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The nocebo effect, the inverse of the placebo effect, is a well-established phenomenon, yet under-appreciated. It refers to nonpharmacological, harmful, or undesirable effects occurring after active or inactive therapy. The frequency of adverse events can dramatically increase by informing patients about the possible side effects of the treatment, and by negative expectations on the part of the patient. Patients who were told that they might experience sexual side effects after treatment with β-blocker drugs reported these symptoms between three and four times more often than patients in a control group who were not informed about these symptoms. Nocebo effect has been reported in several neurological diseases such as migraine, epilepsy, multiple sclerosis, Parkinson's disease and neuropathic pain, and in patients with depression. The investigation of the biological and theoretical underpinning of the nocebo phenomenon is at an early stage, and more research is required. Physicians need to be aware of the influence of nocebo phenomenon and be able to recognize it and minimize its effects.

Ramadan is one of the five fundamental pillars of Islam. During this month, the majority of the 1.6 billion Muslims worldwide observe an absolute fast from dawn to sunset without any drink or food. Our review shows that the impact of fasting during Ramadan on patients with stable cardiac disease is minimal and does not lead to any increase in acute events. Most patients with the stable cardiac disease can fast safely. Most of the drug doses and their regimen are easily manageable during this month and may need not to be changed. Ramadan fasting is a healthy nonpharmacological means for improving cardiovascular risk factors. Most of the Muslims, who suffer from chronic diseases, insist on fasting Ramadan despite being exempted by religion. The Holy Quran specifically exempts the sick from fasting. This is particularly relevant if fasting worsens one's illness or delays recovery. Patients with unstable angina, recent myocardial infarction, uncontrolled hypertension, decompensated heart failure, recent cardiac intervention or cardiac surgery or any debilitating diseases should avoid fasting.

The doctor-patient relationship is an intricate concept in which patients voluntarily approach a doctor and become part of a contract by which they tend to abide by doctor's instructions. Over recent decades, this relationship has changed dramatically due to privatization and commercialization of the health sector. A review of the relevant literature in the database of MEDLINE published in English between 1966 and August 2015 was performed with the following keywords: doctor-patient relationship, physician-patient relationship, ethics, and Islam. The Muslim doctor should be familiar with the Islamic teachings on the daily issues faced in his/her practice and the relationship with his/her patients.

Objectives: To investigate the effect of Ramadan fasting on the symptoms of chronic heart failure with a reduced ejection fraction (HFrEF). Globally, more than one billion Muslims fast during Ramadan. Data regarding the effect of fasting in heart failure patients with a reduced ejection fraction are limited. Methods: We prospectively studied 249 outpatients with HFrEF who undertook Ramadan fasting at tertiary care cardiac center in Saudi Arabia in 2017. We obtained information regarding the clinical assessment, diagnosis, emergency department visits, and hospitalization during and in the month preceding Ramadan. Results: We enrolled 249 patients, 227 (91%) undertook the fast for the entire month. During Ramadan, 209 (92%) patients remained hemodynamically stable, whereas 18 (8%) developed instability. The mean New York Heart Association (NYHA) functional class was significantly lower in the stable than in the unstable group (1.46±0.7 vs. 3.22±0.55, p less than 0.0001), although no intergroup differences were observed before Ramadan. Patients from the unstable vs. the stable group showed significantly less adherence to medications (67% vs. 94%, p less than 0.0001) and to diet (39% vs. 79%, p less than 0.0001), and a lower likelihood of demonstrating ischemic cardiomyopathy as an underlying etiology of HFrEF (33% vs. 57%, p =0.046). Dependent t-test analysis including all patients showed that the NYHA classification before Ramadan was significantly higher than during Ramadan (2.19±0.9 vs. 1.6±0.8, t-value 8.5, p less than 0.0001). Conclusion: In most patients with chronic HFrEF, Ramadan fasting is considered safe. Non-adherence to medication and diet are significantly associated with decompensated heart failure during Ramadan. Saudi Med J 2018; Vol. 39 (4): 395-400 doi: 10.15537/smj.2018.4.22011 How to cite this article: Abazid RM, Khalaf HH, Sakr HI, Altorbak NA, Alenzi HS, Awad ZM, et al. Effects of Ramadan fasting on the symptoms of chronic heart failure. Saudi Med J . 2018 Apr;39(4):395-400. doi: 10.15537/smj.2018.4.22011.

Islam acknowledges that infertility is a significant hardship. Attempts to cure infertility are not only permissible, but also encouraged in Islam. Over the last three decades, a multitude of advances in assisted reproductive technologies (ARTs) have appeared. This review was carried out to inform readers, who are not familiar with Islamic doctrine, about the Sunni perspective on this topic.Systematic review of the literature.A series of searches was conducted of Medline databases published in English between January 1978 and December 2013 with the followingassisted reproduction, infertility, gender selection, ethics, bioethics, and Islam.In Islamic Sunni law, all ARTs are allowed, provided that the source of the sperm, ovum, and uterus comes from a legally married couple during the span of their marriage. All forms of surrogacy are forbidden. A third-party donor is not allowed, whether he or she is providing sperm, eggs, embryos, or a uterus. Frozen preimplantation may be transferred to the wife in a successive cycle provided the marital bondage is not absolved by death or divorce. Gender selection for medical reasons is permitted. It is allowed for limited social reasons by some jurists, provided it does not involve discrimination against either sex.ART is acceptable and commendable in Islamic Sunni law provided it is practiced within the husband and wife dyad during the span of their marital contract. No third party should intrude upon the marital function of procreation. Surrogacy is not accepted by Sunni Islamic authorities.

Muslim patients and families are often reluctant to discuss and accept fatal diagnoses and prognoses. In many instances, aggressive therapy is requested by a patient's family, prolonging the life of the patient at all costs. Islamic law permits the withdrawal of futile treatment, including life support, from terminally ill patients allowing death to take its natural course. “Do not resuscitate” is permitted in Islamic law in certain situations. Debate continues about the certainty of brain death criteria within Islamic scholars. Although brain death is accepted as true death by the majority of Muslim scholars and medical organizations, the consensus in the Muslim world is not unanimous, and some scholars still accept death only by cardiopulmonary criteria. Organ transplantation has been accepted in Islamic countries (with some resistance from some jurists). Many fatwas (decrees) of Islamic Jurisprudence Councils have been issued and allowed organs to be donated from living competent adult donor; and from deceased (cadavers), provided that they have agreed to donate or their families have agreed to donate after their death (usually these are brain-dead cases). A clear and well-defined policy from the ministry of health regarding do not resuscitate, brain death, and other end-of-life issues is urgently needed for all hospitals and health providers in most (if not all) Muslim and Arab countries.

The coronavirus disease 2019 (COVID-19) pandemic placed an extraordinary demand on health systems and healthcare providers all over the world. The pandemic presented a number of unprecedented challenging ethical issues. Across the globe, hospitals are being challenged by a large number of patients presenting to the emergency room for treatment, creating scarcities of critical care resources, and uncovering the need for formal crisis standards of care. Difficult life and death decisions, which may create severe moral distress to the physicians, have to be made in emergency rooms and intensive care units. Other ethical issues, such as that related to conducting clinical trials during the pandemic, and the increase in domestic violence during the quarantine period, will be also discussed.

The holy month of Ramadan is one of the five pillars of Islam. During this month, fasting Muslims refrain from eating, drinking, smoking, and sex from dawn until sunset. Although the Quran exempts sick people from the duty of fasting, it is not uncommon for many heart disease patients to fast during Ramadan. Despite the fact that more than a billion Muslims worldwide fast during Ramadan, there is no clear consensus on its effects on cardiac disease. Some studies have shown that the effects of fasting on stable patients with cardiac disease are minimal and the majority of patients with stable cardiac illness can endure Ramadan fasting with no clinical deterioration. Fasting during Ramadan does not seem to increase hospitalizations for congestive heart failure. However, patients with decompensated heart failure or those requiring large doses of diuretics are strongly advised not to fast, particularly when Ramadan falls in summer. Patients with controlled hypertension can safely fast. However, patients with resistant hypertension should be advised not to fast until their blood pressure is reasonably controlled. Patients with recent myocardial infarction, unstable angina, recent cardiac intervention or cardiac surgery should avoid fasting. Physician advice should be individualized and patients are encouraged to seek medical advice before fasting in order to adjust their medications, if required. The performance of the Hajj pilgrimage is another pillar of Islam and is obligatory once in the lifetime for all adult Muslims who are in good health and can afford to undertake the journey. Hajj is a physically, mentally, emotionally, and spiritually demanding experience. Medical checkups one or two months before leaving for Hajj is warranted, especially for those with chronic illnesses such as cardiovascular disease. Patients with heart failure, uncontrolled hypertension, serious arrhythmias, unstable angina, recent myocardial infarction, or cardiac surgery should be considered unfit for undertaking the Hajj pilgrimage.

During the month of Ramadan, all healthy, adult Muslims are required to fast from dawn to sunset. Fasting during Ramadan involves abstaining from food, water, beverages, smoking, oral drugs, and sexual intercourse. Although the Quran exempts chronically ill from fasting, many Muslims with diabetes still fast during Ramadan. Patients with diabetes who fast during the month of Ramadan can have acute complications. The risk of complications in fasting individuals with diabetes increases with longer periods of fasting. All patients with diabetes who wish to fast during Ramadan should be prepared by undergoing a medical assessment and engaging in a structured education program to undertake the fast as safely as possible. Although some guidelines do exist, there is an overwhelming need for better designed clinical trials which could provide us with evidence-based information and guidance in the management of patients with diabetes fasting Ramadan.

More than 23 million adults worldwide have heart failure (HF). Although survival after heart failure diagnosis has improved over time, mortality from heart failure remains high. At the end of life, the chronic HF patient often becomes increasingly symptomatic, and may have other life-limiting comorbidities as well. Multiple trials have shown a clear mortality benefit with the use of implantable cardioverter defibrillators (ICDs) in patients with cardiomyopathy and ventricular arrhythmia. However, patients who have an ICD may be denied the chance of a sudden cardiac death, and instead are committed to a slower terminal decline, with frequent DC shocks that can be painful and decrease the quality of life, greatly contributing to their distress and that of their families during this period. While patients with ICDs are routinely counseled with regard to the benefits of ICDs, they have a poor understanding of the options for device deactivation and related ethical and legal implications. Deactivating an ICD or not performing a generator change is both legal and ethical, and is supported by guidelines from both sides of the Atlantic. Patient autonomy is paramount, and no patient is committed to any therapy that they no longer wish to receive. Left ventricular assist devices (LVADs) were initially used as bridge in patients awaiting heart transplantation, but they are currently implanted as destination therapy (DT) in patients with end-stage heart failure who have failed to respond to optimal medical therapy and who are ineligible for cardiac transplantation. The decision-making process for initiation and deactivation of LVAD is becoming more and more ethically and clinically challenging, particularly for elderly patients.

Introduction: Over one billion Muslims elect to fast during the month of Ramadan worldwide. The data available regarding the effect of Islamic fasting in patients with heart failure and reduced ejection fraction (HFrEF) are insufficient. Methodology: We prospectively studied 249 outpatients with HFrEF who plan to fast Ramadan in three Cardiac centers in Saudi Arabia. A detailed clinical assessment, diagnostic data, emergency department visit, and hospitalization during Ramadan and the preceding month were obtained. Results: A total of 249 patients were enrolled, 227 (91%) patients fast for the full lunar month. During Ramadan 209 (92%) patients remained stable while 18 (8%) patients became unstable. With fasting, the mean New York Heart Association (NYHA) functional class was significantly lower in the stable when compared to the unstable group (1.46 ± 0.7 vs. 3.22 ± 0.55. P

Ibn Sina, known in the West as Avicenna, was the most famous and influential of all the Islamic philosopher-scientists. His most important medical works are the Canon of Medicine medical encyclopedia and a treatise on cardiac drugs. His Canon of Medicine remained the standard text in both the East and West until the 16 th century. Avicenna′s description of cardiac diseases was logically presented perhaps for the first time in the history of medicine. Avicenna was the first to describe carotid sinus hypersensitivity, which presents with vasovagal syncope. He was a pioneer in pulsology and the first correct explanation of pulsation was given by Avicenna, after he refined Galen′s theory of the pulse. Besides, he discussed the action of available drugs on the heart in details and mentioned their indications and contraindications. In conclusion, Avicenna made important contributions to cardiology. This article describes some of his contributions in this field.

There is a wide gap between organ supply and demand, which results in a very long waiting time for kidney transplantation and an increasing number of deaths of the patients while on the waiting list. These events have raised many ethical, moral and societal issues regarding organ donation, allocation and use of living donors through exploitation of the poor for the benefit of the wealthy. Success in the implementation of kidney transplantation programs in a country depends on various factors including the economic situation, religious approval, public views, medical expertise and existing legislation. The public attitude toward donation is pivotal in all transplantation programs; increasing the awareness of the leaders of religion is vital in this regard.

Alcohol use disorders (AUDs)-a spectrum including at-risk drinking, alcohol abuse, dependence, and addiction-is a highly prevalent problem worldwide with a substantial economic impact. The toll of alcohol on individual health and healthcare systems is devastating. Alcohol is estimated to be the fifth leading risk factor for global disability-adjusted life years. Tackling the problem of AUD requires a comprehensive strategy that includes solid action on price, availability, and marketing of alcohol. Restricting or banning alcohol advertising may reduce exposure to the risk posed by alcohol at the individual and general population level. Warning labels about the cancer risks associated with drinking have a high degree of public support and may be an inexpensive and acceptable way to educate the public. Religiosity may reduce risk behaviors and contribute to health decision making related to alcohol use.

Objectives: To study the feasibility and additional value of real time three-dimensional transthoracic echocardiography (RT3D-TTE) for anatomical and functional assessment of malformed aortic valve (AV) compared to conventional two-dimensional TTE (2D-TTE). Methods: Malformed AV was evaluated in 35 patients (mean age 18 ±9.5years, 70% male) by both 2D-TTE and RT3D-TTE. The anatomical definition of aortic cusps (number, direction, and commissures) was evaluated by a 3-point visualization score (1: nonvisualized, 2: inadequate, 3: adequate). 2D-TTE and RT3D-TTE measurements included AV area and maximum diameters of both AV annulus and left ventricular outflow tract (LVOT). Results: Adequate visualization of AV cusps was achieved in 86% of patients by RT3D-TTE compared to 63% by 2D-TTE. The mean and median visualization score obtained by RT3D-TTE were higher than that by 2D-TTE. The opening of commissures was detected in (80%) of patients by RT3D-TTE compared to (34%) by 2D-TTE. AV area planimetry could be obtained in 77% of patients by RT3D-TTE compared to 43% by 2D-TTE. RT3D-TTE visualization score of AV cusps and commissures showed better interobserver agreement (Kappa: 0.62 and 0.72, respectively) than 2D-TTE (0.58 and 0.69, respectively). RT3D-TTE and 2D-TTE measurements of AV annulus and LVOT were well correlated (r = 0.85; P < 0.001) but the RT3D-TTE measurements were significantly larger than that obtained by 2D-TTE (2.05 ± 0.7 cm and 2.5 ± 0.86 cm vs 1.94 ± 0.67 cm and 1.98 ± 0.74 cm; P < 0.01). Conclusion: RT3D-TTE is a feasible technique that allows comprehensive quantitative and qualitative assessment of malformed AV. (Echocardiography, 2012;**:1-6)

We read with great interest the article entitled “Ethical Criteria for Human Trials of Stem-Cell-Derived Dopaminergic Neurons in Parkinson's Disease” by Hurst and colleagues (2015). Hurst and colle...

Hepatocellular carcinoma is the most common primary tumor of the liver accounting for 4.6% of all new human cancers. Cardiac metastasis in hepatocellular carcinoma is an uncommon secondary cardiac malignancy. We described two cases of advanced hepatocellular carcinoma with large masses in the right atrium mimicking atrial myxoma. The RA masses were incidentally detected during two-dimensional echocardiographic examination.

Lutembacher's syndrome is a rare combination of congenital atrial septal defect and mitral stenosis (almost always rheumatic). The hemodynamic effect of this combination makes the clinical diagnosis difficult due to a wide variation of clinical presentation. Echocardiography and cardiac catheterization are useful tools for proper diagnosis and planning of the therapeutic strategy. We present a 28-year-old female with Lutembacher's syndrome associated with partial anomalous pulmonary venous connection (PAPVC), which was surgically corrected. To our knowledge, this combination has never been reported in the literature.

Many Muslim patients and families are often reluctant to accept fatal diagnoses and prognoses. Not infrequently, aggressive therapy is sought by the patient or his/her family, to prolong the life of the patient at all costs. A series of searches were conducted of Medline databases published in English between January 2000 and January 2015 with the following Keywords: End-of-life, Ethics and Islam. Islamic law permits the withdrawal of futile treatment, including all kinds of life support, from terminally ill patients leaving death to take its natural course. However, such decision should only take place when the physicians are confident that death is inevitable. All interventions ensuring patient's comfort and dignity should be maintained. This topic is quite challenging for the health care providers of Muslim patients in the Western World.

Although several studies described the experience of doctors in their first postgraduate years, few shed the light on the ethical issues encountered by them. These doctors face a broad range of ‘everyday’ ethical challenges, from breach of confidentiality to truth-telling or improper informed consent. The daily ethical issues faced by junior doctors are not as dramatic as the major issues learned at medical school. Junior doctors have to make the best ethical decisions within the time limits available. Undergraduate medical ethics curricula should give priority to the real-life issues that doctors will face in their first years of practice.

Because statements of sympathy and regret can be used to prove legal liability in medical malpractice cases, lawyers routinely advise doctors against apologising and being open about what happened.1 2 Doctors who admit errors may face the discredit of their peers, the anger and disappointment of their patients and their …

Although moral values are universal, their application varies in different cultures. To Aristotle moral values are the result of habitual adherence to them. They become second nature. Galen combined the innate nature and temperaments. Al-Mawardi divided the origin of morality into two main branches: (a) The innate ones, (b) The voluntary character, which emanates from the training and using our faculties. Muslim philosophers tried to combine Aristotle and Galen; Miskawaih defined morality as being innate, controlled by instincts and humors, but definitely can be changed by training, cultivation, and culture. The motive and intention play an important role in the formation of moral character. In Islam, Prophet Muhammad (PBUH) taught that acts will be judged in accordance with the intention. If the motive is good and the act is good, the person will be rewarded by God; however, if the act is good and the motive is bad, the person will be punished for it.

It is a disgrace to find many millions worldwide dying from malnutrition, famines, diarrhea, malaria, and tuberculosis. Health services should be distributed in a fair way between rural areas and cities; and between tertiary hospitals and primary healthcare. Disease prevention, health education, and health promotion deserve their fair share. It is not only the number of physicians or nurses or beds that will improve the health standard of the nation. It needs equity in distribution of health resources and an efficient system of delivery. USA spends on health per capita double or triple of all the 28 industrialized countries; nevertheless, it is behind all these countries in certain health criteria put by WHO, such as infant mortality rate, and 5-year-old mortality rate. There are about 50 million citizens with no health insurance, or partial on and off insurance, in the USA until the beginning of the twenty-first century. The health system should move from only curative medicine to preventative medicine and health promotion.

Seeking a cure for infertility is not only permissible, but also encouraged in Islam. In Islamic law, all assisted reproductive technologies (ARTs) are allowed, provided that the source of the sperm, ovum, and uterus comes from a legally married couple during the span of their marriage. No third party should intrude upon the marital functions of sex and procreation. Surrogacy is not accepted in Islam. An excess number of fertilized embryos can be preserved by cryopreservation and may be transferred to the same wife in a successive cycle, while the marriage is intact. Using frozen sperm after the death of the husband is not permitted.

All nations have common principles in morality and ethics. The source of these moral and ethical attitudes can be traced back to three main sources: (a) Intuitive Reasoning (al-fitra) or the basic innate constitution of all human beings; (b) Faculty of Reason (al-‘Aql): The ability to reason and derive a decision by using one’s mind. It is logical to derive that people of wisdom acquire morality. Muslim philosophers like Ibn Tufail believe that any normal human being can recognize God, with his divinely endowed nature and his reason; (c) Divine Revelation (al-wahy, Tanzil): Muslims believe that God guides humanity by sending a number of prophets and apostles, who are the bearers of the revelation.

Islam differs from many other religions in providing a complete code of life. It encompasses the secular with the spiritual, the mundane with the celestial. Man is the vicegerent of God on earth “Behold thy Lord said to the Angels: I will create a vicegerent (khalifa) on earth” (Q. 2:30). The satanic claim to superiority is the source of arrogance. Islam considers it the worst sin since through arrogance all other sins are committed. Freeing humanity from the original sin, empowering human beings, and giving them full responsibility of their actions is the message of the Qur’an: “Every soul will be held responsible for what it had done” (Q. 74:38)—is the essence of morality and ethics in Islam.

Medical advances make it possible to restore health and sustain the life in circumstances previously regarded as hopeless. This capability brings with it considerable clinical, moral, socio-cultural, legal, and economic issues that challenge the values and goals of patient care. Many patients are kept alive through futile medical therapy. Delaying death with futile or hopeless treatment is unacceptable in Islam. Withholding medical therapy in terminally-ill patients has been widely accepted around the world on medical, legal, and ethical grounds. Terminally-ill Muslim patients are permitted to have life-sustaining treatments withheld or withdrawn when the treatment is deemed by the expert physicians to be futile. The basic human rights of the patient including food, water, nursing, and painkillers, should be continued.

Professional virtues and codes of conduct were historically associated with the philosophy and ethos of each community. The old Egyptians, Chinese, Indians, Persians, Babylonians, etc., had a mode of conduct for the medical profession, requirement for the priest physicians, and laws regulating the profession. The Hippocratic Oath extolled the following principles: Beneficence, Nonmaleficence and Confidentiality. From 1970, the Hippocratic tradition started to collapse. The rights of the patient became more important. These included fidelity, autonomy, and veracity. Islamic teachings differ from the paternalistic approach of the Hippocratic Oath. The Qur’an is replete with such verses, which orders freedom of faith and human personal responsibility. In Islam the consent of the person or his guardian is imperative. Seeking remedy may be obligatory (mandatory) in certain life saving situations or may be preferred or encouraged (Mandoob) in other situations. It may be facultative or optional and may be Makrooh, i.e., not preferred and in some situations and with certain types of treatment may be Haram, i.e., not allowed. There were many codes especially for medical research since the appearance of the Nuremberg code (1946) to the present time.

Genetic disorders occur at a high frequency in several Islamic communities and impose heavy medical, financial, and emotional burdens. Genetic testing and screening raise some of the most difficult issues in the entire field of bioethics. The premarital examination for sickle cell, thalassemia, and G6PD to avoid these genetic diseases is carried out in a number of Islamic countries. Preimplantation genetic diagnosis is permissible in Islam provided the sperms and oocytes are from the husband and wife. Genetic engineering is allowed for disease prevention, treatment, or amelioration on the condition that they do not cause further damage. Human cloning is forbidden in Islam. The majority of Islamic jurors permit Human Embryonic Stem Cells research if its source is legitimate. DNA fingerprinting may be used in certain conditions.