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Aims: To assess the clinical characteristics and outcomes of patients hospitalized with DKA., Methods: We examined the hospital database for patients admitted with DKA to all government hospitals in Qatar over 6 years., Results: We evaluated a total of 1330 patients [(37.3 % with type 1 diabetes (T1DM) and 62.7 % with type 2 diabetes (T2DM)] with 1613 episodes of DKA. Patients with T2DM were older than those with T1DM [48.0 (38.0-60.0), 26.0 (21.0-31.0) years] while there was no difference in DKA severity and laboratory values on admission or time to resolution of DKA. Admission to the intensive care unit was higher (38.9 % vs. 26.6 %; P < 0.001) with a longer hospital stay [5 (2.0-9.0) vs. 2 (2.0-4.0) days, P < 0.001] and markedly higher mortality (7.4 % vs. 1 %; P < 0.001) in patients with T2DM compared to T1DM. On multivariable logistic regression analysis, significant predictors of mortality were older age (odds ratio, 1.11; 95 % CI, 1.07-1.15; P = 0.0001), and admission to the intensive care unit (odds ratio, 3.61; 95 % CI, 1.69-7.72;P = 0.001)., Conclusion: In this national cohort of patients hospitalized with DKA, those with T2DM had a 7-fold increase in inpatient mortality associated with older age and admission to the intensive care unit., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objectives: Current knowledge and research on diabetes and Ramadan form the basis for evidence-based clinical practice. In this context, we aimed to explore physicians' perceptions of current knowledge gaps about research fasting (RF), barriers to, and foreseeable directions for advancement of the field., Methods: We conducted an online survey of a convenience sample of 260 physicians from 27 countries. The survey questionnaire addressed three main domains: perceived current knowledge gaps and unmet needs in research about RF and diabetes, barriers to the conduct of research, and future directions for furthering the evidence in this field., Results: Majority of respondents (65.7%) were senior physicians in adult endocrinology/diabetes (45.9%) working at tertiary centers (65.2%). The majority (67.3%) reported seeing an average of 20+ patients with diabetes weekly and felt "very or fairly confident" in managing diabetes during RF (67.7%). The knowledge gaps identified were the management of high-risk patients with diabetes (54.1%), such as renal impairment (59.8%), and pregnancy (61.5%). The main barriers to research were lack of adequate funding to academic centers (75.7%) and lack of interest of institutions in the subject (64.6%). Future efforts should be directed at the conduct of large epidemiological studies (49.5%) or double-blinded, placebo-controlled clinical trials (48.6%) to address the former gaps. Research findings should be widely disseminated via hands-on workshops (recommended by 70.3% of respondents) or international conferences (61.2%)., Conclusions: There is a wide agreement regarding the knowledge gaps in the management of diabetes during RF. Future efforts should focus on addressing these critical deficiencies., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

The IDF-DAR guidance was most recently updated this year. The most notable change is the moving to a scoring system from a tabulated risk categorization to determine and classify the risk of harm from fasting derived from an online survey. This change may be appealing and is welcomed. However, such a system and the methodology underpinning it is not without limitations. This commentary highlights some of these limitations and the associated limited safe options available to individuals with diabetes desiring to fast during Ramadan. Overlooked clinical considerations that deserve formal recognition include the role of technology (aspects relating to glucose monitoring and/or insulin delivery) and previous experience of safe Ramadan fasting. Further, duration of fast (which can almost double in temperate regions from winter to summer) needs greater emphasis. We also advocate separate scoring systems for people with type 1 diabetes and complex type 2 diabetes. The guidance acknowledges fasting is an individual's decision, however the general message needs to be more person-centred and currently only presents a binary approach to fasting - all or nothing choices. We propose and discuss addition options including, trial fasting of voluntary fasts, starting the fast and terminating due to health and/or safety, intermittent fasting and winter fasting., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2021. Published by Elsevier B.V. All rights reserved.)

Diabetic ketoacidosis (DKA) is an acute complication of diabetes mellitus that can be associated with increased morbidity and mortality, particularly if it is diagnosed late and not treated appropriately. The management of DKA includes careful clinical evaluation, correction of metabolic abnormalities with intravenous fluids, insulin and electrolyte replacement with frequent monitoring of the patients' clinical and laboratory findings and also identification and treatment of the precipitating condition. There are special populations where features, management and outcome may differ from the usual patient with diabetes. Data on management of DKA in such special populations such as chronic kidney disease and pregnancy are sparse and recommendations are based mainly on small case series and expert opinion. Clinicians need to recognize and manage euglycaemic DKA in patients prescribed sodium-glucose cotransporter inhibitors. DKA is particularly a major health concern due to high rates of hospital admissions and mortality in resource-limited settings due to financial constraints, limiting the adequate provision of insulin and access to health care systems, and dysfunctional health systems. We review the challenges of diagnosis and management of DKA in these specific groups and provide recommendations on optimal patient care., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Introduction: The literature on health aspects of Ramadan fasting is widely spread in many journals making it not readily available to those interested in the subject., Materials and Methods: A narrative, non-systematic review of the international literature from two major online databases (viz. Scopus, PubMed) in one year (2019). The search term "Ramadan fasting AND Diabetes" was used, and relevant literature was narrated in a concise thematic account., Results: Research design included qualitative, quantitative, and mixed methods. Articles included controlled trials, critical appraisals, literature narrations, and systematic reviews, and meta-analyses. The publications spanned a vast array of topics related to Ramadan fasting, including assessments of current safety and efficacy profiles of newer diabetes therapies, modes of insulin delivery, and utilization of advanced technology for the treatment and monitoring of blood glucose during Ramadan fasting. Increased interest was particularly evident in capturing the experience element manifested by perceptions, attitudes, and practices of both patients and healthcare professionals during Ramadan. The current literature consolidates previous data on the safety of fasting practices amongst the well-controlled. On the other hand, it emphasizes the need for more aggressive interventions for high-risk patients, promoting the usage of newer anti-diabetic agents and advanced glucose monitoring technology for safer fasting practices., Conclusions: The volume of global literature production related to Ramadan fasting and Diabetes remains modest. Observational studies of small size prevail. Greater improvements in both quality and quantity of research on Ramadan are needed., Competing Interests: Declaration of Competing Interest None of the authors disclosed any conflicts of interests., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: We followed up the evolving perceptions and practices regarding use of SGLT-2 inhibitors in Ramadan., Methods: We compared results of the three survey in 2015, 2017, 2019., Results: Senior doctors represented 43.5-66.4% and endocrinologists accounted for 38.1-60.2%. There was a steady reduction in the proportions of respondents who did not know SGLT2-Is at all, who have just heard about the class and those who are quite familiar with the class but have not yet used any. Whereas the proportions of those using the SGLT2-Is class occasionally only was stable. However those who use the SGLT2-Is regularly increased from 11.0% to 45.6% and 62.6%. The respondents' who SGLT2-Is are safe and may be used in all fasting diabetic patients increased from 15.5%, 14.7% to 23.1%. Whereas the view that SGLT2-Is should not be used decreased progressively. Majority of respondents in the three surveys suggested that specific advice is given if they allow the use of SGLT2-Is during Ramadan. More respondents advise taking the medication with the first evening meal than before the last pre-dawn meal and advised to attend to their hydration status. One third of respondents would resume SGLT2-Is immediately after the end of Ramadan; 15% after 1-2 weeks, or prefer to wait till the next medical or educator's clinic visit and others would re-evaluate patients' management plan., Conclusions: The medical professions' knowledge and perceptions regarding the use of SGLT2-Is during Ramadan fasting have evolved over the last few years due to increasing research and experience., Competing Interests: Declaration of Competing Interest TGS declared no conflicts of interest. SAB and KH declared receiving honoraria for lectures and consulting services from the 4 manufacturers of the locally available SGLT2-Is. However, none had any knowledge of nor any involvement in this research inception nor conduct., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Aim: To ascertain the awareness and practice of neonatal diabetes mellitus (NDM) among paediatricians in Arab countries., Methods: An online questionnaire was distributed to physicians associated with the Arab Society for Paediatric Endocrinology and Diabetes (ASPED)., Results: We received 126 replies, from 16 countries. All except one classified the survey's case scenario as NDM and 94% agreed that NDM patients should have detailed assessment to identify extra-pancreatic features. Although 92% felt that genetic testing is necessary, only 72% requesting them routinely and 32% unaware of the availability of free genetic testing. Insulin is considered the initial therapy for 93% and 80% diluted insulin to deliver accurate doses. Basal-bolus regimen was preferred by 36% and similar percentage used insulin pump. The remaining 28% favour long acting insulin alone. Oral sulfonylureas would be tried empirically by 34% and 69% would do so if genetic testing is unavailable. Whilst 70% have no local NDM management guidelines, 41% are unaware of any international guidelines., Conclusions: The ASPED surveyed clinicians have good awareness of NDM diagnosis with marked variation in their practice raising the need to establish management guideline for the condition. The survey highlights areas to focus on in developing consensus and educational activities., Competing Interests: Declaration of Competing Interest None of the authors has any conflict of interest., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: To quantify the research contribution related to Ramadan fasting and diabetes., Methods: We searched for the combination of "Ramadan" and Diabetes" in the title, abstract and keywords in the Scopus database between 1989 and 2018. Articles were analysed for standard bibliometric methodology and VOSviewer was used to construct bibliometric diagrams., Results: The total number of retrieved articles was 424 articles; 112 were "Open Access". Two-thirds of articles covered original research. Articles were published in medical journals of varying influence. UK-based authors and affiliated institutions were dominant. A single author has an evident dedication to Ramadan research whereas for many authors it Ramadan research was just one aspect of their academic interest. The number publications and the extent of international collaborations were lower than expected, given the world-wide practice of Ramadan fasting by many populations with an increased prevalence of diabetes. The need to share experiences and generalizable conclusions., Conclusions: This is the first bibliometric study on diabetes in Ramadan. It is a good starting point to evaluate gaps in research activity in the field and should help identify future research directions and foster more collaboration., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: To evaluate the validity of the perceived increased risk and the actual occurrence of DKA observed during fasting in Ramadan., Methods: This is a non-systematic narrative review of the literature on the occurrence of DKA during Ramadan. Online databases (PubMed, Google Scholar, Cochrane Database, Medline OVID and CINAHL EBSCO) were searched. Three research questions are addressed 1. What is the basis of the expert opinion on the risk for DKA? 2. What is the likelihood that DKA is precipitated by Ramadan fast? and 3. What is the frequency of observed DKA during Ramadan?, Results: The expert opinion suggesting a risk of DKA during Ramadan fasting was proposed with no evidence in the early writing on Ramadan fasting and has been reiterated and propagated since then. However, from first principles, DKA is not readily precipitated by the usual stress-free metabolic environment induced by Ramadan fasting with the exception of cases involved in the usual risk factors for metabolic decompensation. Furthermore, recent studies could not document any increase in observed DKA during Ramadan fasting in retrospective, prospective and database studies., Conclusions: The current state of knowledge and evidence suggests the risk of DKA is not increased during Ramadan fasting., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Context: There has been an increased interest in the potential metabolic derangements and acute complications of diabetes related to the Muslims' fasting during the month of Ramadan., Objectives: We compared the incidence of admissions due to diabetic ketoacidosis (DKA) during Ramadan with the admissions during other months., Methods: This is a retrospective electronic database and chart review study that included all Muslims who were admitted with DKA to Sheikh Khalifa Medical City in Abu Dhabi, United Arab Emirates. We explored the relationship of admissions to Ramadan over ten years (2005-2014)., Results: There were 432 episodes of DKA involving 283 patients. Of these, 370 episodes (85.6%) involved 231 patients (81.6%) with type 1 diabetes. The number of admission episodes was not different during Ramadan from the average calendar month [3.6 ± 2.6 (Range 0-15) episodes/month versus 3.3 ± 2.1 (Range 1-7) episodes/month respectively, P = 0.77]. No recurrences of admissions were observed during Ramadan. There was a non-significant numerical tendency for more episodes in March and September (4.6 episodes for both) and fewer episodes in July (2.6 episodes) than other months; P values were 0.06; 0.13, and 0.32 respectively. This seasonality was not related to the month of Ramadan., Conclusions: The present study confirmed that DKA admissions during Ramadan were not significantly higher than the average monthly admissions over ten years. Seasonality trends were not related to Ramadan., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Aim: To ascertain the pattern of diabetes management during Ramadan fasting in childhood and adolescence among physicians in Arab countries., Methods: An online electronic survey questionnaire was distributed to physicians registered in the Arab society for Paediatric Endocrinology and Diabetes (ASPED)., Results: Of the 167 responders, 114 (86.0%) were paediatricians and the remaining 14.4% were adult physicians. 117 (79.6%) would allow patients to fast and 60.7% of them emphasized providing education before fasting. 69.1% of physicians thought that their patients complete >50% of fasting days. 46.9% recognized those with hypoglycemia unawareness among the very high-risk group for fasting. 62% reported that fasting should be broken if symptomatic hypoglycemia regardless of glucose level and 48.2% indicated that blood glucose above 300 mg/dl is another indication. 63.4% of respondents would decrease basal insulin by 25%, and 52.8% reported that using insulin pump during fasting reduced the frequency of hypoglycemia. 81.1% recommend several dietary adjustments and 56.4% used rapid-acting insulin analog according to carbohydrate counting., Conclusions: There is a wide variation in the management of children and adolescents with diabetes during Ramadan in ASPED countries. A targeted educational program for physicians and establishing a guideline for this challenging area is needed., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: To describe the risk of hypoglycaemia during Ramadan and determine its risk factors, and the impact of hypoglycaemia on patients' behaviour., Methods: A cross-sectional multi-country observational study, with data captured within 6 weeks after Ramadan 2015. Patients' and disease characteristics and its management, the risk of hypoglycaemia and patients' response to hypoglycaemia were recorded., Results: A cohort of 1759 patients; majority with type 2 diabetes mellitus from North Africa, Arabian Gulf, Saudi Arabia, and the Indian subcontinent. Hypoglycaemia was reported by 290 patients (16.8%); particularly affecting type 1 diabetes patients and in insulin-treated patients in general. Age was significantly younger in the hypoglycaemia group (P < 0.001). The commonest responses were reducing the dose or frequency of medications (42%), attending primary care providers (24.5%) or increasing monitoring (20.7%). Fasting was interrupted by 67% only of those who experienced hypoglycaemia and recourse to emergency services was pursued by less than a quarter of patients with hypoglycaemia. The country-wise analysis of the rates of hypoglycaemia was greatest in Egypt (51.3%) and lowest in Pakistan (3.5%)., Conclusions: Hypoglycaemia is a significant complication of fasting during Ramadan. It may be predicted by type of diabetes, and use of insulin. Patients' responses are varied and call for more formal pre-Ramadan education., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Aims: To describe diabetes treatment and hypoglycaemia in individuals with Type 2 diabetes mellitus during Ramadan., Methods: A multi-country, retrospective, observational study with data captured before, during, and after Ramadan. We report on a cohort of people (N=3250) with Type 2 diabetes mellitus in four culturally distinct regions: Asia, North Africa, Europe, and the Middle East., Results: During Ramadan, the proportion of participants on oral anti-diabetic medication alone ranged from 68.4% (Middle East) to 80.5% (Asia); the proportion on insulin alone ranged from 3.7% (Middle East) to 8.6% (Europe). The average number of days fasted for individuals with an American Diabetes Association (ADA) risk status of very high was 27 (Middle East), 25.7 (Asia), 25.4 (North Africa), and 21 (Europe). The incidence of hypoglycaemia according to an ADA risk status of very high was 5.6% (n=1/18, Europe), 6.1% (n=2/33, Middle East), 8.7% (n=4/46, Asia), and 38% (n=10/26, North Africa). The incidence of hypoglycaemia, during Ramadan, for the entire cohort was 16.8% with insulin treatment and 5.3% with oral anti-diabetic medication. Having an episode of hypoglycaemia before Ramadan was associated with hypoglycaemia during Ramadan (odds ratio 7.80; 95% confidence interval 5.31-11.45)., Conclusions: Approaches to the management of Type 2 diabetes mellitus during Ramadan varied across regions. Episodes of hypoglycaemia and insulin therapy predicted risk of hypoglycaemia during Ramadan and identified individuals who required Ramadan-specific education., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

The aim of the present article is to increase awareness concerning safe driving for patients with diabetes in the Gulf Cooperation Council (GCC) countries and to provide recommendations concerning the management of these patients. The cognitive, motor, and sensory skills required for driving can be adversely affected by diabetes as well as the side effects of anti-diabetic medications, particularly hypoglycemia. The prevalence of diabetes in the GCC countries is among the highest in the world. As the number of diabetic drivers in these countries continues to increase, the number at risk of having a motor vehicle accident is also expected to increase. We reviewed the available literature concerning driving and diabetes, particularly in relation to the current situation in the GGC countries. Unfortunately, very little published information is available addressing this issue in the GCC countries. Most of the GCC countries lack legislation on driving and diabetes. We have proposed recommendations to help diabetic drivers in the GCC countries as well as to provide guidance to health care professionals managing these patients., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)