Salem A Beshyah

Insulin pump therapy in Moslem patients with type 1 diabetes during Ramadan fasting: an observational report.

BACKGROUND Many Moslem patients do observe the fast during Ramadan. There are limited data on insulin pump therapy during Ramadan. We report our experience with type 1 diabetes patients on insulin pumps during Ramadan 2008 (29 days). PATIENTS AND METHODS A total of 63 patients were evaluated. Forty-nine patients fasted, and 14 elected not to fast. Those who fasted (24 males, 25 females) were 22 +/- 7 years of age (mean +/- SD) and had had diabetes for 9.6 +/- 5.6 years. Patients used the Medtronic (Northridge, CA) MiniMed 722 model and had been using pump therapy for 20 +/- 10 months. Outcome measures included number of days fasted, hypoglycemia, unusual hyperglycemia, and number of emergency hospital visits. RESULTS Thirty patients (61.2%) fasted the whole month with no problems, nine (18.4%) fasted 27-28 days, eight (16.3%) fasted 24-25 days, and two (4.1%) fasted 23 days. Nearly half of the patients decreased their basal insulin by 5-50% of their prefasting doses. Seventeen patients had hypoglycemia requiring breaking the fast. Fasting was broken on 55 out of 1,450 potential fasting days (3.8%). No severe hypoglycemia was reported by any patient. Unusual hyperglycemia was reported in nine patients (18.4%). Hospital visits were reported for one patient for hyperglycemia (a 16-year-old girl who disconnected her pump). Twelve patients had fructosamine levels measured both before and immediately after Ramadan; pre-Ramadan fructosamine level was 4.0 +/- 0.6 mmol/L, and the post-Ramadan value was 3.6 +/- 0.6 mmol/L (P = 0.007). CONCLUSIONS Fasting during Ramadan is feasible in patients with type 1 diabetes using an insulin pump, with adequate counseling and support.

Needle Stick Injuries: An Overview of The Size of The Problem, Prevention And Management

Over 20 million dedicated health care providers (HCP) expose themselves to biological, chemical and mechanical hazards everyday. The World Health Organization estimates that approximately 3 million health care providers are exposed to blood and body fluid due to needle stick or sharp injuries annually. Blood and body fluid exposures have resulted in 57 documented cases of HIV seroconversion among healthcare personnel through 2001. Two thousand workers a year become infected with hepatitis C, and 400 contact hepatitis B. There are more than 20 additional types of infectious agents documented to be transmitted through needle sticks. More than 80% of needle stick injuries are preventable with the use of safer needle devices. Legislation has been developed in many countries to protect HCPs by encouraging employers to use best practices to prevent these exposures. Many different protocols for post exposure management of needle stick injuries or blood and body fluid exposure have been proposed. Effectiveness of a protocol depends on early initiation of post exposure management HIV prophylaxis has the smallest window of time treatment has to be started as soon as possible in the first few hours. Hepatitis B Immunoglobulin could be given within the first 7 days. Healthcare institutions should try to develop policies and procedures to reduce needle stick injuries by acting proactively and vaccinating all HCP for hepatitis B and incorporating improved engineering controls into a comprehensive needle stick injury prevention program. In this review, we present historical background, nature and size of the problem followed by the state of the art review of the prevention, management and corporate responsibilities. DOI: 10.4103/1947-489X.210971

Guidelines for managing diabetes in Ramadan.

Globally there are approximately 90 million Muslims with diabetes of which approximately 400 000 reside within the UK. The holy month of Ramadan is a fundamental practice of this religion of which fasting from sun‐rise to sun‐set is an integral part. This poses many potential risks for those with diabetes who wish to observe Ramadan.

Mini-Symposium: Ramadan Fasting and The Medical Patient: An Overview for Clinicians

The day time fasting of Ramadan is observed annually by millions of adult Moslems all over the world. Some may have mild, moderate or severe medical conditions. They may seek advice on feasibility and safety of fasting and/or their management. Physicians ought to have a working knowledge about the religious rules of Ramadan fast and their medical implications. In this article we present a concise summary of the proceedings of a series of symposia. Their objectives were to review the effects of Ramadan fasting on the health of Moslem patients with various chronic medical conditions and to propose practical management strategies. An initial introductory Islamic perspective on fasting to sets the scene for the following presentations. The religious rulings excluding patients with acute and chronic medical conditions from fasting were highlighted. The roles of the medical professional in guiding patients on best ways to make informed decisions to fast and feast safely were stressed. Available evidence from published literature and clinical practice was reviewed and practical guidance covering the major body systems was given. Generally speaking, fasting in Ramadan is possible for most stable chronically ill patients under medical supervision. The effect of fasting on health issues should be explained to patients well ahead of starting the holy month. Counselling patients about their use of medications as well as their suitability to undertake the fast is a major step in health care for Moslem patients. Available observations cover a spectrum of chronic medical conditions affecting various body systems. These include renal, hematological cardiac, neurological, rheumatologic, gastroenterological, endocrine conditions and drug therapy during Ramadan. Changes in the parameters of clinical functions in healthy people and in non renal patients were minimal, insignificant and remained within the normal range. Patients on hemodialysis could fast safely on non dialysis days. Stable renal transplant recipients do not seem to sustain any risk from fasting after the first year. No evidence of increased risk of renal stones and colic was found during Ramadan. No consistent rise in cardiac events was observed during Ramadan. Hypertension needs special treatment manipulations. Headache and risk of seizures are two neurological conditions with relevance to fasting. These can be managed by simple medical measures. Peptic acid disease complications may increase by the long fasting, however treatment with peptic disease medications reduces the risks. Hematological conditions influenced by dehydration such as sickle disease are better managed by adequate hydration particularly under stressful circumstances. Rheumatological conditions can be managed by usual therapies during Ramadan. Diabetes received most attention from the medical profession for obvious reasons. Several expert statements were published. Where the risk of hypoglycemia or hyperglycemia is increased many would advise against fasting. Patients controlled by simple regimens with low risk of hypoglycemia patients may be able to fast safely. Changes in medication aim at adjusting the amount and timing of the drug administration to match calorie intake thus preventing hypoglycemia in the day time and hyperglycemia after sunset. In conclusion, management of the medical patients during Ramadan represents a special challenge to patients alike. Taking on this challenge is an opportunity to test the cultural-competence of health services.

Blood and Body Fluid Exposure Related Knowledge, Attitude and Practices of Hospital Based Health Care Providers in United Arab Emirates

Objectives Knowledge, attitudes, and practices of healthcare providers related to occupational exposure to bloodborne pathogens were assessed in a tertiary-care hospital in Middle East. Methods A cross-sectional study was undertaken using a self-administered questionnaire based on 3 paired (infectivity known vs. not known-suspected) case studies. Only 17 out of 230 respondents had an exposure in the 12 months prior to the survey and of these, only 2 had complied fully with the hospitals exposure reporting policy. Results In the paired case studies, the theoretical responses of participating health professionals showed a greater preference for initiating self-directed treatment with antivirals or immunisation rather than complying with the hospital protocol, when the patient was known to be infected. The differences in practice when exposed to a patient with suspected blood pathogens compared to patient known to be infected was statistically significant (p < 0.001) in all 3 paired cases. Failure to test an infected patients blood meant that an adequate risk assessment and appropriate secondary prevention could not be performed, and reflected the unwillingness to report the occupational exposure. Conclusion Therefore, the study demonstrated that healthcare providers opted to treat themselves when exposed to patient with infectious disease, rather than comply with the hospital reporting and assessment protocol.

CREED study: Hypoglycaemia during Ramadan in individuals with Type 2 diabetes mellitus from three continents

AIMS To describe diabetes treatment and hypoglycaemia in individuals with Type 2 diabetes mellitus during Ramadan. METHODS A multi-country, retrospective, observational study with data captured before, during, and after Ramadan. We report on a cohort of people (N=3250) with Type 2 diabetes mellitus in four culturally distinct regions: Asia, North Africa, Europe, and the Middle East. RESULTS During Ramadan, the proportion of participants on oral anti-diabetic medication alone ranged from 68.4% (Middle East) to 80.5% (Asia); the proportion on insulin alone ranged from 3.7% (Middle East) to 8.6% (Europe). The average number of days fasted for individuals with an American Diabetes Association (ADA) risk status of very high was 27 (Middle East), 25.7 (Asia), 25.4 (North Africa), and 21 (Europe). The incidence of hypoglycaemia according to an ADA risk status of very high was 5.6% (n=1/18, Europe), 6.1% (n=2/33, Middle East), 8.7% (n=4/46, Asia), and 38% (n=10/26, North Africa). The incidence of hypoglycaemia, during Ramadan, for the entire cohort was 16.8% with insulin treatment and 5.3% with oral anti-diabetic medication. Having an episode of hypoglycaemia before Ramadan was associated with hypoglycaemia during Ramadan (odds ratio 7.80; 95% confidence interval 5.31-11.45). CONCLUSIONS Approaches to the management of Type 2 diabetes mellitus during Ramadan varied across regions. Episodes of hypoglycaemia and insulin therapy predicted risk of hypoglycaemia during Ramadan and identified individuals who required Ramadan-specific education.

A SURVEY OF CLINICAL PRACTICE PATTERNS IN MANAGEMENT OF GRAVES DISEASE IN THE MIDDLE EAST AND NORTH AFRICA

OBJECTIVE Graves disease (GD) is commonly seen in endocrine clinical practice. The objective of this study was to evaluate the current diagnosis and management of patients with GD in the Middle East and North Africa (MENA). METHODS An electronic survey on GD management was performed using an online questionnaire of a large pool of practicing physicians. Responses from 352 eligible and willing physicians were included in this study. They were mostly endocrinologists (157) and internal medicine physicians (116). RESULTS In addition to serum thyroid-stimulating hormone (TSH) and free thyroxine assays, most respondents would request serum antithyroid peroxidase antibody and TSH-receptor autoantibody (50% and 46%, respectively), whereas serum antithyroglobulin antibodies would be ordered by fewer respondents (36%). Thyroid ultra-sound would be requested by a high number of respondents (63.7%), while only a small percentage would order isotopic thyroid studies. Antithyroid drug (ATD) therapy was the preferred first-line treatment (52.7%), followed by radio-iodine (RAI) treatment (36.8%), β-blockers alone (6.9%), thyroidectomy (3.2%), and no therapy (1.3%). When RAI treatment was selected in the presence of mild Graves orbitopathy and/or associated risk factors for its occurrence/exacerbation, steroid prophylaxis was frequently used. The preferred ATD in pregnancy was propylthiouracil in the first trimester and carbimazole in the second and third trimesters. On most issues, choices of the MENA physicians fell between European and American practices. CONCLUSION Hybrid practices are seen in the MENA region, perhaps reflecting training and affiliations. Management approaches most suitable for patients in this region are needed. ABBREVIATIONS ATD = antithyroid drug CBZ = carbimazole FT3 = free T3 FT4 = free T4 GD = Graves disease GO = Graves orbitopathy MENA = Middle East and North Africa MMI = methimazole RAI = radioactive iodine RAIU = RAI uptake T3 = tri-iodothyronine T4 = thyroxine TG Ab = antithyroglobulin antibodies TRAb = TSH-receptor autoantibody TSH = thyroid-stimulating hormone PTU = propylthiouracil TID = thrice daily UAE = United Arab Emirates US = ultrasound.

Driving and diabetes mellitus in the Gulf Cooperation Council countries: Call for action

The aim of the present article is to increase awareness concerning safe driving for patients with diabetes in the Gulf Cooperation Council (GCC) countries and to provide recommendations concerning the management of these patients. The cognitive, motor, and sensory skills required for driving can be adversely affected by diabetes as well as the side effects of anti-diabetic medications, particularly hypoglycemia. The prevalence of diabetes in the GCC countries is among the highest in the world. As the number of diabetic drivers in these countries continues to increase, the number at risk of having a motor vehicle accident is also expected to increase. We reviewed the available literature concerning driving and diabetes, particularly in relation to the current situation in the GGC countries. Unfortunately, very little published information is available addressing this issue in the GCC countries. Most of the GCC countries lack legislation on driving and diabetes. We have proposed recommendations to help diabetic drivers in the GCC countries as well as to provide guidance to health care professionals managing these patients.

Hospitalization Patterns of Diabetic Patients to a Tertiary Hospital in Abu Dhabi, United Arab Emirates

Background: Hospitalization occurs more often in diabetic than non-diabetic patients and is associated with increased morbidity and mortality.. Data on these issues are limited in the Middle East , particularly in new nations suffering from a high prevalence of diabetes. Objectives: We studied the contribution of diabetes to the hospital admission rates and evaluated the database- documented causes and outcomes of hospitalization of people with diabetes in a tertiary hospital. Methods and Patients: This was a descriptive, retrospective electronic records-based study. We identified 14,032 episodes accounted for by diabetes (i.e. 19.1% of the total 51,169 episodes) between 2000-06. Results: 19.1% of admission episodes involved diabetes with an ascending linear trend. The median length of stay was five and four days for diabetes as a primary diagnosis and as a secondary diagnosis respectively. Diabetes as a primary diagnosis was noted in 1,227 patients. The mean age was 42.5 years, and majority were in the 50-70 years age group. Most patients were admitted from the emergency room (71%). Reason for admission was attributed to diabetes per se in >50%, and the majority were discharged home in good condition. On the other hand, diabetes was present as a secondary diagnosis in 8,540 patients (3,494 women and 2,794 Emirati nationals). The mean age of this subgroup was 58.4 years with majority being 41-80 years old. These patients were admitted either as a medical emergency (70%) or directly from home (27%). Patients were admitted under internal medicine (36%), cardiology (27%) and haematology (21%) services. The majority (91%) were discharged home in good condition. A total of 353 patients died while hospitalized (23 with diabetes as a primary diagnosis and 330 when it was a secondary diagnosis respectively. The age at death was 68.8 and 65.4 years in the two subgroups respectively. Conclusions: The present study demonstrated that diabetes is associated with a high number of inpatient episodes. These involved mainly middle-aged adults due to medical and cardiovascular complications of diabetes, and poses a high burden on both health care and the economy. Key Words: Diabetes Mellitus, Middle East, Acute Diabetic Complications, Morbidity, Mortality, Hospitalization, Inpatient Diabetes Care.

Diabesity in the Arabian Gulf: Challenges and Opportunities

Diabesity (diabetes associated with obesity) is a major global and local public health concern, which has almost reached an epidemic order of magnitude in the countries of the Arabian Gulf and worldwide. We sought to review the lifestyle trends in this region and to highlight the challenges and opportunities that health care professionals face and attempt to address and correct them. In this regard, we aimed to review the regional data and widely held expert opinions in the Arabian Gulf and provide a thematic review of the size of the problem of diabesity and its risk factors, challenges, and opportunities. We also wished to delineate the barriers to health promotion, disease prevention, and identify social customs contributing to these challenges. Lastly, we wished to address specific problems with particular relevance to the region such as minimal exercise and unhealthy nutrition, concerns during pregnancy, the subject of childhood obesity, the impact of Ramadan fasting, and the expanding role of bariatric surgery. Finally, general recommendations for prevention, evidence-based, and culturally competent management strategies are presented to be considered at the levels of the individual, community, and policymakers.