167 versus n = 74, respectively; P = 0.002). Continued diabetic education (given to n = 384; 94%) and counseling on the importance of adhering to the recommended medical regime, addressing the social and cultural barriers that precipitate DKA, as well as the provision of timely medical attention may greatly reduce DKA episodes and their associated complications.

Cabergoline-Induced Pneumocephalus Following Treatment for Giant Invasive Macroprolactinoma Presenting With Spontaneous Cerebrospinal Fluid Rhinorrhea:

Cerebrospinal fluid (CSF) rhinorrhea is rarely reported as the first presenting feature of giant invasive macroprolactinomas. Cerebrospinal fluid rhinorrhea is usually reported as a complication of trauma, neurosurgical, and skull-based procedures (such as pituitary surgery or radiations), and less frequently after medical treatment with dopamine agonists (DAs) for macroprolactinomas. This phenomenon results from fistula creation that communicates between the subarachnoid space and the nasal cavity. Meanwhile, pneumocephalus is another well-recognized complication after transsphenoidal surgery for pituitary macroadenomas. This entity may present with nausea, vomiting, headache, dizziness, and more seriously with seizures and/or a decreased level of consciousness if tension pneumocephalus develops. Case reports about the occurrence of spontaneous pneumocephalus after medical treatment with DAs without prior surgical interventions are scarce in the literature. Our index case is a young man who was recently diagnosed with a giant invasive prolactin-secreting pituitary macroadenoma with skull base destruction. A few months before this diagnosis, he presented with spontaneous CSF rhinorrhea with no history of previous medical or surgical treatment. In this case report, we report an uncommon presentation for giant invasive macroprolactinoma with a CSF leak treated with cabergoline that was subsequently complicated by meningitis and pneumocephalus. This is a very rare complication of cabergoline therapy, which occurred approximately 1 month after treatment initiation.

Assessment of Ramadan Education and Knowledge Among Diabetic Patients

Background: During Ramadan, Muslims fast from dawn until dusk for one lunar month every year. Most of the Muslim patients with diabetes are unaware of the potential complications that can occur while fasting, such as hypoglycemia. The aim of this study is to assess the the patient education level and patients’ overall awareness of any possible complications that could occur while fasting during Ramadan and to determine how these patients deal with these complications. Methods: We conducted a cross-sectional study and surveyed diabetic patients about their diabetes-related knowledge over a period of 4 months from the outpatient clinic at the Obesity, Endocrine, and Metabolism Center at King Fahad Medical City. Patients were included if they were ≥16 years and if they had been receiving treatment for at least 1 year before the study, irrespective of the medications used; patients were also asked about the presence or absence of complications. Results: This study included 477 patients (325 women and 152 men). Most patients (297; 62.3%) had type 2 diabetes. The patients’ mean age was 39.72 ± 15.29 years, and the mean duration of diabetes was 10.80 ± 5.88 years. During the preceding Ramadan, 76% of patients reported fasting, whereas 58% said that they monitored their blood glucose levels once per day. Hypoglycemic episodes were reported in 60.3% of cases with type 2 diabetes and in 8.3% of cases with type 1 diabetes. Among those who had hypoglycemia, 2.8% of patients with type 1 diabetes and 17.8% with type 2 diabetes broke their fast. Finally, 54% of patients reported that their health care providers offered them instructions on diabetes management during Ramadan. Conclusions: Ramadan health education in diabetes can encourage, improve, and guide patients to change their lifestyles during Ramadan while minimizing the risk of acute complications.