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Abstract Ramadan fasting (RF) involves abstaining from food and drink during daylight hours; it is obligatory for all healthy Muslims from the age of puberty. Although sick individuals are exempt from fasting, many will fast anyway. This article explores the impact of RF on individuals with kidney diseases through a comprehensive review of existing literature and consensus recommendations. This study was conducted by a multidisciplinary panel of experts. The recommendations aim to provide a structured approach to assess and manage fasting during Ramadan for patients with kidney diseases, empowering both healthcare providers and patients to make informed decisions while considering their unique circumstances.

Introduction: The decision to fast or not is quite complex. Personal, medical and religious matters may influence it for individuals with diabetes. However, a diagnosis of diabetes does not constitute an automatic exemption from Ramadan fasting. We aimed to evaluate the characteristics of the non-fasting cohort and explore the potential reasons during Ramadan through the global Ramadan surveys of 2020 and 2022. Method: The Diabetes and Ramadan (DaR) Global Study is an observational retrospective survey conducted between 2020 and 2022, which included adult patients (18 and older) who fasted and those who opted not to fast. The survey captured demographic data and patient characteristics (co-morbidities, duration and type of diabetes, diabetes-related complications and medications, development of acute complications during Ramadan, hospitalisations and ER visits) for both groups. Results: Of 12,059 patients, 1822 (14.5 %) did not fast during Ramadan; that population leaned towards females (54.6 %). They had an average age of 60.58 years (SD=12.12) with a statistically significant difference from the fasting population, averaging 54.29±11.45 (p = 0.000). Also of note was the more significant average duration of diabetes in the non-fasting cohort (12.54 years vs 9.44). There are notable regional differences in rates of fasting that ranged between 6.3 % and up to 51.2 % of patients opting not fast in certain regions (Chart 1). The risk factors that showed apparent differences of high statistical significance (p ≤ 0.001) included: long duration of diabetes of over ten years, age above 60+ years, HbA1c value over 9 %, use of insulin therapy, and being affected by one or more vascular complications (these include CKD, CVD, and diabetic foot problems). Conclusions: Many factors and comorbidities might influence patients’ decisions when planning Ramadan fasting. The non-fasting population's demographic and clinical profiles reveal distinctive features, emphasising a need for tailored risk assessments. Furthermore, regional disparities in the decision to fast underscore the multifaceted nature of this decision-making process. The new IDF-DAR risk assessment tool can help to stratify patients’ risk during Ramadan fasting and bridge the gap among different populations and cultures.

Background: Current guidelines recommend that glucagon-like peptide-1 receptor agonists (GLP-1 RAs) with proven cardiovascular benefit should be considered for first-line therapy in patients with type 2 diabetes (T2D) who have/are at high risk of atherosclerotic cardiovascular disease (CVD). Summary: Only one GLP-1 RA – dulaglutide – has demonstrated superiority versus placebo in reducing cardiovascular risk in patients with T2D with or without a history of CVD in a cardiovascular outcomes trial (CVOT). This trial – REWIND – is the only GLP-1 RA-based CVOT that recruited patients with a CVD prevalence (31%) that is similar to the estimated prevalence in primary care T2D populations in the Gulf and Levant region. In contrast, baseline CVD prevalence in all other GLP-1 RA-based CVOTs ranged from 73 to 100%. REWIND’s results provided the European Association for the Study of Diabetes and American Diabetes Association with data on which to base updated guidelines. These organisations subsequently recommended that GLP-1 RAs should be considered for primary CVD prevention in high cardiovascular-risk patients with T2D, and acknowledged that present evidence supporting GLP-1 RAs for primary prevention of CVD in T2D is strongest for dulaglutide but limited for other GLP-1 RAs. The Emirates Diabetes Society guidelines also support the use of GLP-1 RAs for primary cardiovascular prevention in patients with T2D. The cardiovascular benefit conferred by dulaglutide in patients with no CVD history, and the close alignment of the REWIND cohort with patient populations in the Gulf and Levant region, may better inform physicians in the early use of dulaglutide in patients with T2D and multiple cardiovascular-risk factors, regardless of CVD history. Utilizing published data and author opinion, this review explores the importance of taking a cardiocentric approach to T2D management, and discusses the clinical implications of REWIND for people with T2D in the Gulf and Levant region. Key Messages: Guideline recommendations, including those of the Emirates Diabetes Society, state that GLP-1 RAs with proven cardiovascular benefit should be considered for primary CVD prevention in high cardiovascular-risk patients with T2D. This recommendation was informed, in part, by REWIND; REWIND was the only CVOT to show that a GLP-1 RA (dulaglutide) reduces cardiovascular risk in patients with T2D with or without established CVD. Demonstration of cardiovascular benefit in the REWIND cohort, which aligns closely with patient populations in the Gulf and Levant region, may better inform physicians in the early use of dulaglutide in patients with T2D, regardless of CVD history.

Background: Cardiovascular diseases (CVDs) are the major cause of mortality and disability in patients with type 2 diabetes mellitus (T2DM). The increased risk of major cardiovascular (CV) events in patients with T2DM causes an estimated 12-year reduction in life expectancy. Despite their heightened CV risks, most T2DM patients do not meet treatment targets for multiple CV risk factors. Moreover, in the UAE, the incidence of cardiometabolic diseases is exceedingly high, impacting young patients and leading to a high burden of premature CV events. Summary: We propose this comprehensive cardiometabolic evaluation to address both glycemic control and early diagnosis of CV complications as well as early implementation of multifactorial intensive therapies that are evidence and guideline based. Widespread utilization and implementation of the guidelines in primary diabetic care, coupled with early referral to a CV or the relevant specialists, will result in a significant reduction of CV events and CV hospitalization in the UAE population. Hence, the Emirates Diabetes and Endocrine Society with the Emirates Cardiac Society collaborated for the first time to develop these recommendations. These will aid in the early identification of CV risk factors in persons with prediabetes and diabetes, as well as their effective assessment and management. These guidelines are aimed not just at primary care physicians but also specialists, perhaps leading to a more collaborative and multidisciplinary approach to the prevention, diagnosis, and treatment of patients with diabetes and CVD. Key Message: The establishment of combined cardiometabolic clinics providing comprehensive assessment and management in every major cardiology and diabetology center, particularly in patients who have already had a CV event, where the combined involvement of a cardiologist and a diabetologist in an intensive multifactorial outpatient program is urgently required to prevent recurrent CV events. In addition, establishing a National Cardiometabolic Registry is an essential element of this recommendation.

Background: Typically Functional (secondary) tricuspid insufficiency is the most prevalent tricuspid valve disease on top of mitral diseases. Different repair techniques were introduced to deal with this problem. Objectives: The target of this study was to evaluate the repair of Tricuspid valves using a commonly used suture annuloplasty technique (DE VEGA) versus a patient-tailored synthetic band made of Dacron short-term results. Patients and methods: From January 2021 to October 2022, 40 patients with secondary tricuspid insufficiency participated in our prospective cohort single-center study. we equally split the patients into two different groups. A total of 20 patients were randomized to the flexible Dacron band group while the remaining 20 patients were allocated to the De-Vega annuloplasty technique group. Preoperative data, major intraoperative and immediate postoperative adverse events, and postoperative regurgitation were assessed. Results: studied groups’ properties regarding Demographic and Preoperative echo data were statistically comparable. The rate of acute postoperative morbidities and complications had no statistical significance. There was no significant difference in postoperative recurrence of tricuspid insufficiency Around (85%) of patients in the De-Vega group and (90 %) in the Band group did not have TR on discharge and after 6 months of follow-up. There was no statistical significance in the incidence of immediate post-operative complications. Conclusions: Tricuspid repair using a customized Dacron band is a reliable surgical technique for functional Tricuspid Regurgitation. Additional studies with a larger number of patients and a longer term of follow-up are needed to confirm our findings.

BackgroundAttempts to subtype, type 2 diabetes (T2D) have mostly focused on newly diagnosed European patients. In this study, our aim was to subtype T2D in a non-white Emirati ethnic population with long-standing disease, using unsupervised soft clustering, based on etiological determinants.MethodsThe Auto Cluster model in the IBM SPSS Modeler was used to cluster data from 348 Emirati patients with long-standing T2D. Five predictor variables (fasting blood glucose (FBG), fasting serum insulin (FSI), body mass index (BMI), hemoglobin A1c (HbA1c) and age at diagnosis) were used to determine the appropriate number of clusters and their clinical characteristics. Multinomial logistic regression was used to validate clustering results.ResultsFive clusters were identified; the first four matched Ahlqvist et al subgroups: severe insulin-resistant diabetes (SIRD), severe insulin-deficient diabetes (SIDD), mild age-related diabetes (MARD), mild obesity-related diabetes (MOD), and a fifth new subtype of mild early onset diabetes (MEOD). The Modeler algorithm allows for soft assignments, in which a data point can be assigned to multiple clusters with different probabilities. There were 151 patients (43%) with membership in cluster peaks with no overlap. The remaining 197 patients (57%) showed extensive overlap between clusters at the base of distributions.ConclusionsDespite the complex picture of long-standing T2D with comorbidities and complications, our study demonstrates the feasibility of identifying subtypes and their underlying causes. While clustering provides valuable insights into the architecture of T2D subtypes, its application to individual patient management would remain limited due to overlapping characteristics. Therefore, integrating simplified, personalized metabolic profiles with clustering holds greater promise for guiding clinical decisions than subtyping alone.

Active lupus nephritis (LN) in pregnancy is strongly associated with poor maternal and fetal outcomes and, therefore, has implications on the planning, timing, and management. Prepregnancy evaluation is essential for all LN patients with childbearing potential to ensure pregnancies proceed in a safe and timely manner. Both maternal and fetal risks are communicated to patient during the evaluation. Stratification into different risk profile groups is then made based on disease activity and organ impairment severity. Patients with LN are generally divided into 3 main groups. Patients with LN who become pregnant receive treatments that are nonteratogenic and optimal for fetal and maternal outcomes. Throughout the pregnancy period, these patients are monitored closely under surveillance by a multidisciplinary team of clinicians. The management of patients with LN in pregnancy can be challenging both diagnostically (distinguishing LN from pre-eclampsia and determining the role and timing of kidney biopsy) and therapeutically (LN flares during pregnancy and managing a newly diagnosed LN during pregnancy).

Background: Lockdown was a unique experience that affected many aspects of life, particularly during the challenge of Ramadan fasting (RF). Studying this can increase understanding of the effects of lifestyle changes on quality of life (QoL) for children with type 1 diabetes (T1D) during RF. Methods: A cross-sectional study that assessed the effect of lockdown on lifestyle and QoL on fasting children living with T1D during Ramadan in the Middle East and North Africa region (2020-2021). We compared the child (self) and parent (proxy) reports using PEDQoL v3.0 disease specific questionnaire during lockdown and non-lockdown periods, and assessed correlations with lifestyle changes using regression and gap analyses. Results: A total of 998 reports from 499 children with T1D aged 8 to 18 years (study = 276, control = 223), and their parents during RF in lockdown and non-lockdown periods. Fathers were more involved in their children’s care during lockdown ( P = .019). Patients had better compliance with treatment ( P = .002), a reversed sleep pattern ( P = .033), increased food intake ( P ⩽ .001), and less exercise ( P

Lupus nephritis is a severe, organ-threatening manifestation of systemic lupus erythematosus. The current standard of care in the treatment of lupus nephritis is limited to broad-spectrum immunosuppressants, which have significant concerns of short- and long-term toxicity. With traditional approaches, kidney survival and patient outcomes have remained suboptimal. Robust research in the therapeutics of lupus nephritis has resulted in development of many novel drugs targeting specific inflammatory response pathways. Some newer agents have shown a definitive signal of benefit when added to standard of care. With the advent of precision medicine in nephrology, lupus nephritis treatment may undergo a shift toward incorporating approaches using these newer drugs and individualizing care of our patients. This review highlights major advances in management of lupus nephritis over the last 25 years and explores the ongoing trials of emerging therapies in lupus nephritis.

Introduction: A novel clinical calculator was developed to assist physicians in classifying the risk for individuals with diabetes planning to observe fasting during the holy month of Ramadan. The aim of this study was to evaluate the necessity to use this approach. Methods: A survey with twenty-six clinical scenario questions was developed. All cases were pre-scored using the proposed Diabetes and Ramadan Risk Calculator. The survey was sent to 350 reputable practicing physicians with considerable expertise in managing patients with diabetes. The survey sought expert opinion on patients’ risk classification during Ramadan fasting. Quantitative methods were used for data analysis. Results: Responses of 312 participants were valid for analysis. There was a wide variation in evaluating patients’ risk, particularly in moderate-risk cases. Overall, responses to case scenarios were classified correctly with 33–85% variation in correct response. Geographical and inter-specialty differences were noted. Conclusion: There is a broad variation among physicians on how to estimate the risk for patients with diabetes planning to fast during the month of Ramadan. A practical method using many variables might help physicians in the decision making.

Background: Injectable glucagon-like peptide-1 receptor agonists (GLP-1RAs) are proven to be well tolerated and efficacious in people with type 2 diabetes mellitus (T2DM) fasting during Ramadan. The first oral GLP-1RA semaglutide, also indicated for the treatment of T2DM, has specific dosing instructions to optimize treatment exposure, which may need to be altered during Ramadan fasting to ensure optimal efficacy. Summary: Given the lack of current published evidence for the effect of oral semaglutide during Ramadan, a panel of experts formulated recommendations for the administration of oral semaglutide during Ramadan. Key Messages: This statement reports recommendations for oral semaglutide administration during Ramadan.

Introduction: The safety and effectiveness of gliclazide modified release (MR) in patients with type 2 diabetes mellitus (T2DM) who fasted during Ramadan were previously published. Here, we carried out a regional analysis among patients living in Gulf Cooperation Council (GCC) countries. Patients and Methods: DIA-RAMADAN was a real-world, observational, international, noncomparative study conducted in nine countries that included >1200 T2DM adults receiving gliclazide MR for at least 90 days before inclusion. The study comprised 2 visits: at inclusion, 6–8 weeks before the start of Ramadan (V0) and 4–6 weeks after the end of Ramadan (V1). The primary endpoint was the proportion of patients reporting ≥1 symptomatic hypoglycemic event as collected using a patient diary. Changes in HbA1c, fasting plasma glucose (FPG), and weight were also analyzed. This manuscript represents data collected in GCC countries (Kuwait, Saudi Arabia, and United Arab Emirates). Results: Data from 161 patients were analyzed: mean (SD) age 56.8 (10.6) years, 30.4% women, body mass index 29.1 (3.7) kg/m2, T2DM disease duration 6.7 (3.3) years, baseline HbA1c 7.9% (0.8). The proportions of patients reporting ≥1 symptomatic hypoglycemic event or confirmed hypoglycemia during Ramadan were 4.3% and 0.6%, respectively. No cases of severe hypoglycemia were reported. Significant reductions in main variables were observed before the start of Ramadan (V0) and 4–6 weeks after the end of Ramadan (V1): HbA1c (from 7.9 [0.8] to 7.6 [0.7]%; p value

Abstract The upsurge of type 2 diabetes mellitus is a major public health concern in the Middle East and North Africa (MENA) and Africa (AFR) region, with cardiorenal complications (CRCs) being the predominant cause of premature morbidity and mortality. High prevalence of cardiometabolic risk factors, lack of awareness among patients and physicians, deficient infrastructure, and economic constraints lead to a cascade of CRCs at a significantly earlier age in MENA and AFR. In this review, we present consensus recommendations by experts in MENA and AFR, highlighting region‐specific challenges and potential solutions for management of CRCs. Health professionals who understand sociocultural barriers can significantly increase patient awareness and encourage health‐seeking behavior through simple educational tools. Increasing physician knowledge on early identification of CRCs and personalized treatment based on risk stratification, alongside optimum glycemic control, can mitigate therapeutic inertia. Early diagnosis of high‐risk people with regular and systematic monitoring of cardiorenal parameters, development of region‐specific care pathways for timely referral to specialists, followed by guideline‐recommended care with novel antidiabetics are imperative. Adherence to guideline‐recommended care can catalyze utilization of sodium glucose cotransporter 2 inhibitors and glucagon‐like peptide 1 receptor agonists with demonstrated cardiorenal benefits—thus paving the way for overcoming care gaps in a cost‐effective manner. Leveraging digital technology like electronic medical records can help generate real‐world data and provide insights on voids in adoption of newer antidiabetic medications. A patient‐centric approach, collaborative care among physicians from different specialties, alongside involvement of policy makers are key for improving patient outcomes and quality of care in MENA and AFR.

Introduction: Prior studies show that many patients with diabetes whose health maybe impacted by fasting, choose to fast during Ramadan. This study describes the implementation and evaluation of an online module targeting bachelor of pharmacy (BPharm) and doctor of pharmacy (PharmD) students that aims to improve participants' knowledge, communication, and self-efficacy concerning proper care for patients with diabetes in Ramadan. Methods: An online module consisting of two phases targeting both BPharm and PharmD students was implemented over two semesters in fall 2020 and spring 2021. Participants were directed to fill pre-module and post-module assessments to evaluate the change in their knowledge and self-efficacy using two scales. Pre- and post-survey data for participants’ knowledge and self-efficacy were analyzed for significance using paired sample t-tests. Qualitative data analysis was performed to assess participants’ responses to the open-ended question concerning what they liked and disliked about the module. Results: All BPharm and PharmD students taking the lesson responded to both the baseline survey and the follow-up one resulting in 92 responses (participation rate of 100%). The average score for participants in the pre-module self-efficacy section was 1.5 (SD = 1) and increased post-module to 3.5 (SD = 0.7), t (91) = 20.2, p

Abstract Reliable assessment of glycemia is central to the management of diabetes. The kidneys play a vital role in maintaining glucose homeostasis through glucose filtration, reabsorption, consumption, and generation. This review article highlights the role of the kidneys in glucose metabolism and discusses the benefits, pitfalls, and evidence behind the glycemic markers in patients with chronic kidney disease. We specifically highlight the role of continuous glucose monitoring as an emerging minimally invasive technique for glycemic assessment.

Background: Contrast-induced encephalopathy (CIE) is an infrequent but serious neurological condition that occurs shortly after the administration of contrast during endovascular and angiography procedures. Patients suffering from chronic kidney disease (CKD) or end-stage kidney disease (ESKD) are considered to be at a higher risk of contrast medium neurotoxicity, due to the delayed elimination of the contrast medium. However, the occurrence and characteristics of CIE in CKD/ESKD patients have not been extensively investigated. Methods: We conducted a comprehensive literature search, utilizing databases such as MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, up to September 2022. The purpose was to identify documented cases of CIE among patients with CKD or ESKD. Employing a random-effects model, we calculated the pooled incidence and odds ratio (OR) of CIE in CKD/ESKD patients. Results: Our search yielded a total of eleven articles, comprising nine case reports and two observational studies. Among these studies, 2 CKD patients and 12 ESKD patients with CIE were identified. The majority of the CKD/ESKD patients with CIE (93%) had undergone intra-arterial contrast media and/or endovascular procedures to diagnose acute cerebrovascular disease, coronary artery disease, and peripheral artery disease. The male-to-female ratio was 64%, and the median age was 63 years (with an interquartile range of 55 to 68 years). In the two observational studies, the incidence of CIE was found to be 6.8% in CKD patients and 37.5% in ESKD patients, resulting in a pooled incidence of 16.4% (95% CI, 2.4%–60.7%) among the CKD/ESKD patients. Notably, CKD and ESKD were significantly associated with an increased risk of CIE, with ORs of 5.77 (95% CI, 1.37–24.3) and 223.5 (95% CI, 30.44–1641.01), respectively. The overall pooled OR for CIE in CKD/ESKD patients was 32.9 (95% CI, 0.89–1226.44). Although dialysis prior to contrast exposure did not prevent CIE, approximately 92% of CIE cases experienced recovery after undergoing dialysis following contrast exposure. However, the effectiveness of dialysis on CIE recovery remained uncertain, as there was no control group for comparison. Conclusions: In summary, our study indicates an association between CIE and CKD/ESKD. While patients with CIE showed signs of recovery after dialysis, further investigations are necessary, especially considering the lack of a control group, which made the effects of dialysis on CIE recovery uncertain.

Abstract Background Minimal data is available on the prevalence and correlates of hypertension and prehypertension in Dubai. The study aims to measure the prevalence of hypertension and pre-hypertension and the associated socio-demographic characteristics, behavioral risk factors and comorbidities among the adult population of Dubai. Methods This study used data from the Dubai Household Health Survey, 2019. A cross-sectional population survey based on a complex stratified cluster random design. The total eligible sample included 2530 adults (18+). Sociodemographic and behavioral factors were considered as independent covariates. The main study outcome variables, pre-hypertension and hypertension, were ordinal, with normotension as the reference group. Results The overall prevalence of hypertension in adults was 32.5% (38.37% in males and 16.66% in females). Prehypertension was prevalent in 29.8% of adults in Dubai (28.85% in males and 32.31% in females). The multivariate logistic regression analysis revealed that age groups, gender, occupation, and high Body Mass Index were significantly associated with a higher risk of hypertension at the level of P

Objective To study the prevalence of overweight and obesity and determine the associated risk factors among adults in Dubai.Design and setting A cross-sectional survey with a multistage, stratified random sampling design was conducted in the Emirate of Dubai in 2019.Participants The study included 2142 adults aged 18+ years in the Emirate of Dubai.Results The overall prevalence of obesity, which was defined as body mass index (BMI) ≥30 kg/m2, was 17.8%. The highest obesity rates were reported among women (21.6%) and the United Arab Emirates (UAE)-nationals (39.6%). Moreover, 39.8% of the population was overweight (BMI ≥25–29.9 kg/m2). Multivariate logistic regression showed associations between obesity and age, sex, nationality, hypertension and occupation. Obesity increases with age, with the highest risk at age group 50–59 years (OR 4.30; 95% CI 1.57 to 11.78) compared with the reference group (18–24 years). Females had a higher risk of obesity than males (OR 1.62; 95% CI 1.10 to 2.38). Compared with those in the reference group (Western and others), UAE nationals, other Arabs and Asians were more likely to be obese ((OR 2.08; 95% CI 1.18 to 3.67), (OR 3.61; 95% CI 2.41 to 5.44) and (OR 1.98; 95% CI 1.12 to 3.50), respectively). Clerical and service workers (OR 4.50; 95% CI 2.54 to 8.00) and elementary and unskilled occupation categories (OR 2.57; 95% CI 1.56 to 4.25) had higher risks of obesity than the reference group (professionals), p

Rationale & Objective: Dysnatremias have been associated with an increased risk of mortality in the chronic kidney disease (CKD) population. Our objective is to identify the prevalence of and risk factors associated with dysnatremias in a CKD population and assess the association of dysnatremias with kidney failure and mortality among patients with CKD enrolled in the Chronic Renal Insufficiency Cohort Study. Study Design: Analysis of prospective cohort study. Setting & Participants: Adult patients aged 21-74 years with CKD from the Chronic Renal Insufficiency Cohort study. Predictors: Baseline and time-dependent hyponatremia and hypernatremia. Outcomes: All-cause mortality and kidney failure. Analytical Approach: Baseline characteristics were compared using χ2 tests for categorical variables, analysis of variance for age, and Kruskal-Wallis tests for laboratory variables. Cox proportional hazards models and competing risk models were used to evaluate the association between baseline sodium level and overall mortality. Results: Of a total of 5,444 patients with CKD, 486 (9%) had hyponatremia and 53 (1%) had hypernatremia. Altogether, 1,508 patients died and 1,206 reached kidney failure. In adjusted Cox models, time-dependent dysnatremias were strongly associated with mortality for both hyponatremia (HR, 1.38; 95% CI, 1.16-1.64) and hypernatremia (HR, 1.54; 95% CI, 1.04-2.29). Factors associated with hyponatremia included female sex, diabetes, and hypertension. Regardless of age, time-dependent hypernatremia was associated with an increased risk of kidney failure (HR, 1.64; 95% CI, 1.06-2.53). Baseline and time-dependent hyponatremia were associated with an increased risk of kidney failure in patients younger than 65 (baseline hyponatremia HR, 1.30; 95% CI, 1.03-1.64 and time-dependent hyponatremia HR, 1.36; 95% CI, 1.09-1.70) but not among patients aged >65 years. Limitations: Inability to establish causality and lack of generalizability to hospitalized patients. Conclusions: Dysnatremias are prevalent among ambulatory CKD patients and are associated with mortality and kidney failure. Time-dependent dysnatremias were significantly associated with mortality in patients with CKD. Time-dependent hypernatremia was associated with progression to kidney failure. Baseline and time-dependent hyponatremia were associated with an increased risk of progression to kidney failure in those younger than 65 years.

Rationale and Objective: Chronic kidney disease is a risk enhancing factor for cardiovascular disease (CVD) and mortality, and the role of aspirin use is unclear in this population. We investigated the risk and benefits of aspirin use in primary and secondary prevention of CVD in the Chronic Renal Insufficiency Cohort Study. Study Design: Prospective observational cohort. Setting & Participants: 3,664 Chronic Renal Insufficiency Cohort participants. Exposure: Aspirin use in patients with and without preexisting CVD. Outcomes: Mortality, composite and individual CVD events (myocardial infarction, stroke, and peripheral arterial disease), kidney failure (dialysis and transplant), and major bleeding. Analytical Approach: Intention-to-treat analysis and multivariable Cox proportional hazards model to examine associations of time varying aspirin use. Results: The primary prevention group was composed of 2,578 (70.3%) individuals. Mean age was 57 ± 11 years, 46% women, 42% Black, and 47% had diabetes. The mean estimated glomerular filtration rate was 45 mL/min/1.73 m2. Median follow-up was 11.5 (IQR, 7.4-13) years. Aspirin was not associated with all-cause mortality in those without preexisting cardiovascular disease (CVD) (HR, 0.84; 95% CI, 0.7-1.01; P = 0.06) or those with CVD (HR, 0.88; 95% CI, 0.77-1.02, P = 0.08). Aspirin was not associated with a reduction of the CVD composite in primary prevention (HR, 0.97; 95% CI, 0.77-1.23; P = 0.79) and in secondary prevention because the original study design was not meant to study the effects of aspirin. Limitations: This is not a randomized controlled trial, and therefore, causality cannot be determined. Conclusions: Aspirin use in chronic kidney disease patients was not associated with reduction in primary or secondary CVD events, progression to kidney failure, or major bleeding.

Diabetes prevalence is on the rise in the Middle East. In countries of the Gulf region—Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates—prevalence rates are among the highest in the world. Further, Egypt now ranks as one of the top 10 countries in the world for high number of people with diabetes. Medical nutrition therapy is key to optimal management of diabetes. Patient adherence to nutritional guidance depends on advice that is tailored to regional foods and cultural practices. In 2012, international experts created a transcultural Diabetes Nutrition Algorithm (tDNA) for broad applicability. The objective of this current project was to adapt the algorithm and supportive materials to the Middle East region. A Task Force of regional and global experts in the fields of diabetes, obesity, and metabolic disorders met to achieve consensus on Middle East-specific adaptations to the tDNA. Recommendations, position statements, figures, and tables are presented here, representing conclusions of the tDNA-Middle Eastern (tDNA-ME) Task Force. Educational materials can be used to help healthcare professionals optimize nutritional care for patients with type 2 diabetes. The tDNA-ME version provides evidence-based guidance on how to meet patients' nutritional needs while following customs of people living in the Middle Eastern region.

Introduction: Hyperglycaemia in pregnancy (HIP) is the most common medical disorder complicating pregnancy. This includes women who have pre-existing Type 1 and Type 2 diabetes mellitus (DM) and those diagnosed to have gestational diabetes mellitus (GDM), with glucose intolerance identified for the first time in pregnancy. In the Middle East and North Africa region, the prevalence of DM in women of reproductive age group is high and it varies widely between different regions due to variation in screening and diagnostic criteria for the identification of GDM. Universal blood glucose screening at first antenatal booking visit helps in identifying women with HIP. Women who are screen negative at first antenatal should subsequently be screened with a fasting oral glucose tolerance test (OGTT) around 24-28 weeks to identify GDM. There is a clear evidence that the identification and management of hyperglycaemia improves pregnancy outcomes. Antenatal care involves more visits as these women are at higher risk of fetal malformations, preterm labour and stillbirth. Timing of delivery is based on glycaemic control, fetal wellbeing, and the presence of co-morbidities. Objective: The objective of this article is to provide guidelines regarding the management of hyperglycemia in pregnancy. Materials and Methods: These recommendations are made after reviewing various existing guidelines including American College of Obstetricians and Gynecologists, Royal College of Obstetricians and Gynecologists, and American College of Sports Medicine. A literature search was done using PubMed, Cochrane Database, Google Scholar, EMBASE, various systematic reviews, and original articles. Search was done using key words “Hyperglycemia in pregnancy,” “gestational diabetes mellitus,” and “diabetes in pregnancy.” Conclusion: Hyperglycemia in pregnancy can be managed effectively if appropriate measures are taken and potential consequences can be avoided.

BackgroundMany Muslims with diabetes choose to fast against medical advice during Ramadan, potentially increasing their risk of acute complications. Patients are often reluctant to disclose fasting to their health care providers, and their needs regarding Ramadan are not met in consultations. For healthcare professionals to provide patient-centred care, it is important to gain more insight into patients' decision-making process. This study therefore aims to explore how Muslims with diabetes decide whether to fast during Ramadan.MethodsA qualitative study was conducted consisting of 15 focus groups with Muslims with diabetes within a constructivist paradigm. Convenience sampling was used. All focus groups were transcribed verbatim and analyzed using Braun and Clarke's reflexive thematic analysis.ResultsFour themes were found to be important in the decision on whether to fast: (1) values and beliefs concerning Ramadan, (2) experiences and emotions concerning Ramadan, (3) the perception of illness, and (4) advice from health care professionals, imams and family. Many participants indicated fasting against medical advice and trusting their subjective assessments on whether they could fast. Moreover, three main stages in the decision-making process for eventually refraining from fasting were identified: (1) the stage where positive experiences with fasting dominate, (2) the stage where one encounters challenges but their determination to fast prevails and (3) the stage where one decides to refrain from fasting after experiencing too many physical difficulties with fasting.ConclusionsMuslims with diabetes experience autonomy in their decisions on Ramadan fasting. The decision to refrain from fasting often resulted from a difficult and dynamic decision-making process and was often made after participants reached their physical limits. These findings highlight the importance of not only shared decision-making to empower patients to make well-informed decisions on Ramadan fasting but also pre-Ramadan diabetes education to help people with diabetes have a safe Ramadan.

Background Data: Balloon kyphoplasty allows surgeons to directly reduce the fractured vertebral body using inflatable balloons. However, the reduction cannot be maintained following balloon deflation and removal. Therefore, mechanical kyphoplasty techniques were designed to avoid loss of the reduction before cement injection and restore the vertebral body indefinitely. Study Design: A prospective cohort clinical case study. Purpose: To assess efficacy and safety of mechanical kyphoplasty using the Spine Jack® system in treatment of osteoporotic vertebral compression fractures (VCFs) of the thoracolumbar spine. Patients and Methods: During the period from April 2016 to March 2018, seventeen patients who sustained recent osteoporotic VCFs of the thoracolumbar spine, presenting with intractable back pain following one-month trial of conservative treatment, were included. Patients with pathological fractures, those with neurological deficits, or those medically unfit were excluded. The study included 6 males and 11 females with mean age of 60.37 years. Fractures were surgically treated using the Spine Jack® system that was inserted percutaneously through the transpedicular approach. Back pain intensity and degree of functional recovery were assessed using the Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI), respectively, whereas segmental deformity of the fractured vertebra was evaluated using standing plain X-rays and CT scan, including measurement of the local kyphotic angle and Beck Index. Results: Patients were followed for at least 6 months (mean 7.4±1.2). At final follow-up, there was significant improvement in mean VAS score (7.3 to 2.9) and mean ODI score (61.4 to 28.7). Postoperative imaging showed significant improvements in mean Beck Index (0.68 to 0.77) and mean local kyphotic angle (21.4° to 14.3°). Cement leakage was noted in 2 patients (11.7%) with no clinical relevance. None of the patients developed neurological deterioration, adjacent fracture, or hardware-related complication during the follow-up. Conclusion: Percutaneous stabilization of osteoporotic VCFs of the thoracolumbar spine using the Spine Jack® system is effective and safe even with posterior wall involvement, with significantly better outcome in terms of pain relief, functional recovery, and vertebral body restoration. (2019ESJ182)

A well-known side effect of statin therapy is myopathy. We report a case of statin induced necrotizing autoimmune myopathy, a rare variant of statin-induced myopathy. A 64-year-old gentleman on atorvastatin presented with muscle weakness. Initial laboratory results showed elevated liver function tests, a creatine phosphokinase (CPK) of 8200 IU/L, and positive urine myoglobin. Despite discontinuing atorvastatin, his CPK remained persistently elevated. Muscle biopsy was consistent with necrotizing myopathy. Anti-HMG CoA reductase antibody was strongly positive. Steroids followed by intravenous immunoglobulin were given. The patient’s muscle weakness, CPK, and liver functions gradually improved, and he was eventually discharged on oral steroids. Statin induced necrotizing autoimmune myopathy should be considered when discontinuing statin does not lead to muscle recovery and improvement in CPK. Diagnosis is confirmed by positive anti-HMG-CoA reductase autoantibody. Keywords: Autoimmune myopathy, Myopathy, Statins

Objectives: In the UAE, the comparative prevalence of diabetes is reported as 18.98%, but there are very few studies evaluating glycemic control. Attaining the optimum glycemic control has been a global challenge over the years. However, there is a trend of global improvement with the availability of newer options of antidiabetic medications, increasing numbers of physicians, and patient awareness. Our primary aim was to assess the level of glycemic control across Dubai Health Authority points of care over the past five years. Additionally, we aimed to compare the differences in glycemic control between primary and tertiary centers, between nationalities, and type I and II diabetes. Methods: We conducted a retrospective analysis of the electronic medical records of all patients who attended primary and tertiary care centers within the Dubai Health Authority between 2012 and 2016. All patients with any type of diabetes were included in this assessment. Results: A total of 26 447 patients were included in the study; of these, 73.8% (n = 19 508) were UAE nationals while the other nationalities accounted for 26.2% (n = 6939) of patients. The overall mean glycated hemoglobin (HbA1c) levels from 2012 to 2016 was 7.76%. Patients attending primary care clinics had a mean HbA1c of 7.64% compared to 7.68% for the tertiary care cohort. Out of the total population, 37.7% achieved HbA1c < 7%. Over 40% of the patients attending primary care centers achieved HbA1c < 7% compared to 34.9% of those who attended tertiary care centers. Conclusions: Optimum glycemic target was achieved by less than 40% of patients. Glycemic control is still below the desired levels. However, there has been a trend of improvement in the last few years and we are achieving the international average targets. Further collaborative actions from clinical, educational, and strategic sectors are needed to improve our goals further.

Ramadan is the 9th month of the lunar calendar during which Muslims abstain from food and drink between dawn and sunset for 30 consecutive days. Ramadan fasting is observed by all healthy Muslim adults, as well many Muslims with type 2 diabetes (T2DM). Hypoglycemic events (HE) are a serious complication associated with diabetes management and are associated with increased cardiovascular disease risk. Conflicting results have been reported concerning the incidence of HE among people with T2DM observing Ramadan fasting. This review summarizes available scientific evidence on the occurrence of HE and the effects of different moderators on the incidence of HE among patients with T2DM during Ramadan. We conducted a systematic review of available observational studies and randomized controlled trials (RCTs) for patients with T2DM who fasted during Ramadan, with HE as the primary outcome. Ten databases were searched for relevant studies from inception until October 31, 2020. In total, 68 studies (35 RCTs and 33 observational studies) met the inclusion criteria. Non-sulfonylureas hypoglycemic medications showed superior effects in lowering the incidence of HE over sulfonylureas hypoglycemic medications. Variable moderators were associated with experiencing HE during Ramadan in both observational studies and RCTs, including sex, geographical location, body anthropometric indicators, season, dietary behaviors, fasting duration, time since diagnosis, and pre-fasting education. This comprehensive systematic review covered the largest number of observational and clinical studies investigating the impact of Ramadan on HE among patients with T2DM. The study highlights the significance of different moderators that influence the effect of Ramadan fasting on HE, including dietary behaviors, fasting time duration, sex, season, country, pre-fasting education, age, and time since diagnosis. The study also highlighted the impact of different hypoglycemic medications on HE and noted the superiority of non-sulfonylureas over sulfonylureas hypoglycemic medications in lowering the risk for hypoglycemia in people with T2DM during Ramadan fasting.

Background and Objectives: Dietary modification is the principal approach to the management of hyperlipidemia in adults. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a key regulator of plasma cholesterol and a target for novel lipid-lowering pharmacotherapies. This study aimed to explore how circulating levels of PCSK9 changed during Ramadan intermittent fasting in metabolically healthy obese subjects. Materials and Methods: This cross-sectional study used convenience sampling to recruit 55 overweight and obese participants (22 females and 33 males) who observed Ramadan fasting. Body weight and composition, glucoregulatory factors, serum PCSK9 concentration, dietary intake, and physical activity were assessed 1 week before and at the end of Ramadan fasting. Results: The median (interquartile range) age was 35 (22) years, and body mass index was 30.2 (5.4). We found significant (p < 0.05) increases in serum levels of PCSK9, serum insulin, insulin resistance, and leptin at the end of Ramadan compared with pre-fasting levels. Significant (p < 0.05) reductions in body weight, waist circumference, systolic and diastolic blood pressure, total cholesterol, triglycerides, high-density lipoprotein cholesterol, and adiponectin were also observed at the end of Ramadan. Conclusions: Observing Ramadan fasting was associated with increased PCSK9 levels in metabolically healthy obese subjects. The complex relationships between PCSK9 and insulin resistance and dysregulation of adipokine secretion in relation to dietary and lifestyle modifications during Ramadan warrant further research.

Background Data: Burst fractures are commonly provoked by axial compression which disrupts the anterior column. In this setting, posterior stabilization using pedicle screws alone may lead to delayed kyphosis and instrumentation failure due to inadequate support of the anterior column. Purpose: To evaluate the efficacy of pedicle screw instrumentation combined with transpedicular titanium mesh cage augmentation for treatment of burst fractures. Study Design: Prospective descriptive cohort clinical case study. Patients and Methods: Fourteen neurologically intact patients with acute incomplete thoracolumbar burst fracture (AO type A 3.1), and operated upon through period from January 2016 to June 2017 were included. Patients were treated using a three vertebrae pedicle screw fixation construct combined with bilateral transpedicular titanium mesh cage augmentation of the fracture. Patients were followed for at least one year. Data about pain (VAS), function (ODI) and vertebral body deformity (Beck index and local kyphotic angle) were recorded prospectively. Results: Patients were operated within 5 days after trauma. The mean VAS score improved after surgeryfrom 8.2±1.3 to 3.7±1.1 postoperatively and to 1.8±0.7 at final follow up(P˂0.05). The mean ODI score improved from 69.4±5.2 preoperatively to 17.2±2.4 at final follow up. The mean Beck index improved from 0.63 preoperatively to 0.81 postoperatively and to 0.79 at final follow up. The mean local kyphotic angle improved from 20.4opreoperatively to 11.5opostoperatively and declined to 13.7o at final visit. No patient had neurological deterioration or hardware failure during the follow up.The mean follow up was 13.4±1.8 months. Conclusion: Posterior stabilization using pedicle screw fixation in combination with titanium mesh cage augmentation can maintain vertebral restoration, prevent hardware failure and lead to better clinical outcome. (2018ESJ162)

Background Data: Percutaneous screws fixation became popular as it depends on minimal muscle destruction and no para-spinal muscle stripping. However, there is a lot of disadvantages of percutaneous fixation technique including the high radiation exposure. Complications reported in conventional midline approach including muscle stripping from lamina and spinous processes and long-term postoperative pain and muscle weakness led the spine surgeon to rediscover minimally invasive technique to manage spinal fractures through posterior approach. One of these techniques is Wiltse technique which access the pedicle through blunt dissection between the longissimus muscle and multifidus muscle. Purpose: This study aims to compare pedicle screw fixation via Wiltse approach, and the traditional posterior midline approach outcome. Study Design: Prospective comparative study. Patients and Methods: A total of 36 patients of single-level thoracolumbar fractures without neurologic injury underwent pedicle screw fixation using two different approaches. Twenty patients were treated using conventional technique (Group 1 ), and 16 patients were operated using Wiltse technique (Group 2 ). Screw placement accuracy rate, operative time, blood loss, postoperative hospitalization time, radiation exposure time, postoperative improvement of Cobb angle for regional kyphosis, functional disability index using Oswestry Disability Index, and Visual Analogue Scale (VAS) of the two groups were compared. Results: There were no significant differences in the accuracy rate of pedicle screw placement, radiation exposure and Cobb angle improvement between the two groups. However, the Wiltse technique had obvious advantages over the conventional technique in operative time, blood loss, hospitalization time, ODI improvement and postoperative short-term improvement in VAS. Conclusion: Our data suggest that pedicle screw insertion using Wiltse technique for treatment of thoracolumbar fracture has the advantages of less tissue trauma, short operative and rehabilitative time on the premise of guaranteed accuracy rate and no significant increased radiation exposure. (2018ESJ160)

Abstract Background Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe hypersensitivity drug reaction involving the skin and multiple internal organ systems. The symptoms typically present with fever and skin rash, and rapidly progress to multiple organ failures. Vancomycin is a rare drug to cause DRESS syndrome with 23 cases reported to date. Case presentation We described a case of a 39 year-old man who was treated with vancomycin for osteomyelitis of the foot. The patient subsequently developed acute respiratory distress syndrome (ARDS) followed by rash and acute interstitial nephritis. These symptoms were improved by withdrawal of vancomycin and a pulsed corticosteroid regimen. According to the European Registry of Severe Cutaneous Adverse Reaction Criteria (RegiSCAR) (Kardaun et al, British Journal of Dermatology, 169:1071-1080, 2013), the probability of vancomycin induced DRESS syndrome was scored as “Definite”. A literature search of vancomycin induced DRESS syndrome was also performed and the overall pulmonary involvement was estimated as 5%. To our knowledge, this was the first case reported with pulmonary involvement as the initial symptom. Conclusion This is the first case to report pulmonary manifestation as the initial symptom in vancomycin induced DRESS syndrome. Prompt recognition of this entity can expedite proper treatment and hasten recovery.

Ramadan fasting has been a major concern among researchers considering the theoretically imposed risk on patients with diabetes mellitus due to prolonged fasting. Studies indicate that the knowledge and practices of physicians do not comply with the proposed recommendations in this regard in many cases. This study aimed to explore the viewpoints and attitudes of physicians toward the management of diabetes mellitus regarding to Ramadan fasting. In addition, we assessed the knowledge and compliance of physicians with available recommendations regarding the management of diabetes mellitus in Ramadan. According to the results, Ninety five present of the physicians (n=862) believed the type of diabetes to be “important” or “very important” in decision-making for Ramadan fasting. Control of diabetes before Ramadan was noted as “important” or “very important” by 95% of the physicians (n=848). Moreover, the majority of respondents emphasized on the pivotal role of self-monitoring of blood glucose in the management of patients receiving insulin or sulphonylureas (SUs), and to a lesser extend in cases treated with other oral hypoglycemic agents than SUs. Among the participants, 63.8% (n=397) confirmed the availability of Ramadan-focused educational programs for their patients, whereas thirty six present (n=225) mentioned the absence of such programs. According to the results of this study, it is crucial to raise the awareness of patients and physicians about the importance of Ramadan fasting through structured educational interventions in order to reduce the health risks associated with fasting in diabetic patients. Therefore, it is recommended that simplified guidelines and educational materials be dispensed for healthcare providers for related training programs before Ramadan.

Sarcoidosis is a systemic inflammatory disease characterized by the presence of noncaseating granulomas in different organs. Sarcoidosis associated with monoclonal gammopathy of undetermined significance (MGUS) is a rare finding with only 10 cases reported to date. We describe a 79-year-old male patient who presented with dry mouth for 4 months. Lip biopsy done prior to admission showed nonnecrotizing epithelioid cell granulomas. On admission, laboratory analysis was significant for elevated calcium, decreased parathyroid hormone, increased erythrocyte sedimentation rate, undetectable parathyroid hormone-related peptide (PTHrp), mildly decreased 25-hydroxyvitamin D, elevated 1,25-dihydroxyvitamin D, elevated angiotensin converting enzyme, and positive Bence Jones protein in the urine. Serum protein electrophoresis showed an elevated gamma globulin level at 38% and an IgG monoclonal gammopathy with an M-spike of 1.47. Bone marrow biopsy was consistent with MGUS. The patient showed significant improvement with steroids and was discharged with close follow-up from nephrology and oncology. Salivary gland involvement in patients with sarcoidosis is a rare finding. Our case is a valuable addition to the small number of cases described in the literature supporting an association between plasma cell disorders and sarcoidosis. Larger prospective studies are needed to determine if a true association between the two diseases exists.

The challenge of insulin use during Ramadan could be minimized, if people with diabetes are metabolically stable and are provided with structured education for at least 2-3 months pre-Ramadan. Although, American diabetes association (ADA) recommendations 2010 and South Asian Consensus Guideline 2012 deal with management of diabetes in Ramadan and changes in insulin dosage, no specific guidance on widely prescribed low-ratio premix insulin is currently available. Hence, the working group for insulin therapy in Ramadan, after collective analysis, evaluation, and opinion from clinical practice, have formulated a practical advice to empower physicians with pre-Ramadan preparation, dose adjustment, and treatment algorithm for self-titration of low-ratio premix insulin.