Managing People with Diabetes Fasting for Ramadan During the COVID-19 Pandemic: A South Asian Health Foundation Update

The month of Ramadan forms one of the five pillars of the Muslim faith. Adult Muslims are obligated to keep daily fasts from dawn to sunset, with exceptions. This year Ramadan is due to begin on 23 April 2020 and the longest fast in the UK will be approximately 18 hours in length. In addition, due to the often high-calorie meals eaten to break the fast, Ramadan should be seen as a cycle of fasting and feasting. Ramadan fasting can impact those with diabetes, increasing the risk of hypoglycaemia, hyperglycaemia and dehydration. This year, Ramadan will occur during the global COVID-19 pandemic. Reports show that diabetes appears to be a risk factor for more severe disease with COVID-19. In addition, the UK experience has shown diabetes and COVID-19 is associated with dehydration, starvation ketosis, diabetic ketoacidosis and hyperosmolar hyperglycaemic state. This makes fasting in Ramadan particularly challenging for those Muslims with diabetes. Here, we discuss the implications of fasting in Ramadan during the COVID-19 pandemic and make recommendations for those with diabetes who wish to fast.

The South Asian Health Foundation (UK) guidelines for managing diabetes during Ramadan

BACKGROUND

Fasting in the holy month of Ramadan is among the five pillars of Islam and is considered as a religious obligation by the Muslim population. People with diabetes observing the practice of fasts are at a higher risk of complications such as hypoglycaemia, hyperglycaemia and ketoacidosis due to changes in eating patterns and circadian rhythms. With the objective of mitigating these complications, the South Asian Health Foundation (UK) has developed the present guidelines based on robust evidence derived from epidemiological studies and clinical trials.

METHODS

We have highlighted the role of pre-Ramadan risk stratification and counselling by healthcare professionals with emphasis on the need for advice on adequate dietary and fluid intake, blood glucose monitoring and awareness of when to break the fast.

RESULTS

We reviewed the current literature and have given clinically-relevant recommendations on lifestyle modifications and glucose-lowering therapies such as metformin, sulphonylureas, dipeptidyl peptidase-4 inhibitors, sodium glucose co-transporter-2 inhibitors, thiazolidinediones, glucagon-like peptide-1 receptor agonists and insulin.

CONCLUSIONS

An individualised patient-centric treatment plan is essential to not only achieve optimal glycaemic outcomes but also enable people with diabetes to observe a risk-free month of fasting during Ramadan.

Oral semaglutide versus injectable glucagon-like peptide-1 receptor agonists: a cost of control analysis

Aims: The efficacy and safety of oral semaglutide, the first glucagon-like peptide-1 (GLP-1) receptor agonist developed for oral administration for the treatment of type 2 diabetes, was evaluated in the PIONEER clinical trial program, and a recently published network meta-analysis allowed comparison with further injectable GLP-1 receptor agonists. The present study aimed to assess the short-term cost- effectiveness of oral semaglutide 14 mg versus subcutaneous once-weekly dulaglutide 1.5 mg, once-weekly exenatide 2 mg, twice-daily exenatide 10 µg, once-daily liraglutide 1.8 mg, once-daily lixisenatide 20 µg, and once-weekly semaglutide 1 mg, in terms of the cost per patient achieving glycated hemoglobin (HbA1c) targets (cost of control).Materials and methods: Cost of control was calculated by dividing the annual treatment costs associated with an intervention by the proportion of patients achieving the treatment target with an intervention, with outcomes calculated for targets of HbA1c ≤6.5% and HbA1c <7.0% for all included GLP-1 receptor agonists. Annual treatment costs were accounted in 2019 United States dollars (USD), based on 2019 wholesale acquisition cost.Results: For the treatment target of HbA1c ≤6.5%, once-weekly semaglutide 1 mg and oral semaglutide 14 mg were associated with the lowest costs of control, at USD 15,430 and USD 17,383 per patient achieving target, respectively. Similarly, the cost of control was lowest with once-weekly semaglutide 1 mg at USD 12,627 per patient achieving target, followed by oral semaglutide 14 mg at USD 13,493 per patient achieving target for the target of HbA1c <7.0%. All other interventions were associated with higher cost of control values for both targets.Conclusions: Oral semaglutide 14 mg is likely to be cost-effective versus dulaglutide, exenatide (once weekly and twice daily), liraglutide, and lixisenatide in terms of bringing people with type 2 diabetes to glycemic control targets of HbA1c ≤6.5% and HbA1c <7.0% in the US.

High frequency abrupt shifts in the Indian summer monsoon since Younger Dryas in the Himalaya

In order to quantify the Indian summer monsoon (ISM) variability for a monsoon dominated agrarian based Indian socio-economy, we used combined high resolution δ¹³C, total organic carbon (TOC), sediment texture and environmental magnetic data of the samples from a ~3 m deep glacial outwash sedimentary profile from the Sikkim Himalaya. Our decadal to centennial scale records identified five positive and three negative excursions of the ISM since last ~13 ka. The most prominent abrupt negative ISM shift was observed during the termination of the Younger Dryas (YD) between ~11.7 and 11.4 ka. While, ISM was stable between ~11 and 6 ka, and declined prominently between 6 and 3 ka. Surprisingly, during both the Medieval Warm Period (MWP) and Little Ice age (LIA) spans, ISM was strong in this part of the Himalaya. These regional changes in ISM were coupled to southward shifting in mean position of the Intertropical Convergence Zone (ITCZ) and variations in East Asian monsoon (EAM). Our rainfall reconstructions are broadly in agreement with local, regional reconstructions and PMIP3, CSIRO-MK3L model simulations.

Which patients with gynaecomastia require more detailed investigation?

Gynaecomastia may be due to medication, chronic liver or kidney disease, hypogonadism (primary or secondary to pituitary disease) or hyperthyroidism. Having excluded these aetiologies, it is imperative to be vigilant for underlying malignancy causing gynaecomastia. These include human chorionic gonadotrophin-secreting testicular and extratesticular tumours and oestrogen-secreting testicular tumours and feminising adrenal tumours.

A Case-control Study of Haemorrhagic Septicaemia in Buffaloes and Cattle in Karachi, Pakistan, in 2012

A retrospective epidemiological case-control study was performed in Karachi, Pakistan, from January to April 2013. The owners of 217 dairy cattle and buffalo farms from six different locations in Karachi were interviewed. The aim of the study was to identify risk factors associated with the presence of haemorrhagic septicaemia (HS). Farms with a history of at least one instance of sudden death in a dairy animal during 2012 and a positive clinical HS diagnosis (made by local veterinarians) were defined as cases. Farms having no history of sudden deaths in 2012 were defined as controls. Univariable analyses were initially conducted, and factors with P ≤ 0.25 were offered to a multivariable logistic regression model to identify putative risk factors. The final multivariable logistic model contained five factors. Vaccination was found to be a protective factor (OR = 0.22) along with the length of time cattle were kept on farm (months). For every extra month cattle were kept, the odds of HS disease were reduced by a factor of 0.9. In contrast, for every extra animal in a herd, the risk of infection increased by a factor of 1.01. Supplying underground water and the presence of foot and mouth disease on the farm increased the risk by 2.90 and 2.37, respectively. To understand the epidemiology of HS in Karachi dairy herds, more in-depth research is required to study the risk and protective factors identified in this survey and to evaluate risk mitigation strategies, where possible.

Prevalence of Depression in Patients with Type II Diabetes Mellitus and its Impact on Quality of Life

BACKGROUND

Diabetes mellitus (DM) is a frequently encountered chronic metabolic disease with various complications throughout its course, which causes severe restriction and disability in an individual's life. It has been well documented that the incidence of depression is higher in diabetic patients and co-morbid depression causes further deterioration in the quality of life in diabetic patients.

AIMS

To study the prevalence of depression and its impact on quality of life in patients with type II DM.

SETTINGS AND DESIGN

Single centre, cross-sectional, single interview.

MATERIALS AND METHODS

Total 195 type II DM patients are included in this study. To diagnose Depressive Episode Structured Clinical Interview for DSM IV Axis-1 Disorders, Research Version patient edition was applied. All patients were evaluated with a semi-structured socio-demographic proforma to assess socio-demographic characteristics, Hamilton Rating Scale for Depression (HAM-D) and Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) SF (Short Form) to measure the quality of life.

RESULTS

Among them, 46.15% (N=90; males: 41, females: 49) met the DSM-IV diagnostic criteria for major depressive episodes. Among the depressed group, majority were (36.7%) moderately depressed. QLESQ-SF total and each item scores were significantly lower in the depressed group than in the non-depressed group. Both the HAM-D scores and HbA1c level have significant negative correlations with QLESQ-SF total scores.

CONCLUSION

Our study demonstrates that the presence of depression in type II DM further deteriorates the quality of life of the patients. Therefore, treating depression would have a beneficial effect on the quality of life.

ACUTE CALCIFIC TENDINITIS OF THE FINGER — A CASE REPORT

Acute calcific tendinitis of the hand is rare and often misdiagnosed as infection, fracture or periarthritis. It frequently occurs in peri-menopausal women and is caused by deposits of hydroxyapatite crystals. We describe acute calcific tendinitis of the flexor digitorum superficialis insertion in an elderly man taking oral anticoagulants. The differential diagnoses and recommended treatment are discussed.

Aetiology and outcome of burns in the elderly

INTRODUCTION

This retrospective study, analyses aetiology and factors affecting the outcome of burns in patients over 65 years of age.

METHODS

Sixty-three consecutive patients, over 65 years of age, were admitted to a Burns Unit over a period of 3 years. Retrospective data was analyzed, taking into account aetiology, burn thickness and area, co-morbid factors. Also, surgery as a factor-affecting outcome was examined.

RESULTS

There was a significant difference of total body surface area burn (TBSA), Abbreviated Burn Severity Index (ABSI), Baux score and the number of pre-existing co-morbid factors between survivors and non-survivors. Age and surgery were not significant to the outcome. Patients undergoing surgery had increased hospital stay without any difference in mortality. The timing of surgery did not have any impact on hospital stay or survival.

CONCLUSION

This study shows a positive correlation between the number of co-morbid conditions and mortality. Early surgery after careful patient selection does not have any negative impact on patient survival.

Self-inflicted burns, outcome and cost

INTRODUCTION

Self-inflicted burns represent a small number of total admissions to a burns unit, yet they constitute a major workload.

METHODS

A retrospective analysis of self-inflicted burns admitted between 1998 and 2002.

RESULTS

One thousand six hundred and fifty six patients were admitted with acute burn injuries, of these 56 were self-inflicted. 24 patients had a previous history of self-harming and 22 were unemployed. History of a psychiatric illness was found in 46 patients. Flames caused 46 out of 56 injuries. Mean total body surface area (TBSA) was 27%. Approximately 39% needed admission to intensive care unit (ICU). The mortality rate was 25%. On discharge, 29% of the patients re-self harmed.

CONCLUSION

Self-inflicted burns have a poorer outcome. Improving the psychiatric and social support can reduce the incidence of self-harming behaviour, its repetitiveness and subsequently the cost of burn care.

Free DIEP flap breast augmentation following excessive reduction

A two-stage procedure using bilateral free DIEP flaps to correct excessive bilateral breast reduction is described. The reconstructive challenge was to achieve satisfactory breast projection on a large torso without recourse to prosthetic implants or extensive back scars. The literature on the use of TRAM and latissimus dorsi flaps in subtotal breast reconstruction for various other breast deformities is reviewed. We have not found a similar case to ours in the literature.

Genomic in situ hybridization analysis of a trigenomic hybrid involving Solanum and Lycopersicon species

A 4x potato (+) tomato fusion hybrid (2n = 4x = 48) was successfully backcrossed with a diploid Lycopersicon pennellii (2n = 2x = 24). Genomic in situ hybridization (GISH) on somatic and meiotic chromosomes confirmed that the progenies were triploids (2n = 3x = 36) and possessed three different genomes: potato, tomato, and L. pennellii. Therefore, they have been called trigenomic hybrids. Total genomic probes of both Lycopersicon species were found to hybridize mutually, whereas the potato genome was clearly differentiated. During metaphase I, bivalents were formed predominantly between tomato and L. pennellii chromosomes and the univalents of potato chromosomes were most common. Trivalents in all cases included homoeologous chromosomes of potato, tomato, and L. pennellii. However, the triploids were totally sterile as determined from extensive crossing. On chromosome doubling of triploids by shoot regeneration from callus, hexaploids (2n = 6x = 72) were obtained. Despite exhibiting clear allohexaploid behaviour by forming 36 bivalents at meiosis, these were also completely sterile like their triploid counterparts. In spite of this drawback, the prospects of chromosome pairing between potato L. pennellii and Solanum genomes does open the possibilities for bringing the two genera close.

An antitumor cardenolide with inhibitory activity against pseudomonas pseudomallei

The antibacterial activity of a new cardenolide, 7beta, 14beta - dihydroxy-5-card-20(22) enolide has been studied and it has been found to be active against Pseudomonas pseudomallei. The new cardenolide also exhibited antitumor activity in a potato disc assay.

Kinetics of electron entry, exit, and interflavin electron transfer during catalysis by sarcosine oxidase

Sarcosine oxidase contains 1 mol of covalently bound plus 1 mol of noncovalently bound FAD per active site. The first phase of the anaerobic reduction of the enzyme with sarcosine converts oxidized enzyme to an equilibrium mixture of two-electron-reduced forms (EH2) and occurs at a rate (2700 min-1, pH 8.0) similar to that determined for the maximum rate of aerobic turnover in steady-state kinetic studies (2600 min-1). The second phase of the anaerobic half-reaction converts EH2 to the four-electron-reduced enzyme (EH4) and occurs at a rate (k = 350 min-1) which is 7-fold slower than aerobic turnover. Reaction of EH2 with oxygen is 1.7-fold faster (k = 4480 min-1) than aerobic turnover and 13-fold faster than the anaerobic conversion of EH2 to EH4. The results suggest that the enzyme cycles between fully oxidized and two-electron-reduced forms during turnover with sarcosine. The long wavelength absorbance observed for EH2 is attributable to a flavin biradical (FADH.FAD.-) which is generated in about 50% yield at pH 8.0 and in nearly quantitative yield at pH 7.0. The rate of biradical formation is determined by the rate of electron transfer from sarcosine to the noncovalent flavin since electron equilibration between the two flavins (k = 750 s-1 or 45,000 min-1, pH 8.0) is nearly 20-fold faster, as determined in pH-jump experiments. Only two of the three possible isoelectronic forms of EH2 are likely to transfer electrons to oxygen since the reaction is known to occur at the covalent flavin. However, equilibration among EH2 forms is probably maintained during reoxidation, consistent with the observed monophasic kinetics, since interflavin electron transfer is 10-fold faster than electron transfer to oxygen.

New bioactive compounds of plant origin

Crude extracts of Withania somnifera (WS) and Polygonum equisetiforme (PE) as well as the pure compounds isolated therefrom were screened for antibacterial and antifungal activity against 20 bacterial and 17 fungal cultures. The crude extract of PE and WS inhibited the growth of T. mentagrophyte, M. canis and A. boydii at an MIC of 450-500 microg/ml whereas the pure compounds inhibited the growth at MIC of 300-350 micro/ml. Species of Corynebacterium, Bacillus, Streptococcus and Staphylococcus were found to be highly susceptible to both the crude sad the pure compounds. MIC values of both crude extracts for different organisms tested were found to be higher (200-350 microg/ml) than the pure compounds (150-170 microg/ml). The crude extract of PE did not inhibit the growth of Ps. aeruginosa, however, the pure compound was found to be bacteriostatic. Brine shrimp and BALB/c mice lethality test indicated that these extracts maybe toxic at high concentration.

Lipid biosynthesis in Paramphistomum microbothrium (Trematoda)

In vitro studies with Paramphistomum microbothrium indicated that the trematode is capable of synthesizing its complex lipids using exogenous substrates. U-14C glucose and 2-14C acetate were predominantly incorporated into phospholipids while 1-14C oleic acid and U-14C palmitic acid appeared more in the neutral lipids. A large proportion of the labelled acetic acid incorporated into neutral lipids appeared in the triglycerides. P. microbothrium is capable of synthesizing its cholesterol de novo.

Carbohydrate metabolism of malarial parasites--I. Metabolism of lactate in Plasmodium knowlesi infected monkey erythrocytes

Lactate metabolism by Plasmodium knowlesi infected erythrocytes was examined after careful removal of leucocytes from cell preparations. Infected cells were able to metabolize glucose, pyruvate and lactate. Respiration of infected erythrocytes was maximally stimulated by lactate and to a lesser degree by pyruvate and glucose. Respiration of infected cells was insensitive to stimulation by succinate or glutamate or inhibition by malonate. Mepacrine was found to be a potent respiratory inhibitor. Chromatographic analysis of end products of lactate metabolism showed incorporation of carbon from [2-C14]lactate into phosphoenol pyruvate, 3-phosphoglycerate and malate. Experimental data failed to provide evidence for the presence of a functional citric acid cycle activity in infected cells.

Paper chromatographic separation of phosphate esters, tricarboxylic cycle acids and amino acids in extracts from malaria parasites

A paper chromatographic method for the separation and identification of complex mixtures of phosphate esters, tricarboxylic cycle acids and amino acids in biological extracts is described. The method has been applied to the investigation of carbohydrate metabolism pathways in the intraerythrocytic, simian malaria parasite Plasmodium knowlesi; on treatment of parasitized erythrocytes with [U-C14]glucose, a perchloric acid extract was prepared and separated by chromatography on Whatman 31 ET filter-paper. A simple procedure for the measurement of the specific activities of radioactive compounds without prior elution from the chromatographic support is also described.

The precursors of the xylene ring in riboflavine

1. The nature of the precursors of the xylene ring in riboflavine was reinvestigated with growing as well as resting cells of Eremothecium ashbyii. 2. The incorporation of acetoin into riboflavine was very low; further, [2-(14)C]pyruvate and [1-(14)C]acetate were equally effective as precursors of lumichrome, and pyruvate was much more active as a precursor of acetoin. These results exclude acetoin as a direct precursor of riboflavine. 3. Addition of unlabelled glucose decreased the incorporation of [(14)C]acetate into riboflavine more than it decreased the conversion of acetate into carbon dioxide, indicating that acetate is not a direct riboflavine precursor. 4. The incorporation of various sugars and dilution experiments suggest that a derivative of the intermediates of the pentose phosphate cycle is the precursor of the xylene ring in riboflavine.