Clinical practice recommendations for management of Diabetes Mellitus in Arab region: An expert consensus statement from Arab Diabetes Forum (ADF).

Prevalence of diabetes in Arab region has significantly increased, resulting in a significant economic burden on healthcare systems. This surge can be attributed to obesity, rapid urbanization, changing dietary habits, and sedentary lifestyles. The Arab Diabetes Forum (ADF) has established localized recommendations to tackle the region's rising diabetes prevalence. The recommendations, which incorporate worldwide best practices, seek to enhance the quality of treatment for people with diabetes by raising knowledge and adherence among healthcare providers. The guidelines include comprehensive recommendations for screening, diagnosing, and treating type 1 and type 2 diabetes in children and adults for better overall health results.

Real-world effectiveness and safety of insulin glargine 100 U/mL plus lixisenatide in adults with type 2 diabetes: An international, multicentre, 12-month, prospective observational study.

AIM: To assess the impact of insulin glargine (100 U/mL) and lixisenatide (iGlarLixi) fixed-ratio combination therapy on the overall management of glycaemia in patients with type 2 diabetes (T2D), previously inadequately controlled with oral antidiabetic drugs ± basal insulin or glucagon-like peptide-1 receptor agonists (GLP-1 RAs). MATERIALS AND METHODS: This 12-month, international, multicentre, prospective, observational study included patients (age ≥ 18 years) with T2D who had initiated iGlarLixi within 1 month prior to study inclusion. Data were collected at study inclusion, month 3, month 6 and month 12 from patient diaries, self-measured plasma glucose, and questionnaires. The primary endpoint was change in HbA1c from baseline to month 6. RESULTS: Of the 737 eligible participants (mean age: 57.8 [standard deviation: 11.2] years; male: 49%), 685 had baseline and post-baseline HbA1c data available. The least squares mean change in HbA1c from baseline to month 6 was -1.4% (standard error [95% confidence interval (CI)]: 0.05 [-1.5, -1.3]). The absolute change from baseline at month 12 was -1.7% ± 1.9% (95% CI: -1.9, -1.5). There were 72 hypoglycaemia events reported during the study period, with a very low incidence of severe hypoglycaemia (two participants [rate: 0.003 events per patient-year]). CONCLUSIONS: This real-world observational study shows that initiation of iGlarLixi in people with T2D inadequately controlled on oral antidiabetic drugs ± basal insulin or GLP-1 RAs improves glycaemic control with a low incidence of hypoglycaemia.

Factors Influencing the Choice of Glucose-Lowering Medications Among Physicians Treating Patients With Type 2 Diabetes.

Background The factors considered by physicians when prescribing a glucose-lowering agent to patients with type 2 diabetes (T2D) in real-world settings are not necessarily consistent with those recommended by clinical practice guidelines. Here, we identify the major factors that drive physicians' selection of glucose-lowering agents in the real world and how these factors may differ by physician's specialty.  Methods A web-based survey was conducted among 135 physicians who manage patients with T2D in Saudi Arabia. Physicians were categorized according to their specialty into "specialists" (endocrinologists and/or diabetologists) and "generalists" (internists, family physicians, and primary care physicians). Physicians were asked about the type of glucose-lowering medication that they would typically prescribe in certain clinical scenarios and what factors drive such a selection. Results Sulfonylurea remains the most frequently prescribed second-line agent, as an add-on to metformin, according to 50% of the physicians surveyed. Most physicians (89%) reported prescribing glucagon-like peptide 1 receptor agonists (GLP-1RA) to less than half of their patients with T2D and ischemic heart disease; over two-thirds reported prescribing sodium-glucose cotransporter 2 inhibitors (SGLT-2i) to less than half of their patients with T2D and heart failure. When prescribing GLP-1RAs, the cost was a "major consideration" by 75% and 65% of the specialists and generalists, respectively. Likewise, when prescribing SGLT-2i, the cost was a major consideration by 57% and 71% of the specialists and generalists, respectively. Several other factors differed between the generalists and specialists when prescribing thiazolidinedione (TZD), sulfonylurea, dipeptidyl peptidase 4 (DPP-4) inhibitors, GLP-1RAs, and SLGT-2i, but not insulin.  Conclusion Our findings highlight several challenges faced by physicians in the real world that may prevent them from adopting the latest evidence-based guidelines when managing patients with T2D. Health policies to increase accessibility to novel glucose-lowering agents, particularly for patients with T2D and cardiovascular/renal diseases, are needed.

Ultrasonographic predictors of thyroid cancer in Bethesda III and IV thyroid nodules.

Background: Bethesda III and IV thyroid nodules continue to be difficult to manage. Although molecular testing may assist in decision-making, it is expensive, not widely available, and not without pitfalls. The objective of this study is to assess whether certain thyroid ultrasonographic features may predict the risk of thyroid cancer in patients with Bethesda III and IV thyroid nodules and be used as additional decision-making tools to complement cytopathological results in deciding on diagnostic thyroidectomy. Methods: We retrospectively evaluated the ultrasonographic features of Bethesda categories III and IV thyroid nodules in patients who underwent subsequent thyroidectomy. We used the final histopathological examination of the surgical specimens as the gold-standard test and analyzed individual preoperative ultrasonographic features as predictors of malignancy. Results: Of the 278 patients who were diagnosed with Bethesda III and IV thyroid nodules on fine needle aspiration cytology (FNAC), 111 (39.9%) had thyroid cancer, and 167 (59.9%) exhibited benign nodules. The malignancy rate was higher in patients with Bethesda IV nodules (28/50, 56%) than those with Bethesda III nodules (83/228, 36.4%; p=0.016). In univariate analysis, hypoechogenicity (55.6% in malignant vs. 35.3% in benign, p=0.006) and calcifications (54.5 in malignant vs. 35.4% in benign, p=0.008) were significantly different between the benign and malignant pathology groups, whereas the size of the dominant nodule, number of nodules, irregular borders, taller-than-wide shape, and the presence of lymph nodes were comparable between the two groups. These two ultrasonographic features (hypoechogenicity and calcifications) remained significantly associated with the risk of malignancy in multivariate logistic regression analysis (for hypoechogenicity, p=0.014, odds ratio: 2.1, 95% CI:1.0-3.7 and for calcifications, p=0.019, odds ratio: 1.98, 95% CI:1.12-3.50). The sensitivity, specificity, positive and negative predictive values, and accuracy were 31.5%, 83%, 55.6%,64.7%, and 62.6%, for hypoechogenicity, respectively and 32.4%, 82%, 54.5%, 67.8%, and 62%, for calcification, respectively. Conclusions: Hypoechogenicity and calcifications in Bethesda III and IV thyroid nodules are strong predictors of thyroid cancer and associated with a two-fold increased risk of malignancy.

Evaluating the Clinical Effectiveness and Safety of Semaglutide in Individuals with Uncontrolled Type 2 Diabetes. Real-World Evidence from Saudi Arabia: The Observational, Multicenter, 15-Month EVOLUTION Study.

INTRODUCTION: This study aimed to assess the safety and effectiveness of semaglutide, administered either by weekly subcutaneous (SC) injection or orally, in real-life practice in Saudi Arabia in individuals with type 2 diabetes mellitus (T2DM). METHODS: A retrospective chart review study was conducted at 18 Saudi Arabia centers. An accredited centralized institutional review board approved the study. Medical records were included for individuals of any age ≥ 18 years with uncontrolled T2DM. The primary outcome measure was the laboratory glycated hemoglobin (HbA1c) level. Secondary measures included fasting blood glucose (FBG), weight, and hypoglycemia. All variables were checked after 6 and 12 months of semaglutide initiation. RESULTS: The analysis of this study included 1223 patients with uncontrolled T2DM (HbA1c > 7%). The mean (SD) baseline HbA1c was 10.02% (1.17). HbA1c was reduced by an average of 3.02% (0.84) and 3.17% (0.84) at 6 and 12 months, respectively. Results of a repeated measure analysis of variance (ANOVA) indicated significant differences in HbA1c (p value < 0.001). HbA1c levels at 6 and 12 months were significantly lower, 7.00% (0.70) and 6.85% (0.69), than at baseline, 10.02% (1.17). About 193 patients (56.4%) of the 295 patients having HbA1c < 9% achieved HbA1c of 5.7% or less. The frequency of hypoglycemia events was 4.60 (1.10) in the 3 months before semaglutide was initiated. The frequency of hypoglycemia events in the last 3 months was 2.30 (0.80) events and 0.80 (0.50) events at 6-month and 12-month follow-up visits, respectively. The percent reduction in body mass index (BMI) was an average of 13.07% (1.53) and 19.89% (4.07) at 6 and 12 months, respectively. Lipid profile and blood pressure were improved at 6 and 12 months. CONCLUSION: Semaglutide, administered either by SC injection or orally, provided substantial glycemic and weight-loss benefits in adults with T2DM.

The American Thyroid Association risk stratification and long-term outcomes of differentiated thyroid cancer: a 20-year follow-up of patients in Saudi Arabia.

Background: Studies have reported differing factors associated with poor outcomes in patients with differentiated thyroid cancer (DTC). We aimed to describe our 20 years of experience in the management of thyroid cancer (TC) and identify predictors of treatment outcomes. Methods: We conducted a retrospective review of medical records of patients with TC seen in the Thyroid Center at King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia, between the years 2000 and 2020. Demographic and clinical data including pathological characteristics were collected. The American Thyroid Association (ATA) risk stratification was determined for all patients at the postoperative period as well as the response to therapy at the final follow-up visit. Results: A total of 674 patients (mean age: 47.21 years) with TC, 571 (84.7%) of which were women, were included. There were 404 (60.0%) patients with ATA low risk, 127 (18.8%) with intermediate risk, and 143 (21.2%) with high-risk histology. Overall, 461 patients (68.4%) had an excellent response to treatment, 65 (9.6%) had an indeterminate response, 83 (12.3%) had a biochemical incomplete response, and 65 (9.6%) had a structural incomplete response. Patients who had an excellent response were mostly ATA low risk (n = 318 of 431, 68.1%), whereas 40 of 65 patients (61.5%) of those with ATA high-risk histology had a structural incomplete response to treatment. There were significantly more women who had an excellent response compared with men. Obesity, lymphovascular invasion, and size of the tumor were significant predictors of worse outcomes to therapy. Conclusion: Tumor size, lymphovascular invasion, and obesity are strong predictors of a worse response to therapy among patients with TC. Patients with obesity should be carefully followed up regardless of their risk stratification in light of the recent compelling evidence associating obesity with thyroid cancer and its higher risk of a worse disease outcome. ATA risk stratification is well correlated with patient long-term outcomes.

"Pre-Ramadan" telemedicine: Effect on fasting experience and glycemic control during ramadan in people with type 1 diabetes.

OBJECTIVE: People with type 1 diabetes (T1D) are advised to have a "pre-Ramadan" visit to receive the assessment and education needed to safely fast during the holy month of Ramadan. The COVID-19 lockdown has interrupted this standard of care in Muslim-majority countries where telemedicine is not well-established. Here, we examined the impact of virtual"pre-Ramadan" visits, as an alternative option to the traditional (in-person) visits, on fasting experience and glycemic control during Ramadan in people with T1D. METHOD: 151 individuals with T1D were categorized into 3 groups according to the type of"pre-Ramadan" visit that they attended in 2020: virtual (n = 50), in-person (n = 56), and no visit (n = 45). Number of days fast was broken and CGM metrics were retrospectively compared across the groups. RESULT: Patients who had a virtual"pre-Ramadan" visit were more likely to use continuous glucose monitors (CGM) than those who had no visit (61.7% and 38.6%, respectively, p < 0.05). Attending a virtual"pre-Ramadan" visit was associated with the least number of days fast was broken compared to those who had no visit (p < 0.01) or in-person visit (p = 0.02). CGM time in range (TIR) during Ramadan was the highest in those who had virtual "Pre-Ramadan" visits compared to those who had no visit or in-person visits (59%, 44%, and 47%,respectively). After adjusting for age, gender, pre-Ramadan A1c, and CGM use, the odds of fasting most days of Ramadan were highest in the virtual group [OR (CI): 9.13 (1.43, 58.22)] followed by the in-person group [3.02 (0.54,16.68)] compared to the no visit group. CONCLUSION: Virtual"pre-Ramadan" visits are effective alternative to in-person visits when managing people with T1D who plan to fast during Ramadan.

Optimal Timing of Thyroid Hormone Replacement During Ramadan Fasting: A Randomized Controlled Trial in Patients with Prior Total Thyroidectomy.

Background: Fasting during Ramadan may be challenging for patients on levothyroxine (LT4), as the drug has a narrow therapeutic index and is administered on an empty stomach. The majority of Muslims who fast in Ramadan have two meals per day, iftar immediately after sunset and suhoor just before dawn. This study aimed at evaluating the impact of LT4 timing during Ramadan on thyrotropin (TSH) levels in patients who underwent total thyroidectomy to determine the best timing for intake and identify the predictors of TSH level changes. Methods: We conducted a parallel, double-blind, randomized controlled trial on Saudi patients diagnosed with hypothyroidism who underwent total thyroidectomy. Patients were required to have stable thyroid function for 6 months before the study period and fast ≥20 days of Ramadan. Participants were randomized to one of three times for LT4 administration: Group A, 30 minutes pre-iftar (n = 48); Group B, 3 hours post-iftar (n = 47); or Group C, 1 hour pre-suhoor (n = 47). The number of participants in the final analysis (excluding patients who dropped out) was as follows: Group A, (n = 31); Group B, (n = 34); and Group C, (n = 22). The changes in TSH and free thyroxine (fT4) levels two weeks before and after Ramadan were compared. Factors associated with a change in TSH levels were examined through multivariable analysis. Results: The TSH levels significantly increased in Group B (1.7 ± 1.8 mU/L vs. 3.1 ± 3.9 mU/L, p = 0.003) and Group C (2 ± 1.7 mU/L vs. 5.5 ± 10 mU/L, p = 0.011), but not Group A (1.8 ± 1.6 mU/L vs. 3.3 ± 4.2 mU/L, p = 0.158). The change in fT4 levels was comparable among the groups: Group A, 16.5 ± 2.7 mcg/dL vs. 15.9 ± 3.2 mcg/dL, p = 0.144; Group B, 15.8 ± 3.8 mcg/dL vs. 16.3 ± 3.6 mcg/dL, p = 0.620; and Group C, 17.5 ± 2.8 mcg/dL vs. 17.3 ± 3.9 mcg/dL, p = 0.770. In multivariable linear regression analysis, the following variables were significantly independently associated with TSH level change: age, weight gain, and the number of nonadherence days to LT4, where ß = -0.2, p = 0.026; ß = + 0.2, p = 0.026; and ß = + 0.5, p < 0.0001, respectively. Conclusions: Fasting patients who took LT4 pre-iftar did not experience significant changes in TSH, whereas those who took LT4 post-iftar or pre-suhoor did. The TSH changes during Ramadan may be associated with age (inverse association), weight gain, and the number of non-adherence to LT4 days. Trial Registration: SCTR Application no. 21122002.

Fructosamine as an Index of Short-Term Glycemic Control in Pregnant Women with Diabetes: Before, During and After Ramadan.

Purpose: Impact of ramadan fasting on healthy and women with diabetes is already known. However, there is a scarcity of data on impact of fasting on pregnant women with diabetes. Moreover, religious and medical recommendations advise pregnant women against fasting as it is unsafe. Despite being exempted, many pregnant Muslim women with diabetes still choose to fast during ramadan. This study investigated different glycemic marker as an indicator for diabetes control in fasting pregnant women. Patients and Methods: This is a prospective observational study. A total of 89 pregnant diabetes women were recruited. Blood glucose was self-monitored in all the pregnant women using glucose monitoring device at home. We measure the fructosamine, HbA1c levels before, during and after ramadan. Results: Pregnant women with type 1 diabetes were 14 (25%), type 2 diabetes were 21 (37.5%), and gestational diabetes were 21 (37.5%). The mean fructosamine level decreased during and after ramadan in gestation diabetes pregnant women compared to type 2 diabetes and type 1 diabetes pregnant women subjects (p = 0.009). Conclusion: The present study indicates that pregnant women with diabetes were able to fast during ramadan and there fructosamine level reduced during fasting. Utilization of fructosamine for short-term monitoring of glycemic control in addition to home glucose monitoring in pregnant women with diabetes will provide a good index of glycemic control. Recommendation: Religious and medical recommendations advise pregnant women against fasting as it is unsafe, and they are under high risk. However, if they insist to do fast, they must do under strict medical supervision and fructosamine can be used as a glycemic control marker.

Predictors of use and improvement in glycemic indices after initiating continuous glucose monitoring in real world: Data from Saudi Arabia.

BACKGROUND AND AIMS: To identify predictors of use and benefit from continuous glucose monitoring (CGM) in people with type 1 diabetes (T1D). METHODS: Predictors of CGM use and changes in glycemic indices and other clinical parameters after initiating intermittently-scanned CGMs were examined in 116 individuals with T1D living in Saudi Arabia. Participants were categorized based on frequency of CGM sensor scanning at month 6 into: Frequent users (≥10 scans/day) and infrequent users (<10 scans/day). RESULTS: Frequent CGM users had an improvement in time in range (TIR) and time above range (TAR) at months 6 and 12; whereas infrequent users had comparable improvements but only at month 12. Individuals with baseline TIR <50% had a significant improvement in TIR and TAR; whereas those with baseline TIR ≥50% had a significant improvement only in time below range (TBR). Baseline TIR <50% and higher frequency of scans were predictive of improvement in TIR at month 6 (OR: 4.84, p <0.01, 1.05, p= 0.04; respectively); whereas baseline TBR was the only predictor of improvement in TBR (OR:1.24,p < 0.01). Being a woman, higher number of scans/day during the first 2 weeks of CGM use, and having a lower A1C at baseline predict being a frequent scanner at month 6 (OR: 2.81, p=0.04; 1.12, p <0.01; and 0.73, p <0.01; respectively). CONCLUSIONS: Improvement in glycemic control with CGM use can be predicted by: number of scans per day and baseline TIR and TBR in people with T1D.

Assessment of the Effectiveness of a Protocol to Manage Dexamethasone-Induced Hyperglycemia Among Hospitalized Patients With COVID-19.

OBJECTIVE: Well-controlled glucose levels (ie, 70-180 mg/dL) have been associated with lower mortality from COVID-19. The addition of dexamethasone to COVID-19 treatment protocols has raised concerns about the potential negative consequences of dexamethasone-induced hyperglycemia. METHODS: We developed a protocol to guide the management of dexamethasone-induced hyperglycemia in hospitalized patients with COVID-19. Two of the 4 medical teams managing patients with COVID-19 at a tertiary center in Saudi Arabia used the protocol and the other 2 teams continued to manage hyperglycemia at the discretion of the treating physicians (protocol and control groups, respectively). The glycemic control and clinical outcomes in 163 patients hospitalized with COVID-19 and dexamethasone-induced hyperglycemia between July 5th and September 30th, 2020, were retrospectively compared between the 2 groups. RESULTS: Compared to the control group, the protocol group had higher proportions of patients with well-controlled glucose across all premeals and bedtime glucose readings throughout the hospital stay. The differences in glycemic control between the 2 groups were statistically significant for fasting glucose on days 4, 5, and the discharge day; prelunch glucose on the discharge day; predinner glucose on days 3, 5, and the discharge day; and bedtime glucose on day 1 (all P < .05). After adjusting for age, sex, nationality, body mass index, Charlson score, and diabetes status, patients in the protocol group were more likely to have well-controlled glucose levels compared with those in the control group. Moreover, the in-hospital mortality was significantly lower in the protocol group (12.93%) compared to the control group (29.93%) (P < .01). CONCLUSION: The implementation of a protocol to manage dexamethasone-induced hyperglycemia in hospitalized patients with COVID-19 resulted in more patients achieving well-controlled glucose levels and was associated with lower mortality from COVID-19.

COVID-19 Precautionary Measures and Type 1 Diabetes Patients in Saudi Arabia.

AIM: To minimize the spread of COVID-19, the Kingdom of Saudi Arabia (KSA) enforced a nationwide lockdown. We aimed to explore whether the manner in which Saudi patients with type 1 diabetes (T1D) manage their disease has changed during this unparalleled lockdown. METHODS: An online survey exploring the effect of lockdown on T1D outcomes was distributed among T1D patients residing in KSA during lockdown. RESULTS: A total of 1010 patients responded to the survey. Around 40% reported communicating with their physicians during lockdown. Age, level of education, residence, previous visits to diabetes education clinics, last HbA1c value, and average monthly income were all significantly associated with communication with the treating physician (p = 0.008, p < 0.001, p < 0.001, p = 0.002, p < 0.001, and p < 0.001, respectively). Age, level of education, and average monthly income were significantly associated with experiencing severe hypoglycemia (p = 0.036, p = 0.03, and p < 0.001, respectively), while average monthly income and level of education were significantly associated with experiencing diabetic ketoacidosis (DKA) (p < 0.001 and p = 0.0039, respectively); during lockdown. Patients who communicated with their physicians reported lower rates of severe hypoglycemia compared to those who did not (25.2% vs 30.7%, respectively). CONCLUSION: Age and level of education were significantly associated with communication with the treating physician, and experiencing severe hypoglycemia and DKA; in patients with T1D during the lockdown period in Saudi Arabia. Keeping two-way virtual communication channels between physicians and their T1D patients should be encouraged.

The current reproduction number of COVID-19 in Saudi Arabia: is the disease controlled?

The infectiousness of COVID-19 is high among the susceptible population, making the calculation of the reproduction number (R) an essential step to implement preventive measures. We aim to estimate COVID-19 transmission to determine if the disease is successfully controlled or extra measured should be adopted to attain this goal. The daily incidence data of COVID-19 in Saudi Arabia from March 2nd, 2020, to April 4th, 2021, were obtained from the continuously updated Saudi Ministry of Health COVID-19 repository. To get accurate estimation of the situation over the last 4 months (from December 1st, 2020, to April 4th, 2021), we calculated the weekly (every 7 days) R starting from March 2nd, 2020, and till the last week of the available data. The calculated values of R were represented as median, first quantile (Q1), and third quantile (Q3). As early as the first week of December 2020, the median R was 0.81 (0.80-0.83) which means that each existing infected case would transmit infection to only one person. This was followed by fluctuations over the next few weeks around R value of 1, reaching its highest level of 1.45 (1.42-1.47) between December 31st, 2020, and January 6th, 2021. This was followed by a relatively steady decline over the following weeks, with some till mid-March where the R values started to slightly rise again. Social distancing, protective precautions, avoiding abuse of the partial lifting, expanding the screening process, and other Saudi measures sound to be successful and should be replicated in similar communities. This measure should be continued till the vaccination process is completed, to reduce the number of contacts and to avoid uncontrolled transmission of the disease.

Glycemic Variability in Type 1 Diabetes Mellitus Saudis Using Ambulatory Glucose Profile.

BACKGROUND: Glucose variability (GV) is a common and challenging clinical entity in the management of people with type 1 diabetes (T1DM). The magnitude of GV in Saudi people with T1DM was not addressed before. Therefore, we aimed to study GV in a consecutive cohort of Saudis with T1DM. METHODS: We prospectively assessed interstitial glucose using FreeStyle® Libre flash glucose monitoring in people with TIDM who attended follow-up in the diabetes clinics at King Fahad Medical City between March and June 2017. Glycemia profile, standard deviation (SD), coefficient of variation (CV), mean of daily differences (MODD), and mean amplitude of glucose excursion (MAGE) were measured using the standard equations over a period of 2 weeks. RESULTS: Fifty T1DM subjects (20 males) with mean age 20.2 ± 6.1 years and mean fortnight glucose 192 ± 42.3 mg/dl were included. The mean SD of 2-week glucose readings was 100.4 ± 36.3 mg/dl and CV was 52.1% ± 13%. Higher levels of glucose excursions were also observed. MODD and MAGE were recorded as 104.5 ± 51.7 and 189 ± 54.9 mg/dl, respectively which is 2 to 4 times higher than the international standards. Higher MODD and MAGE were observed on weekends compared to weekdays (111.3 ± 62.1 vs 98.6 ± 56.2 mg/dl and 196.4 ± 64.6 vs 181.7 ± 52.4 mg/dl, respectively; P ⩽ .001). CONCLUSION: Higher degree of glycemic variability was observed in this cohort of TIDM Saudis. Weekends were associated with higher glucose swings than weekdays. More studies are needed to explore these findings further.

Severe vitamin D deficiency is not related to SARS-CoV-2 infection but may increase mortality risk in hospitalized adults: a retrospective case-control study in an Arab Gulf country.

PURPOSE: As the world continues to cautiously navigate its way through the coronavirus disease 2019 (COVID-19) pandemic, several breakthroughs in therapies and vaccines are currently being developed and scrutinized. Consequently, alternative therapies for severe acute respiratory coronavirus 2 (SARS-CoV-2) prevention, such as vitamin D supplementation, while hypothetically promising, require substantial evidence from countries affected by COVID-19. The present retrospective case-control study aims to identify differences in vitamin D status and clinical characteristics of hospitalized patients screened for SARS-CoV-2, and determine associations of vitamin D levels with increased COVID-19 risk and mortality. METHODS: A total of 222 [SARS-CoV-2 (+) N = 150 (97 males; 53 females); SARS-CoV-2 (-) N = 72 (38 males, 34 females)] out of 550 hospitalized adult patients screened for SARS-CoV-2 and admitted at King Saud University Medical City-King Khalid University Hospital (KSUMC-KKUH) in Riyadh, Saudi Arabia from May-July 2020 were included. Clinical, radiologic and serologic data, including 25(OH)D levels were analyzed. RESULTS: Vitamin D deficiency (25(OH)D < 50 nmol/l) was present in 75% of all patients. Serum 25(OH)D levels were significantly lower among SARS-CoV-2 (+) than SARS-CoV-2 (-) patients after adjusting for age, sex and body mass index (BMI) (35.8 ± 1.5 nmol/l vs. 42.5 ± 3.0 nmol/l; p = 0.037). Multivariate regression analysis revealed that significant predictors for SARS-CoV-2 include age > 60 years and pre-existing conditions (p < 0.05). Statistically significant predictors for mortality adjusted for covariates include male sex [Odds ratio, OR 3.3 (95% confidence interval, CI 1.2-9.2); p = 0.02], chronic kidney disease [OR 3.5 (95% CI 1.4-8.7); p = 0.008] and severe 25(OH)D deficiency (< 12.5 nmol/l), but at borderline significance [OR 4.9 (95% CI (0.9-25.8); p = 0.06]. CONCLUSION: In hospital settings, 25(OH)D deficiency is not associated with SARS-CoV-2 infection, but may increase risk for mortality in severely deficient cases. Clinical trials are warranted to determine whether vitamin D status correction provides protective effects against worse COVID-19 outcomes.

Identification of Protein Changes in the Urine of Hypothyroid Patients Treated with Thyroxine Using Proteomics Approach.

The thyroid gland and thyroid hormones control a multitude of homeostatic functions including maintenance of fluid and electrolyte balance and normal functioning of the kidneys. Thyroid dysfunction alters the sytemic hemodynamic and metabolic balance, thereby affecting the kidney. In this study, we aimed to identify and characterize the urinary proteome of the patients with hypothyroidism. An untargeted proteomic approach with network analysis was used to identify changes in total urinary proteome in patients with newly diagnosed overt hypothyroidism. Urine samples were collected from nine age-matched patients' before and after l-thyroxine treatment. Differences in the abundance of urinary proteins between hypothyroid and euthyroid states were determined using a two-dimensional difference in gel electrophoresis (2D-DIGE) coupled to matrix-assisted laser desorption and ionization time-of-flight (MALDI TOF) mass spectrometry. Alterations in the abundance of urinary proteins, analyzed by Progenesis software, revealed statistically significant differential abundance in a total of 49 spots corresponding to 42 proteins, 28 up and 14 down (≥1.5-fold change, analysis of variance (ANOVA), p ≤ 0.05). The proteins identified in the study are known to regulate processes related to transport, acute phase response, oxidative stress, generation of reactive oxygen species, cellular proliferation, and endocytosis. Bioinformatic analysis using Ingenuity Pathway Analysis (IPA) identified dysregulation of pathways related to amino acid metabolism, molecular transport, and small-molecule biochemistry and involved the MAPK kinase, vascular endothelial growth factor (VEGF), PI3 kinase/Akt, protein kinase C (PKC), signaling pathways. The identified proteins were involved in the regulation of thyroglobulin (Tg) and thyrotropin (TSH) metabolism. Alterations in their levels indicate the presence of a compensatory mechanism aimed at increasing the regulation of Tg in the hypothyroid state.

Practice of thyroid nodule management in the Gulf Cooperation Council countries.

OBJECTIVES: To assessed the current practices for the management of thyroid nodules in the Gulf Cooperation Council (GCC) countries. Methods: We conducted a descriptive web-based survey to physicians and surgeons involved in the management of thyroid nodules. The survey included questions on referral, ultrasound (US) reporting, fine needle aspiration (FNA), management of thyroid nodules including the approach for indeterminate FNA results, and usage of molecular testing. Results: A total of 311 responders, 155 (49.8%) were endocrinologists. Results showed that referrals and US report lack a number of valuable information including family history (84.9%) and high-risk US features (92.9%). Approximately 263 (84.6%) preferred to include a scoring system or protocol to assess the nodule risk in US report. Approximately 193 (62.1%) sent the patient to interventional radiologists for FNA. Almost half (n=147, 47.3%) repeat the FNA in 2-3 months if the FNA result was a follicular lesion or atypia of undetermined significance and 142 (45.7%) opted for lobectomy for follicular neoplasm or suspicious of follicular neoplasm result. Only 44 (14.1%) performed molecular testing; however, 174 (55.9%) preferred it available. Significant variations in the approach were seen between endocrinologists versus non-endocrinologists. Conclusion: Practices variation in the management of thyroid nodules mandate a common practical guideline. Molecular testing is a preferable test for indeterminate FNA results by most of the responders though it is not widely available.

Indirect comparison of efficacy and safety of insulin glargine/lixisenatide and insulin degludec/insulin aspart in type 2 diabetes patients not controlled on basal insulin.

BACKGROUND: Fixed-dose combinations of insulin glargine/lixisenatide (IGlarLixi) or insulin degludec/insulin aspart (IDegAsp) constitute treatment intensification in type 2 diabetes mellitus (T2D). OBJECTIVES: Compare efficacy and safety of IGlarLixi and IDegAsp (as intensification from basal insulin), by indirect comparison of phase III trials, in the absence of head-to-head trials. STUDY ELIGIBILITY CRITERIA: Studies comparing treatment intensification by once-daily IDegAsp or IGlarLixi to basal insulin. Data were extracted from two trials (BOOST: Intensify-Basal and LixiLan-L) retained for analysis. SYNTHESIS METHODS: Treatments were compared in terms of estimated treatment difference (ETD) in glycated haemoglobin (HbA1c), fasting and postprandial plasma glucose (FPG and PPG) change from baseline; in addition to hypoglycaemia incidence and weight changes. RESULTS: In a fixed-effect model examining HbA1c control, IGlarLixi was more effective than IDegAsp in reducing HbA1c (ETD 0.53%, P<0.0001]), PPG (ETD 2.65%, P<0.0001), and body weight (ETD 1.73kg, P<0.0001). Patients on IGlarLixi were more likely to achieve HbA1c<7% than patients on IDegAsp (odds ratio [OR]=0.40, P<0.0001), with lower incidence of hypoglycaemia (OR=1.33, P<0.001). LIMITATIONS: Limited number of studies; different baseline HbA1c and FPG. CONCLUSION: Once-daily IGlarLixi is more efficient than once-daily IDegAsp in controlling HbA1c and PPG and associates with greater weight loss and lower hypoglycaemia incidence.

Consanguinity and Diabetes in Saudi Population: A Case-Control Study.

BACKGROUND AND AIM: Diabetes mellitus (DM) of both types is a genetically determined disorder and is prevalent in the Saudi population. Furthermore, the rate of consanguineous marriages is also high among Saudis. Therefore, we aimed to determine the prevalence of consanguinity among people with DM and investigate the effect of consanguinity on the occurrence of diabetes at different levels. METHODS: A descriptive cross-sectional study was carried out at the Obesity, Metabolism and Endocrine Center of King Fahad Medical City in Riyadh, Saudi Arabia in January 2021. Information on patients' demographics (age, gender), family history of DM, and presence of consanguinity, and degree of consanguineous marriage were collected. RESULTS: We included 324 people with DM, 143 (44.1%) with type 1 diabetes (T1DM), and 181 (55.9%) with type 2 diabetes (T2DM). We included 201 people without DM for T1DM control and 300 people for T2DM control. The mean age was 26.6 ± 11.1 years for the T1DM group and 57.8 ± 11.6 years for the T2DM group. Consanguinity was noted among 73 (51.4%) T1DM patients, but T1DM was not significantly related to consanguinity. T2DM was significantly correlated with consanguinity (r=0.132, p=0.004) particularly among patients with a degree of consanguinity as first-cousins for both paternal and maternal sides (odds ratio [OR]=1.151 and 1.476). Gender and positive family history for DM and consanguineous marriage between cousins were significant factors for T2DM. After controlling for gender and a positive family history of DM, consanguineous marriage between cousins from both the paternal and maternal sides remained significant. CONCLUSION: T2DM occurrence increases in presence of consanguinity in the Saudi population. This relationship might contribute to the higher risk of DM prevalence. Further studies are needed to elucidate this relationship deeply. It's unclear whether lowering consanguineous marriages would decrease the prevalence of diabetes or not. However, a clear message about this correlation has to be delivered to the public.

Diabetes and Covid-19 among hospitalized patients in Saudi Arabia: a single-centre retrospective study.

BACKGROUND: Information on the clinical characteristics and outcomes of hospitalized Covid-19 patients with or without diabetes mellitus (DM) is limited in the Arab region. This study aims to fill this gap. METHODS: In this single-center retrospective study, medical records of hospitalized adults with confirmed Covid-19 [RT-PCR positive for SARS-CoV2] at King Saud University Medical City (KSUMC)-King Khaled University Hospital (KKUH), Riyadh, Saudi Arabia from May to July 2020 were analyzed. Clinical, radiological and serological information, as well as outcomes were recorded and analyzed. RESULTS: A total of 439 patients were included (median age 55 years; 68.3% men). The most prevalent comorbidities were vitamin D deficiency (74.7%), DM (68.3%), hypertension (42.6%) and obesity (42.2%). During hospitalization, 77 out of the 439 patients (17.5%) died. DM patients have a significantly higher death rate (20.5% versus 12.3%; p = 0.04) and lower survival time (p = 0.016) than non-DM. Multivariate cox proportional hazards regression model revealed that age [Hazards ratio, HR 3.0 (95% confidence interval, CI 1.7-5.3); p < 0.001], congestive heart failure [adjusted HR 3.5 (CI 1.4-8.3); p = 0.006], smoking [adjusted HR 5.8 (CI 2.0-17.2); p < 0.001], ß-blocker use [adjusted HR 1.7 (CI 1.0-2.9); p = 0.04], bilateral lung infiltrates [adjusted HR 1.9 (CI 1.1-3.3); p = 0.02], creatinine > 90 µmol/l [adjusted HR 2.1 (CI 1.3-3.5); p = 0.004] and 25(OH)D < 12.5 nmol/l [adjusted HR 7.0 (CI 1.7-28.2); p = 0.007] were significant predictors of mortality among hospitalized Covid-19 patients. Random blood glucose ≥ 11.1 mmol/l was significantly associated with intensive care admission [adjusted HR 1.5 (CI 1.0-2.2); p = 0.04], as well as smoking, ß-blocker use, neutrophil > 7.5, creatinine > 90 µmol/l and alanine aminotransferase > 65U/l. CONCLUSION: The prevalence of DM is high among hospitalized Covid-19 patients in Riyadh, Saudi Arabia. While DM patients have a higher mortality rate than their non-DM counterparts, other factors such as old age, congestive heart failure, smoking, ß-blocker use, presence of bilateral lung infiltrates, elevated creatinine and severe vitamin D deficiency, appear to be more significant predictors of fatal outcome. Patients with acute metabolic dysfunctions, including hyperglycemia on admission are more likely to receive intensive care.