Ramadan fasting in people with diabetes and chronic kidney disease (CKD) during the COVID-19 pandemic: The DaR global survey.

BACKGROUND AND AIMS: The DaR Global survey was conducted to observe the impact of the COVID-19 pandemic on the intentions to fast and the outcomes of fasting in people with diabetes and chronic kidney disease (CKD). METHODS: Muslim people with diabetes and CKD were surveyed in 13 countries shortly after the end of Ramadan 2020, using a simple Survey Monkey questionnaire. RESULTS: This survey recruited 6736 people with diabetes, of which 707 (10.49%) had CKD. There were 118 (16.69%) people with type1 diabetes (T1D), and 589 (83.31%) were with type2 diabetes (T2D). 62 (65.24%) people with T1D and 448 (76.06%) people with T2D had fasted with CKD. Episodes of hypoglycaemia and hyperglycaemia were more frequent among people with T1D compared to T2D, 64.52% and 43.54% vs 25.22% and 22.32% respectively. Visits to the emergency department and hospitalization were more frequent among people with CKD, however no significant difference was found between people with T1D and T2D. CONCLUSION: The COVID-19 pandemic had only a minor effect on the intention to fast during Ramadan in people with diabetes and CKD. However, hypoglycaemia and hyperglycaemia were found to be more frequent, as well as emergency visits and hospital admissions among people with diabetic kidney disease. Prospective studies are needed in future to evaluate the risk indicators of hypoglycaemia and hyperglycaemia among fasting people with CKD, especially in the context of different stages of kidney disease.

Kikuchi's Disease Diagnosed by an Excisional Biopsy in a Patient With COVID-19.

COVID-19 is an ongoing pandemic caused by the novel coronavirus SARS-CoV-2. The clinical features of COVID-19 are myriad. Though it is a multisystem illness, it predominantly involves the respiratory system. There have been case reports on rare manifestations of COVID-19, of which COVID-19-related Kikuchi's disease is one of them. To our knowledge, this is the third reported case in the world. We report a lady in her late 60s with COVID-19 infection and secondary bacterial pneumonia, which necessitated ICU admission, having ongoing fever spikes with high inflammatory markers and leukopenia. She was also found to have tender cervical lymphadenopathy on the third week of illness, whose biopsy revealed histiocytic necrotizing lymphadenitis in keeping with Kikuchi's disease. The patient had an uneventful recovery in two weeks without any intervention. The pathophysiology of COVID-19-related Kikuchi's disease is unclear. However, COVID-19 is a viral illness that involves changes in interleukins. The latter is postulated in Kikuchi's disease.

Recommendations for the prevention and management of obesity in the Iraqi population.

Obesity is a chronic metabolic disease that has become one of the leading causes of disability and death in the world, affecting not only adults but also children and adolescents. In Iraq, one third of the adult population is overweight and another third obese. Clinical diagnosis is accomplished by measuring body mass index (BMI) and waist circumference (a marker for intra-visceral fat and higher metabolic and cardiovascular disease risk). A complex interaction between behavioral, social (rapid urbanization), environmental and genetic factors underlies the etiology of the disease. Treatment options for obesity may include a multicomponent approach, involving dietary changes to reduce calorie intake, an increase in physical activity, behavioral modification, pharmacotherapy and bariatric surgery. The purpose for these recommendations is to develop a management plan and standards of care that are relevant to the Iraqi population and that can prevent/manage obesity and obesity-related complications, for the promotion of a healthy community.

Evaluation of physicians' approaches for the management of patients with diabetes during Ramadan in Iraq.

BACKGROUND/OBJECTIVES: In Diabetes Mellitus, fasting Ramadan comes with several challenges for both patients and physicians. However, majority of Muslims with type 2 diabetes fast Ramadan. Therefore, several guidelines have been developed to help physicians in managing their patients during Ramadan. This survey aims to investigate approaches adopted by Iraqi physicians for the management of diabetes during Ramadan. DESIGN AND METHODS: This was a cross-sectional online survey based study conducted via Google forms from March 20 through March 27, 2021. The participants were specialist doctors from different regions in Iraq who were directly involved in management of people with diabetes mellitus. The Google form was distributed to the intended specialist doctors through an invitation link via emails and WhatsApp groups exclusive for specialist doctors from Iraq. The survey was completely anonymous and participants' confidentiality was maintained throughout the study. A total of 140 responses collected in this study. RESULTS: Majority of the participants were family physicians followed by internal medicine physicians and endocrinologists in the following rates 29.2 %, 27.1 % and 16.4 % respectively. Among the respondents, 94.3% reported giving advice to their patients regarding Ramadan fasting; 84.3% of this advice was based on several factors. Those who do not follow a specific guideline in their provision of care and depend on their experience represent 53%. Of them, family physicians were the predominant (70.2%). Pre-Ramadan education is provided by 75% of the participants. Minority (14.3%) allow patients with type 1 diabetes to fast Ramadan and 32.1% allow those with type 2 diabetes on insulin to fast. Recent diabetic ketoacidosis and recent severe hypoglycemia were the main causes for not allowing people to fast Ramadan, 79.3% and 74.3% respectively. Regarding treatment modification during fasting, 56.4 % of physicians change the frequency of administration. Lastly, 67.8 % scored 7/10 or above in the questions to test the familiarity of physicians with the established international guidelines. CONCLUSIONS: This survey highlights the importance of medical education for doctors and the need for structural education programs directed to the family physicians, internists, and other treating physician regarding the current practical guidelines. Health care providers need to be familiar with current diabetes and Ramadan fasting guidelines.

The DAR 2020 Global survey: Ramadan fasting during COVID 19 pandemic and the impact of older age on fasting among adults with Type 2 diabetes.

OBJECTIVES: The DAR Global survey of Ramadan-fasting during the COVID-19 pandemic aimed to describe the characteristics and care in participants with type 2 diabetes (T2D) with a specific comparison between those <65 years and ≥65 years. METHODS: Participants were consented to answer a physician-administered questionnaire following Ramadan 2020. Impact of COVID-19 on the decision of fasting, intentions to fast and duration of Ramadan and Shawal fasting, hypoglycaemia and hyperglycaemia events were assessed. Specific analysis comparing age categories of <65 years and ≥65 years were performed. RESULTS: Among the 5865 participants, 22.5% were ≥65 years old. Concern for COVID-19 affected fasting decision for 7.6% (≥65 years) vs 5.4% (<65 years). More participants ≥65 years old did not fast (28.8% vs 12.7%, <65 years). Of the 83.6%, participants fulfilling Ramadan-fasting, 94.8% fasted ≥15 days and 12.6% had to break fast due to diabetes-related illness. The average number of days fasting within and post-Ramadan were 27 and 6 days respectively, regardless of age. Hypoglycaemia and hyperglycaemia occurred in 15.7% and 16.3% of participants respectively, with 6.5% and 7.4% requiring hospital care respectively. SMBG was performed in 73.8% of participants and 43.5% received Ramadan-focused education. CONCLUSION: During the COVID-19 pandemic, universally high rates of Ramadan-fasting were observed regardless of fasting risk level. Glycemic complications occurred frequently with older adults requiring higher rates of acute hospital care. Risk stratification is essential followed by pre-Ramadan interventions, Ramadan-focused diabetes education and self-monitoring to reduce and prevent complications, with particular emphasis in older adults.

Pattern-Reversal Visual Evoked Potentials Tests in Persons with Type 2 Diabetes Mellitus with and without Diabetic Retinopathy.

BACKGROUND: Currently, diabetic retinopathy (DR) has a wide recognition as a neurovascular rather than a microvascular diabetic complication with an increasing need for enhanced detection approaches. Pattern-reversal visual evoked potentials (PRVEPs) test, as an objective electrophysiological measure of the optic nerve and retinal function, can be of great value in the detection of diabetic retinal changes. OBJECTIVES: The use of two sizes of checkerboard PRVEPs testing to detect any neurological changes in persons with type 2 diabetes mellitus (T2DM) with and without a clinically detected DR. Also, to compare the results according to the candidate age, duration, and glycemic status of T2DM. METHODS: This study included 50 candidates as group A with T2DM and did not have a clinically detected DR and 50 candidates as group B with T2DM and had a clinically detected early DR and 50 candidates as controls who were neither diabetic nor had any other medical or ophthalmic condition that might affect PRVEPs test results. The PRVEPs were recorded in the consultant unit of ophthalmology in Almawani Teaching Hospital. Monocular PRVEPs testing of both eyes was done by using large (60 min) and small (15 min) checks to measure N75 latency and P100 latency and amplitude. RESULTS: There was a statistically significant P100 latency delay and P100 amplitude reduction in both groups A and B in comparison with the controls. The difference between groups A and B was also significant. In both test results of groups A and B, the proportions of abnormal P100 latency were higher than those of P100 amplitude with a higher abnormal proportions in 15 min test. CONCLUSIONS: The PRVEP test detected neurological changes, mainly as conductive alterations affecting mostly the foveal region prior to any overt DR clinical changes, and these alterations were heightened by the presence of DR clinical changes.

Best Time for Levothyroxine Intake in Ramadan (THYRAM): Basrah Experience.

BACKGROUND: Fasting the month of Ramadan should be achieved by every pubescent Muslim unless they have an excuse. Fasting involves complete abstinence of oral intake throughout daytime. Patients who have hypothyroidism usually require levothyroxine (L-thyroxine) replacement, which is typically given on an empty stomach away from meals. Taking L-thyroxine replacement without feeding is challenging during the nighttime of Ramadan, in addition to being prohibited during daytime. OBJECTIVES: This study aimed to determine the best time of L-thyroxine intake during Ramadan. METHODS: Fifty patients who were taking L-thyroxine treatment for primary hypothyroidism were involved in this prospective study for three months including the fasting and pre-fasting months. The patients were divided into three groups with different times of L-thyroxine intake. In the group one (pre-iftar), the patients were asked to take L-thyroxine at the time of iftar (the sunset meal) but to delay any oral intake for at least 30 minutes. In the group two (post-iftar), the patients were asked to take L-thyroxine two hours after iftar. The patients in the last group (pre-suhoor) were asked not to eat in the last two hours before suhoor (the predawn meal) and to take L-thyroxine tablet one hour prior to suhoor. RESULTS: When thyroid stimulating hormone (TSH) levels were compared before and after Ramadan, there were no significant differences neither within each group nor among all the study groups. Moreover, the frequencies of the TSH control after Ramadan showed no significant differences within each of the study groups (P = 0.18, 0.75, 1.0 for pre-suhoor, pre-iftar, and post-iftar respectively). Similarly, comparison among the groups of the study showed no significant differences regardless of whether the patients had controlled or uncontrolled TSH prior to Ramadan (P = 0.75 and 0.67, respectively). In the patients with controlled TSH before Ramadan, 8 out of 10 (pre-suhoor), 8 out of 12 (pre-iftar), and 4 out of 6 (post-iftar) maintained their control after Ramadan. While in the patients with uncontrolled TSH before Ramadan, 7 out of 10 (pre-suhoor), 6 out of 8 (pre-iftar), and 2 out of 4 (post-iftar) achieved controlled TSH after Ramadan. CONCLUSIONS: No significant differences in TSH control were observed in patients taking L-thyroxine at pre-iftar, post-iftar, or pre-suhoor time in Ramadan.

Effect of high-dose dexamethasone on patients without diabetes during elective neurosurgery: a prospective study.

INTRODUCTION: The peri-operative use of high-dose dexamethasone to reduce cerebral oedema may result in worsening glycaemic control in people with diabetes and glucocorticoid-induced diabetes in susceptible individuals. This study aims to examine the incidence of glucocorticoid-induced diabetes in a cohort of neurosurgical patients receiving high-dose dexamethasone peri-operatively. MATERIALS AND METHODS: Adult non-diabetic neurosurgical patients receiving high-dose dexamethasone were prospectively studied. Exclusion criteria included pregnancy, HbA1c > 6.0%, and use of anti-diabetes therapies. The following data were collected: Family history of diabetes, body mass index, fasting glucose, insulin, C-peptide, and HbA1c (prior to surgery and 6 weeks after last dose of dexamethasone). Homeostatic model assessment values were calculated. Peri-operative glucose readings were recorded and 75 g oral glucose tolerance tests performed at the end of 6 weeks. Paired student t tests and multiple linear regressions were used. RESULTS: Data from 21 participants (11 women) were available. The mean total dose of dexamethasone was 96 ± 34 mg, and treatment duration was 17 ± 7 days. A total of 105 random blood glucose levels were documented peri-operatively (mean 7.0 ± 1.0 mmol/L). Six weeks following cessation of dexamethasone course, none of the participants developed diabetes, defined either by fasting glucose or by 75 g OGTT. There was a statistically significant increase in the mean HOMA-ß from 81.5 to 102.1% (p = 0.01) and a significant decrease in the mean fasting glucose from 5.7 to 4.8 mmol/L (p = 0.001). CONCLUSIONS: The use of high-dose dexamethasone in this cohort of neurosurgical patients did not result in glucocorticoid-induced diabetes. Hyperglycaemia was transient and had resolved by 6 weeks.

Safety and Efficacy of Bipolar Radiofrequency Ablation Device in Hemostasis during Thyroidectomy in Comparison with Ultrasonic Scalpel: A Comparative Study.

AIM: Ultrasonic scalpel is one of the recent advances in surgical technology. The main limitation of their use is the cost. However, radiofrequency ablation device is a refined type of electrosurgical cautery that can be used with conventional reusable bipolar cautery forceps. This study aims to compare the efficacy of bipolar radiofrequency ablation device that can be used with conventional reusable bipolar cautery forceps for hemostasis and dissection during thyroidectomy with that of ultrasonic scalpel. MATERIALS AND METHODS: Sixty patients underwent total thyroidectomy were recruited at Alshiffa General Hospital, Basrah, Iraq from March 2016 to June 2017. The participants were divided into two equal groups: in the first group thyroid dissection was done with ultrasonic scalpel, and in the second group thyroid dissection was done with bipolar radiofrequency ablation device. Outcome and complications of both procedures were analyzed statistically and compared. RESULTS: The bipolar radiofrequency ablation device significantly reduced the mean operative time by (-15.35 min) in comparison to ultrasonic scalpel. The Bipolar Radiofrequency Ablation Device (BRFA) group reported a mean operative time of 50.13 ± 14.16 compared to 65.49 ± 7.78 in the US group with, P value = 0.001. There was no statistically significant difference in the other outcome parameters and the rate of complications reported between the two devices during this study. CONCLUSION: The bipolar radiofrequency ablation device that can be used with conventional reusable bipolar cautery forceps is a simple, safe, and time-saving adjunct for thyroid surgeries and equally effective as compared to costly instruments like ultrasonic scalpel. CLINICAL SIGNIFICANCE: The bipolar radiofrequency device can be used in thyroid surgery to secure hemostasis, save time, and cost.

Epidemiology of type 1 diabetes mellitus in Basrah, Southern Iraq: A retrospective study.

AIMS: To investigate the epidemiology of type 1 diabetes mellitus (T1DM) in Basrah city, Southern Iraq, between 2012 and 2016 among people 0-40year old. METHODS: This was a retrospective data analysis of electronic archives for patients with T1DM registered in Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC), which is a tertiary referring Center in Basrah. The data include electronic database from August 2008 to February 2016. Incidence and prevalence rates are expressed per 100,000. Population of Basrah estimates were derived from official data of The Ministry of Planning of Iraq. RESULTS: There were 2536 people registered at FDEMC. Of them 53.5% were males. The overall mean age at first diagnosis was 15.3±9years and it was significantly higher in males; p value 0.0005. The prevalence rate of T1DM in people 40years old and younger in 2016 was 87 per 100,000. Between 1 January 2012 and 31 December 2016, there were 818 identified new cases of T1DM. Of these, 417 (50%) were males. The average annual incidence rate of T1DM was 7.4 per 100,000 (95% CI, 7.1-8.1). CONCLUSIONS: The incidence of T1DM in Basrah lies in the "intermediate group" according to DIAMOND project group classification. The incidence was increasing over the last three years. The data produced by this study provide a baseline for assessing future changes in the epidemiology of T1DM in Iraq.

The effect of Ramadan fasting on glycaemic control in insulin dependent diabetic patients: A literature review.

BACKGROUND: Ramadan fasting is one of the five pillars of Islam. People with diabetes are exempted from fasting according to Islamic rules. However, many people with diabetes wish to fast. Physicians are asked frequently by their patients about their ability to fast and the possible impact of fasting on their glycaemic control. Studies about the effect of Ramadan on people with insulin-treated diabetes are scarce. This review aims to provide clinicians with the best recommendations for their patients with insulin-treated diabetes who wish to fast. METHODS: Four databases (Medline, EMBASE, Scopus and PubMed) were searched using the following MeSH terms and keywords: "insulin dependent diabetes mellitus", "type 1 diabetes mellitus", 'Ramadan' "and" "fasting". In addition, a hand search of key journals and reference lists was performed. Sixteen full text articles were selected for review and critical analysis. RESULTS: All of the included studies except one found improvement or no change in glycaemic control parameters during Ramadan fasting. The incidence of major complications were negligible. Minor hypoglycaemic events were reported in some studies but did not adversely affect fasting. Postprandial hyperglycaemia was a major concern in other studies. However, the incidence of severe hyperglycaemia and diabetic ketoacidosis were trivial. CONCLUSION: Ramadan fasting is feasible for insulin dependent diabetic patient who wish to fast. Clinicians should advise their patients about the importance of adequate glycaemic control before Ramadan and frequent glucose monitoring during fasting. Certain types of Insulin seem to be more beneficial than other.