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Shireen Suliman,1– 3 Raza Akbar,1,2 Zohaib Yousaf,4 Hafedh Ghazouani,1 Dabia Al-Mohanadi,1,5 Ahmed Al-Mohammed,1,2 Abdullatif Alkhal1– 3,5 1Department of Medicine, Hamad Medical Corporation, Doha, Qatar; 2Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar; 3College of Medicine, Qatar University, Doha, Qatar; 4Internal Medicine, Tower Health, West Reading, PA, USA; 5Medical Education Department, Hamad Medical Corporation, Doha, QatarCorrespondence: Shireen Suliman, Hamad General Hospital, Medicine Department, Hamad Medical Corporation, Doha, 3050, Qatar, Email ssuliman@hamad.qaPurpose: The exponential use of handheld electronic devices (HEDs) among healthcare providers has shown the potential to enhance clinical workflows and improve patient care. However, the challenges and risks of carrying these devices during ward rounds and their impact on postgraduate trainees’ (PGTs’) training in general and more specifically during the COVID-19 pandemic need to be explored.Methods: A cross-sectional mixed-methods online survey was conducted to evaluate the perceptions of trainees and faculty at Accreditation Council for Graduate Medical Education International accredited residency and fellowships programs in Qatar on the use of HEDs on clinical workflow, trainees’ education, and the impact of the COVID-19 pandemic. One hundred and fifty-eight participants were enrolled in the study (87 postgraduate trainees and 71 faculty). Exploratory data analysis and descriptive statistics were performed using STATA version 12 and thematic analysis of 301 qualitative responses to the survey open-ended questions using Atlas. ti qualitative software, version 9.4.0.Results: Almost all PGTs, 83 (95.4%), and faculty 43 (62.3%) use HEDs during ward rounds. Accessibility of patient information by PGTs 73 (94.8%) and faculty 46 (84.4%) and work efficiency were the main perceived benefits. Hindering communication between team members, disruption of interaction with patients, increased risk of infection and breach of patient confidentiality were among the challenges associated with their use. Carrying devices reduced the frequency of hand hygiene practices and physical examinations of patients by trainees. The COVID-19 pandemic led to a decrease in the use of HEDs by both faculty [38(64%)] and PGTs [42(60%)].Conclusion: HEDs’ use is valued by both faculty and PGTs in enhancing workflow, trainees’ education, patient experience, and patient care during the COVID-19 pandemic. Graduate medical education leaders should adopt measures to monitor their use during ward rounds as they can negatively impact trainees’ education, reduce interaction with patients, increase the risk of infection, and breach patient confidentiality.Keywords: COVID-19, handheld electronic devices, ward rounds, postgraduate medical education, Accreditation Council for Graduate Medical Education International, ACGME-I

Mouhand FH Mohamed,1,2 Mohammed Danjuma,1,3 Mohammed Mohammed,4 Samreen Mohamed,4 Martin Siepmann,5 Kristian Barlinn,6 Salah Suwileh,1 Lina Abdalla,1 Dabia Al-Mohanadi,7 Juan Carlos Silva Godínez,8,9 Abdel-Naser Elzouki,1,3 Timo Siepmann2,6 1Department of Medicine, Hamad Medical Corporation, Doha, Qatar; 2Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany; 3College of Medicine, Qatar University, Doha, Qatar; 4Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar; 5Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; 6Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; 7Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar; 8Department of Surgery, National Medical Center Siglo XXI, Mexican Social Security Institute, Mexico City, Mexico; 9Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USACorrespondence: Mouhand FH Mohamed Email Dr.m.oraiby@hotmail.comBackground and Objective: The term myxedema psychosis (MP) was introduced to describe the occurrence of psychotic symptoms in patients with untreated hypothyroidism, but the optimal assessment and treatment of this condition are unclear. We aimed to synthesize data from the literature to characterize the clinical presentation and management of MP.Methods: We performed a systematic review according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines in PubMed (Medline), Embase, Google Scholar, and Cochrane databases, including observational studies, case series, and case reports published from 1/1/1980 to 31/12/2019 in the English language. Descriptive statistics along with univariate and multivariate analysis were used for data synthesis.Results: Out of 1583 articles screened, 71 case reports met our inclusion criteria providing data on 75 MP cases. The median age at diagnosis was 42 years [32– 56]. About 53% had no prior hypothyroidism diagnosis. Delusions occurred in 91%, with a predominance of persecutory ideas (84%), while hallucinations occurred in 78%. Physical symptoms and signs of hypothyroidism were absent in 37% and 26%, respectively. If symptoms occurred, nonspecific fatigue was seen most frequently (63%). The median thyroid-stimulating hormone value was 93 mIU/L [60– 139]. Thyroid peroxidase antibodies were found positive in 75% (23/33) of reported cases. Creatinine kinase was reported abnormal in seven cases. Cranial imaging (CT or MRI) and electroencephalogram were normal in 89%, 75%, and 73% of the cases reported. The majority of patients were treated orally with thyroxine in combination with short-term antipsychotics. More than 90% of them showed complete recovery. Univariate analysis revealed a trend towards a shorter duration of psychosis with IV thyroid hormone therapy (p= 0.0502), but the effect was not consistent in a multivariate analysis.Conclusion: While we identified a substantial lack of published research on MP, our pooled analysis of case observations suggests that the condition presents a broad spectrum of psychiatric and physical symptoms lending support to the value of screening for thyroid dysfunction in patients with first-ever psychosis.Prospero Registration Number: CRD42020160310.Keywords: psychosis, hypothyroidism, madness, myxedema, depression, neuropsychiatric

Mohamed Mahmoud,1 Jessiya Parambil,1 Mohammed Danjuma,1 Ibrahim Abubeker,2 Mostafa Najim,1 Hafedh Ghazouani,1 Dabia Al-Mohanadi,1 Ahmed Al-Mohammed,1 Anand Kartha,1 Mohamed A Yassin3 1Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar; 2Internal medicine, Rochester Regional Health Unit, USA; 3Department of Medical Oncology, National Centre for Cancer Care and Research, Hamad Medical Corporation, Doha, QatarCorrespondence: Jessiya ParambilGeneral Internal Medicine, Hamad General Hospital, Al-Rayyan Road, P O Box 3050, Doha, QatarTel +974 30007415Email dr.jessiya.vp@gmail.comPurpose: The aim of this study was to evaluate the rate of internal medicine residents’ and faculties’ (specialists and consultants) compliance to colorectal cancer screening in Hamad Medical Corporation (Doha, Qatar) and to identify barriers as well as facilitators that will assist in drawing up changes that would enhance physician-related cancer screening.Methods: A cross-sectional web-based survey was distributed among internal medicine physicians at three component hospitals of Hamad Medical Corporation (HMC); focusing on knowledge and practice of colorectal cancer screening, its barriers and facilitators. Chi-square and t-test statistics were used to draw conclusions where appropriate.Results: The response rate for the survey was 91% and over 75% of the survey respondents were post-graduate trainees. The majority (90.6%) of the physicians (n=144) mentioned that they would recommend colorectal cancer screening for their asymptomatic patients, though trainees tend to choose the correct modality of screening compared to the consultants, 86.21% vs 40.74%. Only 43.4% of the survey participants always to usually recommend screening to their patients in their clinics while only 29.4% do so for their inpatients. Even though there was no statistically significant difference among the frequency of outpatient colorectal cancer screening among trainees, specialists or consultants (p=0.628), there was a clear increase in the reported referrals as the training years or the years of experience increases (p=0.049 for trainees and p=0.009 for faculty). Unclear pathway was reported as the main obstacle to outpatient cancer screening by 30.2% (n= 48) and 54% (n=87) pointed out that an easy and clear pathway for cancer screening would facilitate the same.Conclusion: While the attitude towards colorectal cancer screening is positive, the actual practice of recommendation is sub-optimal. Further initiatives are required to facilitate awareness and compliance to colorectal cancer screening.Keywords: bowel cancer, screening, doctors, residents, Middle East

Mohamed Mahmoud,1 Jessiya Parambil,1 Mohammed Danjuma,1 Ibrahim Abubeker,2 Mostafa Najim,1 Hafedh Ghazouani,1 Dabia Al-Mohanadi,1 Ahmed Al-Mohammed,1 Anand Kartha,1 Mohamed A Yassin3 1Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar; 2Internal Medicine, Rochester Regional Health Unit, New York, NY, USA; 3Department of Medical Oncology, National Centre for Cancer Care and Research, Hamad Medical Corporation, Doha, QatarCorrespondence: Jessiya ParambilGeneral Internal Medicine, Hamad General Hospital, Al-Rayyan Road, P O Box 3050, Doha, QatarTel +974 30007415Email dr.jessiya.vp@gmail.comThank you for the recent read and comments on our article “Knowledge, Attitude and, Practice of Physicians Regarding Screening of Colorectal Cancer in Qatar: A Cross-Sectional Survey”; I hope the below response will clarify the queries raised by our colleagues from the UK. View the original paper by Mahmoud and colleaguesThis is in response to the Letter to the Editor

Background: Systematic biases in group decision making (i.e., group biases) may result in suboptimal decisions and potentially harm patients. It is not well known how impaired group decision making in patient care may affect medical training. This study aimed to explore medical residents' experiences and perspectives regarding impaired group decision making and the role of group biases in medical decision making., Methods: This study used a qualitative approach with thematic analysis underpinned by a social constructionist epistemology. Semi-structured interviews of medical residents were conducted at a single internal medicine residency program. Residents were initially asked about their experiences with suboptimal medical decision making as a group or team. Then, questions were targeted to several group biases (groupthink, social loafing, escalation of commitment). Interviews were transcribed and transferred to a qualitative data analysis software. Thematic analysis was conducted to generate major themes within the dataset., Results: Sixteen interviews with residents revealed five major themes: (1) hierarchical influence on group decision making; (2) group decision making under pressure; (3) post-call challenges in decision making; (4) interactions between teamwork and decision making; and (5) personal and cultural influences in group decision making. Subthemes were also identified for each major theme. Most residents were able to recognize groupthink in their past experiences working with medical teams. Residents perceived social loafing or escalation of commitment as less relevant for medical team decision making., Conclusions: Our findings provide unique insights into the complexities of group decision making processes in teaching hospitals. Team hierarchy significantly influenced residents' experiences with group decision making-most group decisions were attributed to consultants or senior team members, while lower ranking team members contributed less and perceived fewer opportunities to engage in group decisions. Other factors such as time constraints on decision making, perceived pressures from other staff members, and challenges associated with post-call days were identified as important barriers to optimal group decision making in patient care. Future studies may build upon these findings to enhance our understanding of medical team decision making and develop strategies to improve group decisions, ultimately leading to higher quality patient care and training., (© 2024. The Author(s).)

Background: Mobile health (mHealth) is increasingly advocated for diabetes management. It is unclear if mobile applications are effective in improving glycaemic control, clinical outcomes, quality of life and overall patient satisfaction in patients with type 2 diabetes (T2DM). A new mobile application was specifically built for people with T2DM with the help of the local expertise. The objective of the study was to evaluate the effectiveness of the mobile app., Methods: The planned study is an ongoing open-label randomised controlled trial in which adults living with T2DM treated with insulin will be randomised 1:1 to the use of this diabetes application versus current standard care. The primary outcome will be the difference in mean HbA1c from baseline to 6 months. Other outcome measures include anthropometric measures, hypoglycaemic events, medication adjustments, number of clinical interactions and missed appointments and patient perceptions of their disease and diabetes self-management. The study will randomise 180 subjects for assessment of the primary outcome., Discussion: We hypothesise that the diabetes-specific mobile application will improve glycaemic control, increase patient empowerment for self-management of diabetes and improve interaction between patients and healthcare providers. If the Qatar Diabetes Mobile Application Trial (QDMAT) demonstrates this, it will inform clinical services for the future self-management of T2DM., Trial Registration: ClinicalTrials.gov Identifier: NCT03998267 . Registered on 26 June 2019., (© 2022. The Author(s).)

Quality improvement and patient safety are cornerstones to the delivery of effective patient care. The introduction of a quality improvement curriculum for medical students and trainee physicians can have a significant effect on their understanding of the science of improvement and its role in improving the quality of healthcare delivery and patient safety. The article describes the development and implementation of a quality improvement curriculum for trainee physicians in the department of internal medicine at a tertiary care center in Qatar through online training courses, workshops, didactic activities, and trainee-led quality improvement projects., (© 2022 Zahid, Khan, Yousaf, Al-Mohammed, Al Mohanadi, licensee HBKU Press.)

Background Adverse events (AE) are responsible for annual deaths that exceed deaths due to motor vehicle accidents, breast cancer, and AIDS. Many AE are considered preventable. Thus, AE needs to be detected and analyzed. Incident reporting systems (IRS) are crucial in identifying AE. Nevertheless, the incident report (IR) process is flawed with underreporting, especially from the physicians' side. This limits its efficiency in detecting AE. Therefore, we aimed to assess the practice and identify the barriers associated with incident reporting among internal medicine physicians in a large tertiary hospital through a survey. Methods A cross-sectional descriptive study. We distributed an online survey to physicians working in the Internal Medicine Department of Qatar's largest tertiary academic institute. The questionnaire was validated and piloted ahead of the start of the trial. The response rate was 53%. Results A total of 115 physicians completed the survey; 59% acknowledged the availability of an institutional IRS. However, only 29% knew how to submit an online IR, and 20% have ever submitted an IR. The survey revealed that participants were less likely to submit an IR when they or a colleague is involved in the incident; 46% and 63%, respectively. The main barriers of reporting incidents were unawareness about the IRS (36%) and the perception that IR will not bring a system change (13%); moreover, there exists the fear of retaliation (13%). When asked about solutions, 57% recommended training and awareness, and 22% recommended sharing learnings and actions from previous IR. Conclusions IRS is underutilized by internal medicine physicians. The main barrier at the time of the survey is the lack of training and awareness. Promoting awareness and sharing previous learning and actions may improve the utilization of the IRS., Competing Interests: Conflict of interest There are no conflicts of interest. Author Contribution A.E., M.F.H.M., and A.A. conceived the idea. M.F.H.M. and A.E. created the first draft questionnaire that was reviewed by I.Y., A.A., and the expert panel. After approval of the questionnaire, I.Y. disseminated the questionnaire to the target population. M.F.H.M. analyzed the results and drafted the tables and the manuscript. Then, the manuscript was reviewed by A.E.. and I.Y. Finally, the revised manuscript was sent to all the authors. All authors revised the manuscript and approved the final version for publication. Discloser The manuscript is currently not submitted for publication to other journal; however, a previous version was published on a preprint server and the link is provided ( https://www.researchsquare.com/article/rs-6372/v1 ). All authors approved the manuscript., (Syrian American Medical Society. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: Well-performing physician reflects the success of the residency program in selecting the best candidates for training. This study aimed to evaluate the selection criteria, mainly the United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge (CK) results and applicants' status as international or locally trained applicants, used by the medical education department and the internal medicine residency program in Hamad Medical Corporation in Qatar to predict the residents' performance during their training., Methods: A retrospective chart review was performed for three batches of graduates who started residency training in 2011, 2012, and 2013. Each group completed 4 years of training. The USMLE Step 2 CK status of the applicant, in-training exam (ITE) scores, formative evaluation scores, Arab Board written and clinical exams pass rate, and other indicators were analyzed. Statistical analysis included chi squares and independent t-test to identify associations. Multivariable analyses were conducted using logistic and linear regressions to test for adjusted associations., Results: The study included 118 (81 international/37 locally trained applicants) internal medicine residents. The ITE score correlated positively with the USMLE Step 2 CK score (r = 0.621, r = 0.587, r = 0.576, r = 0.571, p  < 0.001) over the 4 years of training and among the international compared with locally trained applicants ( p  < 0.001). The rate of passing part 1 and 2 written exam of the Arab Board was higher in international than in local applicants, whereas clinical Arab Board exam and formative evaluation were not associated with any criteria., Conclusions: Higher USMLE Step 2 CK score correlated with better performance on ITE but not with other performance indicators, whereas international applicants did better in both ITE and Arab Board written exam than local applicants. These variables may provide reasonable predictors of well-performing physicians., (© 2021 Rahil, Hamamyh, Al-Mohammed, Kamel, Abubeker, Abu-Raddad, Dargham, Suliman, Mohanadi, Khal, licensee HBKU Press.)

Background: The aims of Evidence-Based medicine (EBM) are to promote critical thinking and produces better patients' outcome (Profetto-McGrath J, J Prof Nurs Off J Am Assoc Coll Nurs 21:364-371, 2005). Accreditation Council for Graduate Medical Education (ACGME) competencies require trainees to locate, appraise and apply clinical evidence to patients' care. Despite the emphasis that ACGME place on EBM, few organizations provide adequate training in EBM. This is even more critical in regions where medical trainees matriculate from diverse backgrounds of undergraduate medical education, where EBM may not be emphasized nor taught at all. EBM practice has a history of research in the West, however, EBM has not been widely studied in the Middle East., Methods: Clinicians and trainees at Hamad Medical Corporation (HMC) matriculate from many countries in the Middle East and North Africa (MENA) and Asia. Because trainees in Graduate Medical Education (GME) come to HMC from a variety of geographic backgrounds, it is assumed that they also have a variety of experiences and aptitudes in EBM. To assess trainees EBM attitudes and knowledge in the internal medicine department at HMC in Doha, Qatar, the authors surveyed residents and fellows using a two-part survey. The first part was adapted from the evidence-based practice inventory by Kaper to assess trainees' attitudes and perceptions of EBM. Trainees were also asked to complete the Assessing Competency in Evidence Based Medicine (ACE) tool to evaluate their aptitude in different elements of EBM. The results from the two parts were analyzed., Results: The average score on the ACE tool among the participants was 8.9 (±1.6). Most participants rated themselves as beginners or intermediate in their EBM capabilities. Higher ACE scores were observed from participants with educational background from South Asia, and among those with more favorable attitudes towards EBM. There was no clear pattern that early incorporation of EBM into practice will result in better ACE score. Participants also reported reasonable abilities in EBM tasks and a favorable work atmosphere for EBM implementation. Lack of knowledge, resources, and time were the most reported barriers to utilizing EBM., Conclusions: While it is clear that participants are enthusiastic about EBM and see it as a useful method for clinical decision making, their aptitude in EBM is not optimal and there are gaps and barriers for them to practice.

Background: Myxedema psychosis (MP) is a rare presentation of hypothyroidism. Although known for >70 years, a significant lack of systematic literature describing this condition exists. This limits the clinician's ability to identify and manage this entity properly. Hence, we aimed to systematically review the literature and summarize the presentation, diagnosis, management, and outcomes of this rare entity., Methods: Systematic review following PRISMA guidance. We will perform a comprehensive search of PubMed, Medline, Embase, Google Scholar (first 300 hits), and Cochrane databases for published observational studies, case series, and case reports. We will use descriptive statistics to provide summary estimates of demographics, common presenting features, laboratory test results, imaging findings, treatment administered, and outcomes. Moreover, continuous variables will be compared by the Wilcoxon Mann Whitney test, whereas categorical variables will be assessed by the χ test. Bivariate and multivariate regression will be performed to assess risk factors associated with poor outcome. A scoping review revealed that a meta-analysis might not be feasible owing to the paucity of systematic studies describing the condition., Results: This is the first systematic review examining this rare entity. Thus, the result of which will be significant. We hope that this review will help in identifying relevant predictive clinical or laboratory characteristics. Additionally, it identifies the best treatment strategies. The findings of this review will help increase our knowledge of this condition so as to recognize this condition promptly. Also, it will assist in differentiating MP from masqueraders, such as Hashimoto encephalopathy (HE). The results of this review will be published in a peer-reviewed journal., Conclusion: This is the first systematic review exploring MP demographics, diagnosis treatment, and outcomes. The information gathered by this review will be necessary for patients, clinicians, researchers, and guideline makers., Prospero Registration Number: CRD42020160310.

Background: The American College of Physicians' (ACP) Internal Medicine In-Training Examination (IM-ITE) is designed to evaluate the cognitive knowledge of residents to aid them and program directors in evaluating the training experience. Objective: To determine the impact of the curriculum reform accompanied by the Accreditation Council for Graduate Medical Education (ACGME)-I alignment and accreditation on the internal medicine residency program (IMRP) using residents' performance in the ACP's ITE from 2008 to 2016, and where the IMRP stands in comparison to all ACGME and ACGME-I accredited programs. Methods: This is a descriptive study conducted at a hospital-based IMRP in Doha, Qatar from 2008 to 2016. The study population is 1052 residents at all levels of training in IMRP. The ACP-generated ITE results of all the United States and ACGME-I accredited programs were compared with IM-ITE results in Qatar. These results were expressed in the total program average and the ranking percentile. Results: There is a progressive improvement in resident performance in Qatar as shown by the rise in total average program score from 52% in 2008 to 72% in 2016 and the sharp rise in percentile rank from 3rd percentile in 2008 to 93rd percentile in 2016 with a dramatic increase during the period 2013 to 2014 (from 32nd percentile to 73rd percentile), which represents the period of ACGME-I accreditation. None of the factors (ethnicity, USMLE or year of residency) were statistically significant with a p value >0.05 and standard coefficient ( - 0.017-0.495). There was negligible correlation between the USMLE test scores with the residents' ITE scores with a p value = 0.023 and a Pearson correlation r = 0.097. Conclusion: The initial ACGME-I alignment followed by the accreditation, together with whole curriculum redesign to a structured, competency-based program starting from 2008, has led to an improvement in the ITE scores in the IMRP. This was further evidenced by the lack of change in the residency entry selection criteria., (© 2020 Al-Mohammed, Al Mohanadi, Rahil, Elhiday, Al khal, Suliman, licensee HBKU Press.)

Background: Problem-based learning (PBL) is an inquiry-based learning strategy which is learner centered and facilitates group discussion and critical thinking. Case-based learning (CBL), which is a more guided approach of PBL, enables students to learn within the context of patients and formulate their knowledge around patients' scenarios. Midweek (MW) activity is an important educational activity in the internal medicine residency program (IMRP). CBL has shown many benefits in postgraduate education. The aim of our study was to describe the implementation of a teaching resident's management of acute medical conditions encountered during their call utilizing the CBL format and to evaluate resident satisfaction with the new teaching style. Methods: This study describes the implementation of CBL in residents' education at the IMRP. CBL was introduced in five of the 10 acute medical sessions taught in the noon activity. A mixed-method study was employed using both a structured questionnaire and a focus group to compare the two methods to evaluate the residents' satisfaction and perception of knowledge acquisition. Results: The focus group discussion showed that sessions conducted in CBL format were more engaging, interactive, and resulted in better knowledge acquisition through sharing and peer-to-peer teaching than the traditional lecture format. Thirty-nine out of 83 (47%) residents ranging from PGY2 to PGY4 responded to the survey. Overall satisfaction with CBL was good. Sixty-four percent preferred it over the lecture format; 87% found that they did improve their knowledge; 84% agreed that they were excellent and more interactive. Seventy-nine percent stated that they would like to have this type of teaching in the MW activity sessions. Conclusion: Based on the present study, we conclude that incorporation of CBL resulted in more engagement, interaction, peer-to-peer education, and overall residents' satisfaction. The key elements for a successful implementation of this format are both instructors' and residents' orientation and careful selection of the case scenarios (problems) that trigger the learning process. Incorporation of various teaching strategies in residents' education is mandatory to enhance learning and create excellent educational experiences., (© 2019 Suliman, Al-Mohammed, Al Mohanadi, Karim, Elbuzidi, Mubasher, Rahil, licensee HBKU Press.)

Objective: There is a lack of consensus among guidelines for screening, diagnosis and management of gestational diabetes (GDM). The purpose of this project was to determine current practices around GDM amongst members of the Medical Women's International Association (MWIA)., Methods: The MWIA with the Division of Endocrinology and Metabolism, University of Ottawa, developed an online survey using "Survey Monkey" and distributed it to its members., Results: A total of 125 members completed the survey. Universal screening was recommended by 83% and most followed published guidelines. The 50 g glucose challenge test (GCT) was used for screening by 23% of participants while 25% recommended fasting blood glucose. There was also variability in how to proceed following a positive screening test. Almost 65 % recommended one of the glucose tolerance tests (50 g OGTT 26.7 % vs. 75 g OGTT 25.6% vs. 100 g OGTT 12.2%), while 18.8% recommended starting treatment and 16.7% used other diagnostic measures. Insulin was the most recommended treatment (75%) if diet/lifestyle failed., Conclusions: Our survey highlights the international variability that exists in the screening, diagnosis, and management of women with GDM. These differences impact on true prevalence rates and may underestimate the costs of this disease. The recommendation to move to a single internationally accepted diagnostic algorithm may be hampered by the variation in current practice globally.

Background: Over one billion Muslims fast worldwide during the month of Ramadan. The impact of fasting on circadian presentation with acute cardiac events is unknown., Aim: To determine if fasting has any effect on the circadian presentation of acute cardiac events., Setting and Design: A prospective study in a general hospital., Materials and Methods: Patients with acute coronary events were divided into two groups based on the history of fasting. Information about age, gender, cardiovascular risk factor profiles and outcome was collected. The relationship of time of presentation of initial symptoms with fasting was evaluated using Student's t-test, Mann-Whitney U-test and chi2 analysis., Results: Of the 1019 patients hospitalized during the study period, 162 were fasting. Although, fasting patients were more likely to present to the emergency department in the time periods 5-6 AM (10.5% vs 6.3%) and 11 PM (11.1% vs 7.1%) and were less likely to present in the time periods 1-2 PM (3.7% vs 7.2%) and 5-6 PM (3.7% vs 7.0%); these differences were not statistically significant. Fasting patients were less likely to have their symptoms start between 5 and 8 AM (11.1% vs 19.4%) and more likely to have symptoms between 5 and 6 PM (11.1% vs 6.0%) and 3 and 4 AM (11.1% vs 6.9%). These differences for time of initial symptoms were statistically significant (P=0.002)., Conclusion: Exogenous factors associated with fasting, namely, the changes in food intake and/or sleep timings, affect the circadian rhythm and influence the timing of presentation of acute coronary events.