Does the seizure frequency increase in Ramadan?

Sex as a Biological Factor in the Changes in Disease Patients During Ramadan Intermittent Fasting: A Systematic Review

Background

During Ramadan, many patients with diabetes, renal, cardiovascular, gastrointestinal diseases, headaches, and epilepsy choose to fast even against their doctor's advice. The impact of this intermittent fasting on health and disease could be different in men and women. The aim of this study was to determine the effect of sex as a factor in diseases outcomes of patients who opt to fast during Ramadan.

Main Body

The articles included in this study reported data on six diseases: diabetes, renal, cardiovascular, gastrointestinal diseases, headaches, and epilepsy. A systematic search was performed on PubMed and Scopus for observational and clinical studies mentioning Ramadan, diabetes, renal, cardiovascular, gastrointestinal diseases, headaches, and epilepsy in both men and women. Data was extracted by two independent reviewers using a standardized data-collection form. From 381 original articles, 38 studies were selected, including 25,023 patients of which 44.4% were women. Sex-based differences were reported by 18 studies for several variables such as body mass index, blood glucose, the frequency of hypoglycemia, renal colic, mortality, thrombosis, and gastrointestinal diseases in patients fasting during Ramadan. Most of the differences between men and women were reported both in the baseline period before Ramadan and during Ramadan. Indeed, during the period outside Ramadan, the frequency of renal colic, cardiovascular, gastrointestinal diseases, were higher in men; while body mass index, Thrombosis, and headache were higher in women. In the remaining 21 studies, it was reported that the sex factor was not associated with the effect of Ramadan fasting in the frequency and other outcomes of these diseases.

Conclusion

Currently, small attention is paid to sex as a determinant factor in patients while fasting during Ramadan. There appeared to be differences in the frequency and incidence of diseases in men and women during Ramadan. Closer attention to sex differences regarding the frequency and the progression of the diseases during fasting may help to improve patient care, especially to benefit those patients willing to fast during Ramadan.

Pediatric emergency department utilisation during Ramadan: a retrospective cross-sectional study

OBJECTIVE

To investigate the impact of Ramadan on patient characteristics, diagnoses and metrics in the paediatric emergency department (PED).

DESIGN

Retrospective cross-sectional study.

SETTING

PED of a tertiary care centre in Lebanon.

PATIENTS

All paediatric patients.

EXPOSURE

Ramadan (June 2016 and 2017) versus the months before and after Ramadan (non-Ramadan).

MAIN OUTCOME MEASURES

Patient and illness characteristics and PED metrics including peak patient load; presentation timings; length of stay; and times to order tests, receive samples and report results.

RESULTS

We included 5711 patients with mean age of 6.1±5.3 years and 55.4% males. The number of daily visits was 28.3±6.5 during Ramadan versus 31.5±7.3 during non-Ramadan (p=0.004). The peak time of visits ranged from 18:00 to 22:00 during non-Ramadan versus from 22:00 to 02:00 during Ramadan. During Ramadan, there were significantly more gastrointestinal (GI) and trauma-related complaints (39.0% vs 35.4%, p=0.01 and 2.9% vs 1.8%, p=0.005). The Ramadan group had faster work efficiency measures such as times to order tests (21.1±21.3 vs 24.3±28.1 min, p<0.0001) and to collect samples (50.7±44.5 vs 54.8±42.6 min, p=0.03).

CONCLUSIONS

Ramadan changes presentation patterns, with fewer daily visits and a later peak time of visits. Ramadan also affects illness presentation patterns with more GI and trauma cases. Fasting times during Ramadan did not affect staff work efficiency. These findings could help EDs structure their staffing to optimise resource allocation during Ramadan.

Epilepsy in Morocco: Realities, pitfalls and prospects

The World Health Organization (WHO) estimates that about 50 million people of all ages have epilepsy and nearly 85% of whom live in low- and middle-income (LMICs) countries. In Morocco, epilepsy is one of the major neurological health conditions, with an estimated prevalence of 1.1%. The management of patients is difficult due to multiple factors. The lack of neurologists whose number is currently 180, the uneven distribution of neurologists who are concentrated in large cities, 43% of whom are in Rabat and Casablanca alone; the low involvement of general practitioners in the management of epilepsy; the frequent consultation of traditional healers; and the low coverage of social security all contribute to the treatment gap. The management of epilepsy has advanced considerably since the early nineties. Several factors contributed to this progress: the increasing number of neurologists compared to previous years, the creation of well-equipped new academic centers, and small units of general neurology, in addition to the disuse of several antiepileptic drugs. However, much work remains to be done against the use of many forms of traditional practices and the low involvement of general practitioners in the management of epilepsy. This is the first study on epilepsy conducted in Morocco.

Fasting and post fasting effect of Ramadan on different seizure types in patients with active epilepsy

BACKGROUND AND OBJECTIVES

Fasting is the basis for the ketogenic diet, and intermittent fasting is emerging as a treatment for epilepsy. There are no available data about the role of Islamic fasting on seizure control. This study aims to assess the effect of Ramadan fasting on the frequency of different seizure types.

METHODS

This was a prospective observational study on Muslim patients with active epilepsy intending to fast during Ramadan in the year 2019, with an average of 16 fasting hours per day. Seizure frequency for each seizure type was followed over three months, one month before (Shaaban), during Ramadan and one month after (Shawwal), after ensuring drug compliance.

RESULTS

Three hundred and twenty one Muslim patients with active epilepsy with median age of 33 years were included (some patients had more than one type of seizure). In Ramadan, 86 out of 224 patients with focal seizures, 17 out of 38 patients with myoclonic seizures and 6 out of 10 patients with absence seizures showed ≥ 50% reduction. In Shawaal, such improvement continued to include 83, 13 and 4 patients with focal, myoclonic and absence seizures. Focal and myoclonic seizures were significantly improved in the months of Ramadan and Shawaal compared to Shaaban. However, absence seizures were significantly improved only in Ramadan compared with Shaaban. The frequency of generalized tonic-clonic seizures did not significantly differ between the three months.

DISCUSSION

Ramadan fasting may have an improving effect, as well as a post-fasting effect, on active focal, myoclonic and absence seizures.

Effects of fasting during Ramadan on seizure control and quality of life in patients with epilepsy

BACKGROUND

During Ramadan, the ninth month of the lunar Islamic calendar, adult Muslims are obliged to fast, which involves refraining from taking any food, beverages, or oral medications from dawn to sunset. Fasting's effect on seizure control is not fully understood, and a few observational studies have provided inconclusive results. This study aimed to investigate the effect of fasting during Ramadan on seizure control and quality of life in adult patients with epilepsy.

METHODS

This was a prospective observational study over a 3-month period (one month before fasting, the fasting month, and one month after fasting). We recruited adult patients with active epilepsy who were able to fast during the month of Ramadan. The primary outcome measures were as follows: 1) seizure control and 2) quality of life score using the Arabic version of the Ferrans and Powers Quality of Life Index (QLI). Changes in anticonvulsant medications were not allowed during the study period. We used a seizure log provided to participants to record the number of seizures during the 3-month period. Quality of life was scored at the end of each month of the study period.

RESULTS

Thirty-seven patients were studied (59% males). The mean age was 30 years (range, 14-51 years), and mean age at epilepsy onset was 13 years (range, 0.5-35 years). On average, patients were on three antiepileptic medications at baseline (range: 2-5). A total of 1576 seizures were reported during the 3-month follow-up, where seizures prior to fasting represented 35.5% of all seizures. Multilinear regression analysis revealed a significant decline of seizures by 21% during the fasting month compared with baseline (adjusted coefficient = 0.79, p < 0.01, 95% confidence interval (CI); 0.61-0.98, R2 = 0.81) and by 29% during post fasting compared with baseline (adjusted coefficient = 0.71, p < 0.01, 95% CI; 0.53-0.90, R2 = 0.79). No significant change was found in the QLI scores calculated during the three months of the study period.

CONCLUSION

Fasting during Ramadan might have a positive impact on seizure control in patients with epilepsy, which continued during the month following fasting, whereas the quality of life scores were not affected by fasting.

Epileptic Adolescents and Ramadan Fasting: A Prospective Cohort Study

This study aimed to evaluate the effect of Ramadan fasting on seizure control in epileptic adolescents. A prospective cohort study that included 56 epileptic patients aged 11 to 18 years. Patients were followed-up in the pediatric neurology clinic at Tanta University Children's Hospital during Ramadan 2019. Seizures frequency and severity, measured by Chalfont seizure severity scale, during Ramadan fasting were compared with those in the month before Ramadan. Before Ramadan, 43/56 patients were controlled and seizure free. Meanwhile, 13/56 patients were uncontrolled and had seizure frequency of one to six seizures in the month before Ramadan. There was no significant difference in seizure frequency during Ramadan compared with before Ramadan (p = 0.132), whereas seizure severity was significantly reduced during Ramadan (p = 0.028). Both seizure frequency and severity were significantly lower during Ramadan in uncontrolled epileptic patients compared with before Ramadan (p = 0.02 and 0.005). Ramadan fasting is safe in adolescents with epilepsy. Fasting is not a precipitating factor for seizures in epileptic adolescents, provided compliance to antiepileptic drugs, and could be beneficial for seizure control in uncontrolled epilepsy.

Managing epilepsy in Ramadan: Guidance for healthcare providers and patients

Ramadan is a regularly recurring period of fasting that takes place in the ninth month of the Islamic calendar. For this period, adult Muslims refrain from eating and drinking between dawn and sunset. The variation in summer daylight hours means that at temperate latitudes, fasting can last up to 20 h. It is already recognized that epilepsy control can deteriorate during Ramadan, and this may be explained by fasting-related changes to adherence to antiseizure drug regimes. This article provides specific advice to help Muslim patients prepare for Ramadan and reduce chances of exacerbation in epilepsy. In addition to advice around sleep hygiene, it explores the use of drugs or preparations of drugs that will demonstrate reduced variation during periods of fasting.

Predictors of successful Ramadan fasting in Muslim patients with epilepsy: A prospective study

PURPOSE

Ramadan fasting represents a challenge for both Muslim patients with epilepsy (MPWE) as well as their treating neurologists who aim to minimize the risk of fasting-related seizures. Several factors may contribute to the risk of fasting-related seizures such as the half-life of antiepileptic drugs (AEDs), seizure control before Ramadan, and sleep fragmentation. The aim of this work was to investigate these factors.

METHODS

An observational prospective study included all MPWE who completed Ramadan fasting in 2019, about 16 h per day for 30 days. They were assessed regarding seizure control, AEDs, and sleep alterations using The Pittsburgh Sleep Quality Index.

RESULTS

The study included 430 MPWE. The majority of patients (75.58%) completed Ramadan fasting without breakthrough seizures. Patients achieved successful Ramadan fasting were significantly younger, had shorter disease duration, longer periods of seizure freedom before Ramadan, more efficient and longer sleep hours. There was no significant difference between patients receiving monotherapy regimens with short versus intermediate long t½. Maximum seizure freedom before Ramadan and sleep hours were identified as independent predictors of successful Ramadan fasting, using multivariate analysis. Every extra week of being seizure free before Ramadan and every extra hour of sleep was associated with an increase in the probability of successful Ramadan fasting by 10% and 30%, respectively.

CONCLUSION

Neurologists should guide their MPWE who wish to fast Ramadan about the risks and precautions. Proper seizure control and ensuring adequate sleep duration can increase the probability of a successful Ramadan fasting.

Patient-guided modifications of oral anticoagulant drug intake during Ramadan fasting: a multicenter cross-sectional study

Fasting Ramadan is known to influence patients’ medication adherence. Data on patients’ behavior to oral anticoagulant (OAC) drug intake during Ramadan is missing. We aimed to determine patient-guided modifications of OAC medication regimen during Ramadan and to evaluate its consequences. A multicenter cross-sectional study conducted in Saudi Arabia. Data were collected shortly after Ramadan 2019. Participants were patients who fasted Ramadan and who were on long-term anticoagulation. Patient-guided medication changes during Ramadan in comparison to the regular intake schedule before Ramadan were recorded. Modification behavior was compared between twice daily (BID) and once daily (QD) treatment regimens. Rates of hospital admission during Ramadan were determined. We included 808 patients. During Ramadan, 53.1% modified their intake schedule (31.1% adjusted intake time, 13.2% skipped intakes, 2.2% took double dosing). A higher frequency of patient-guided modification was observed in patients on BID regimen compared to QD regimen. During Ramadan, 11.3% of patients were admitted to hospital. Patient-guided modification was a strong predictor for hospital admission. Patient-guided modification of OAC intake during Ramadan is common, particularly in patients on BID regimen. It increases the risk of hospital admission during Ramadan. Planning of OAC intake during Ramadan and patient education on the risk of low adherence are advisable.

Self-reported attitudes about medication in Lebanese people with epilepsy

BACKGROUND

Epilepsy is a common worldwide neurological disorder. For people with epilepsy (PWE), adherence and attitudes towards medication is a crucial step to improve efficacy of prescribed treatment and to prevent seizures.

OBJECTIVES

The first aim of this study was to evaluate attitudes towards antiepileptic medications in Lebanese population. Secondary aims were to assess factors affecting attitudes and associated with epilepsy control.

MATERIAL AND METHODS

A cross-sectional study was conducted in outpatient neurology clinics located in Beirut-Lebanon. Data were collected using a structured questionnaire. Self-report of medication taking behaviors were assessed using the abbreviated (4 items) Morisky Medication Adherence Scale (MMAS-4). Epilepsy was considered as controlled if the patient had no seizures in the last 6 months.

RESULTS

Among 250 PWE recruited in this study, male-to-female ratio was 0.87 (116/134), and 50.8% were married. Mean duration of epilepsy was 13.7 ± 12.8 years. Valproate was the most common antiepileptic drug (AED) used followed by levetiracetam and carbamazepine. About 60.8% of the population presented partial epilepsy. Uncontrolled epilepsy was present in more than half of participants (55.2%), with only 32.4% had positive attitudes to their medication. Positive attitudes towards antiepileptic increased in people who found that their treatment was efficacious (odds ratio (OR) = 4.9; 95% confidence interval (CI): 1.2-20.0; p = 0.03), who had controlled epilepsy (OR = 3.4; 95%CI 1.6-7.1; p = 0.001), and who were diagnosed as PWE between the age of 12-20 years (OR = 3.1; 95%CI 1.1-8.4; p = 0.03). Oppositely, these attitudes decreased in participants who felt their treatment as an economic burden (OR = 0.2; 95%CI 0.1-0.4; p ≪ 0.001), and in people with depression (OR = 0.4; 95%CI 0.2-0.9; p = 0.04). Controlled epilepsy was higher in people who contacted a neurologist if seizure occurred, in people with positive attitudes, and after a long duration of disease, but it decreased if patient did not follow neurologist's instructions in fasting period.

CONCLUSIONS

Lebanese PWE were less likely to have positive attitudes towards medication, which may lead to poor epilepsy control. Depression and economic burden were the major factors that decreased these attitudes. Identifying factors affecting attitudes to medication and leading to controlled epilepsy may help clinicians to elaborate educational programs to optimize medication adherence.

Emergency department attendance patterns during Ramadan

BACKGROUND

Patient attendance in the emergency department (ED) is inherently variable and unpredictable. Resources might be better allocated if use of the ER could be predicted during the month of fasting (Ramadan), healthy adult Muslims do not eat or drink from dawn to sunset and in the Middle East, social activities occur mostly during night. There is no published data that has reported changes in local ED attendance pattern during Ramadan.

OBJECTIVES

Determine if there are differences in tertiary care ed attendance during Ramadan compared to other times of the year.

DESIGN

Retrospective, using data from the hospital integrated clinical information system.

SETTING

Tertiary care institution in Riyadh, Saudi Arabia.

PATIENTS AND METHODS

All ED visits during the Islamic calendar years of 1431-1434 (December 18, 2009-October 13, 2013) were analyzed.

MAIN OUTCOME MEASURES

Patient volume, acuity, demographics and admission rate variability between Ramadan and other months.

RESULTS

During the study period of 4 years, of 226075 ED patients, 129178 (57.14%) patients were seen during the day shift (07:00 to 18:59). During Ramadan, 10 293 (60%) patients presented during the night shift compared with the day shift (P < .0001). This trend was seen consistently with no statistically significant differences in admissions 7%, triage acuity or when compared with other months.

CONCLUSION

During Ramadan, ED attendance changes as more patients present during the night shift. In Saudi Arabia and possibly other Muslim countries, appropriate resources should be allocated during Ramadan to manage the nocturnal ED patient surge.

LIMITATIONS

We believe that the majority of our patients fast, but it is not known how many ED patients were actually fasting during the study period. This study was conducted in a tertiary care hospital and the patient population presenting to our ed is predominantly Muslim; therefore, the results may not be generalized to populations that are not predominantly Muslim.

Islamic fasting and multiple sclerosis

Background

Month-long daytime Ramadan fasting pose s major challenges to multiple sclerosis (MS) patients in Muslim countries. Physicians should have practical knowledge on the implications of fasting on MS. We present a summary of database searches (Cochrane Database of Systematic Reviews, PubMed) and a mini-symposium on Ramadan fasting and MS. In this symposium, we aimed to review the effect of fasting on MS and suggest practical guidelines on management.

Discussion

In general, fasting is possible for most stable patients. Appropriate amendment of drug regimens, careful monitoring of symptoms, as well as providing patients with available evidence on fasting and MS are important parts of management. Evidence from experimental studies suggests that calorie restriction before disease induction reduces inflammation and subsequent demyelination and attenuates disease severity. Fasting does not appear to have unfavorable effects on disease course in patients with mild disability (Expanded Disability Status Scale (EDSS) score ≤3). Most experts believed that during fasting (especially in summer), some MS symptoms (fatigue, fatigue perception, dizziness, spasticity, cognitive problems, weakness, vision, balance, gait) might worsen but return to normal levels during feasting. There was a general consensus that fasting is not safe for patients: on high doses of anti-convulsants, anti-spastics, and corticosteroids; with coagulopathy or active disease; during attacks; with EDSS score ≥7.

Summary

These data suggest that MS patients should have tailored care. Fasting in MS patients is a challenge that is directly associated with the spiritual belief of the patient.

Diabetes patient management by pharmacists during Ramadan

Background

Many Muslim diabetes patients choose to participate in Ramadan despite medical advice to the contrary. This study aims to describe Qatar pharmacists’ practice, knowledge, and attitudes towards guiding diabetes medication management during Ramadan.

Methods

A cross-sectional descriptive study was performed among a convenience sample of 580 Qatar pharmacists. A web-based questionnaire was systematically developed following comprehensive literature review and structured according to 4 main domains: subject demographics; diabetes patient care experiences; knowledge of appropriate patient care during Ramadan fasting; and attitudes towards potential pharmacist responsibilities in this regard.

Results

In the 3 months prior to Ramadan (July 2012), 178 (31%) pharmacists responded to the survey. Ambulatory (103, 58%) and inpatient practices (72, 41%) were similarly represented. One-third of pharmacists reported at least weekly interaction with diabetes patients during Ramadan. The most popular resources for management advice were the internet (94, 53%) and practice guidelines (80, 45%); however only 20% were aware of and had read the American Diabetes Association Ramadan consensus document. Pharmacist knowledge scores of appropriate care was overall fair (99, 57%). Pharmacists identified several barriers to participating in diabetes management including workload and lack of private counseling areas, but expressed attitudes consistent with a desire to assume greater roles in advising fasting diabetes patients.

Conclusion

Qatar pharmacists face several practical barriers to guiding diabetes patient self-management during Ramadan, but are motivated to assume a greater role in such care. Educational programs are necessary to improve pharmacist knowledge in the provision of accurate patient advice.

Does fasting during Ramadan affect the use of topical dermatological treatment by Muslim patients in the UK?

BACKGROUND

Ritual fasting during the Muslim religious festival of Ramadan is one of the 'Five Pillars' of Islam, and is widely observed by Muslims. Previous studies have highlighted compliance issues in patients prescribed oral medications during this period. Aim.  To assess whether fasting during Ramadan influence the use of topical treatments for skin disease in Muslim patients.

METHODS

This was a prospective, anonymous, questionnaire survey undertaken in a dermatology centre in a tertiary hospital in the UK. Patients were asked if they would use topical treatment while fasting, and whether they would consider this a breach of their fast.

RESULTS

We found that more than one-third of the people interviewed would not use topical treatment while fasting, and around the same number (> 30%) would also consider this a breach of their fast. Although the majority of these patients thought that using steroid-based topical products was not acceptable, a significant proportion extended this opinion to use of any cream or emollient, and even to light therapy. Gender, age, or educational level were not useful predictors of patient opinion, but there was a significant association with birthplace and likelihood of using topical treatment during Ramadan; patients born outside the UK were significantly (P < 0.01) less likely than those born in the UK to use topical treatment in the fasting period.

CONCLUSIONS

Our study indicates that fasting may be a significant and a hitherto unrecognised cause of non-compliance with topical treatment in Muslim patients in the UK, with potential health, quality and cost implications. Ritual fasting during Ramadan is widely observed by Muslims. Previous studies have highlighted compliance issues in patients prescribed oral medications during this period, and it seems this extends to use of topical treatments for skin disease.

Multicultural challenges in epilepsy

Epilepsy is a common neurological condition throughout the world. Its care involves medical expertise, but may also bring different cultural challenges. We discuss clinical, social and psychological outcomes in different cultural settings. We point out differences and similarities in epilepsy epidemiology (etiology and risk factors, prognosis, and natural history), disparities in care and health services, and cultural influences and traditional beliefs, with special respect to practical issues and possible transcultural misunderstandings. We also discuss the relevance of multicultural issues to clinicians working in developed countries.

Health is a spiritual thing: perspectives of health care professionals and female Somali and Bangladeshi women on the health impacts of fasting during Ramadan

OBJECTIVE

To explore perspectives of health care professionals and female Somali and Bangladeshi Muslim women on practices related to fasting during Ramadan, the impact of fasting on health and the role of health professionals during Ramadan.

DESIGN

A cross-sectional qualitative study was conducted. Two culturally specific focus groups were conducted with six Somali and seven Bangladeshi Muslim women who observed Ramadan and lived in an inner-city neighbourhood of Toronto, Canada. Individual semi-structured interviews were conducted with 22 health care professionals practicing in this inner-city area (three of whom were Muslim). Data were analysed using thematic qualitative analysis.

RESULTS

Both Muslim women and health care professionals recognised the spiritual significance of the Ramadan fast. Muslim participants considered the fast to be beneficial to health overall, whereas health care professionals tended to reflect on health concerns from fasting. Many health care professionals were not fully aware of fasting practices during Ramadan and some found it challenging to counsel patients about the health effects of fasting. Muslim women expressed disagreement regarding which medical interventions were permitted during fasting. They generally agreed that health care professionals should not specifically advise against fasting, but instead provide guidance on health maintenance while fasting. Both groups agreed that guidelines developed by the health care and faith communities together would be useful.

CONCLUSION

There are a variety of health beliefs and observances among female Muslim Somali and Bangladeshi women and a range of knowledge, experience and opinions among health care professionals related to fasting during Ramadan and health. Overall, there is a need for improved communication between members of the Muslim community and health professionals in Canada about health issues related to fasting during Ramadan. Strategies could include published practice guidelines endorsed by the Muslim community; patient education materials developed in collaboration with health and religious experts; or further qualitative research to help professionals understand the beliefs and observances of Muslim people.