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Introduction: Middle East respiratory syndrome coronavirus (MERS-CoV) is an emerging zoonotic viral pathogen and a serious public health concern. The virus was first reported in Saudi Arabia in 2012 and continues to be endemic in the region. Most of the initial MERS-CoV cases in 2012 and early 2013 were sporadic, and it remains unclear whether MERS-CoV was circulating before 2012 or not. Therefore, we tried here to find any molecular evidence of MERS-CoV circulation in humans before or during 2012 in the city of Jeddah, Saudi Arabia. Methodology: We examined 349 archived respiratory samples collected between January 2010 and December 2012 from patients with acute respiratory illnesses from the city of Jeddah in Western Saudi Arabia. All samples were screened for MERS-CoV by real-time RT-PCR targeting the upstream E-gene (UpE) and the open reading frame 1 a (ORF1a). Results: All tested samples which were originally found negative for influenza A H1N1 virus were also found to be negative for MERS-CoV. Conclusions: These results suggest that circulation of MERS-CoV was uncommon among patients with acute respiratory symptoms in Western Saudi Arabia between 2010 and 2012.

IntroductionOne of the complications of diabetes mellitus (DM) is diabetic nephropathy (DN), which plays a significant role in the progression of end-stage renal disease. Oxidative stress is implicated in DN pathogenesis, and genetic variations in antioxidant enzymes such as superoxide dismutase 2 (SOD2) and catalase (CAT) may contribute to the susceptibility. This study aimed to investigate the potential association between single nucleotide polymorphisms (SNPs) in antioxidant enzymes, specifically SOD2 rs4880 and CAT rs769217, and the risk of T2D and susceptibility to DN within the Saudi population.MethodsThis case–control study included 150 participants, comprising 50 patients with T2D without DN (group 1), 50 patients with T2D with DN (group 2), and 50 healthy participants (group 3). The samples were genotyped using real-time PCR for SOD2 rs4880 and CAT rs769217 SNPs. Sanger sequencing was used for validation. Statistical analyses were performed to explore associations between these SNPs and T2D with or without DN.ResultsNo significant difference was observed in CAT rs769217 expression between the groups. However, a significant difference was observed in SOD2 rs4880 expression between the healthy controls and patients with T2D with DN (p = .028). Furthermore, SOD2 rs4880 was associated with approximately threefold increased risk of DN in patients with T2D compared to that in healthy participants (odds ratio [OR] = 2.99 [1.31–6.83]). Validation through Sanger sequencing further confirmed these findings.ConclusionsThe findings of this study provide evidence that SOD2 rs4880 SNP may contribute to inadequate defence by the antioxidant enzyme, SOD2, against DM-induced oxidative stress and thus cause DN in Saudi patients with T2D. Therefore, SOD2 rs4880 may serve as a predictive marker to prevent the development and progression of DN in patients with T2D.

Purpose Primary hyperparathyroidism (PHPT) is a common cause of hypercalcemia and remains understudied within the Arabian population. The present study, the largest of its kind within the Gulf Cooperation Council (GCC) countries, aims to determine the demographics and clinical presentation of PHPT in Saudi Arabia. Methods In this multi-center retrospective study involving three tertiary hospitals in different geographic locations of Saudi Arabia namely, Riyadh, Al Ahsa and Jeddah, a total of 205 out of 243 confirmed PHPT cases aged 16 to 93 years old were included ( N  = 96 from Riyadh; N  = 59 from Al Ahsa and N  = 50 from Jeddah). Demographics, clinical manifestations and surgical outcomes were recorded as well as laboratory and radiologic investigations including serum parathyroid hormone (PTH), 25(OH)D, adjusted calcium, estimated glomerular filtration rate (eGFR) and nuclear scan outcome. Results PHPT cases appeared to increase over time when compared to other local studies published so far, with 12.8 cases per 100,000 hospital population. Females outnumber males (3:1) with 86% seen as out-patients. The average age was 59.8 ± 15.5 years. Abnormal PTH scan was seen in 171 patients (83.4%). Kidney stones was the most common renal manifestation (32 cases, 15.6%) and osteoporosis was the most common skeletal manifestation (67 cases, 32.7%). Al Ahsa had the highest prevalence of multiple comorbidities at 54% and the highest prevalence of obesity as a single comorbidity (17%) compared to other regions ( p  < 0.05). Jeddah recorded the highest prevalence of osteoporosis with bone and joint pains (30%) ( p  < 0.05). Conclusion Comparison of present data with previous local studies suggest an increasing trend in PHPT cases in Saudi Arabia. Regional variations in the clinical presentation of PHPT were observed and warrant further investigation.

Disclosure: R.M. Alamoudi: None. A. Theyab: None. T. Shams: None. H. Alhashemi: None. Background: Pregnancy increases the risk of fasting hypoglycemia and is considered an exemption for fasting during Ramadan. Glucose patterns and hypoglycemia risk in relation to fasting Ramadan in pregnant women are not well studied. Objectives: To compare the risk of hypoglycemia, glucose patterns, and tolerance of fasting in pregnant women with gestational diabetes (GDM) versus women without GDM during fasting Ramadan. Methods: A prospective observational study conducted in the Obstetrics/Endocrine clinics at King Abdulaziz Medical City, Jeddah, Saudi Arabia. Pregnant women without GDM, and with GDM managed by diet or metformin, who were planning on fasting Ramadan and were dedicated to applying a flash glucose monitoring (CGM) device for two weeks were recruited. Women with GDM received standard-of-care diabetes education regarding fasting during Ramadan. Participation was entirely voluntary. Results: 30 women with gestational age ≥ 24 weeks completed the study; 8 without GDM (Gp. 1), 16 with GDM on diet (Gp. 2), and 6 with GDM on metformin (Gp. 3). Mean demographics respectively: Age 30.13 ±4.9 vs. 33.56 ±6.4 vs. 34.50 ±5.8 (p=0.2), BMI 34.36 ±5.88 vs. 30.74 ±3.75 vs. 36.75 ±8.01 (p=0.4), Gravida 3 ±2.2 vs. 3.38 ± 2.48 vs. 4.33 ±2.88 (p=0.6). Breaking Ramadan fasting was reported in 13 (43%) of all participants; 3 (37.5%) vs. 6 (37.5%) vs. 4 (66.7%), respectively. The median (IQR) days fast broken were 2 vs 2 (4) vs 1 (11) days, p=0.2, with the reason being hypoglycemia in 1 vs 4 vs 2, and hyperglycemia in 0 vs 1 vs 2, the other reasons included fatigue and acute illness, p=0.3. The average hypoglycemia glucose reading in mg/dl (M± S.D) associated with breaking the fast was 56 ±4.8, p=0.54. The usual timing of hypoglycemia was late evening, while for hyperglycemia it was post-midnight meal followed by post-Suhoor (predawn meal). Ambulatory glucose profile (AGP) parameters per 450 patient days for the three groups respectively: Average glucose (mg/dl) (median - IQR) 89 (13) vs. 95 (24) vs. 103 (34), p=0.3, Time spent within range (BG 63-140 mg/dl) 87 (6)% vs. 81 (16)% vs. 80 (44) %, p=0.1, Glucose management indicator (M ±S.D) 5.4 ±0.2%, 5.6 ±0.4%, 5.5 ±0.3%, p=0.5, and Glucose variability 17.6 ±1.9%, 20.8 ±2.9%, 24.7 ±11.5%, p=0.07. Time spent above range (BG >140 mg/dl) 7 ±6% vs. 18 ±19% vs. 25 ±26%, p=0.2, Time spent below range (BG <63 mg/dl) 8 ±8% vs. 7 ±8% vs. 10 ±21%, p=0.8, and Duration spent in hypoglycemia (minutes) 90 ±117.4, 65.8 ±61.1, 70 ±108.03, p=0.8. CGM-detected hypoglycemic events (BG <63 mg/dl) were found in 20 (66.7%) of all participants, the average number of events (median-IQR) per group was: 4 (5) vs. 6 (8) vs. 1 (15), p=0.8. Conclusion: Pregnant women with non-insulin-treated GDM compared to those without GDM experienced similar difficulties in tolerating fasting during Ramadan and increased risk of hypoglycemia. The potential perinatal harm needs more research. ClinicalTrials.gov NCT04862390 Presentation: Saturday, June 17, 2023

Introduction: Fasting Ramadan carries high risk for patients with T1DM. Current IDF-DAR guidelines suggest to change basal insulin timing from bedtime to early evening. However, there is paucity of studies to guide physicians toward evidence based management decisions. Objective: To compare glucose profiles in patients with T1DM while taking basal insulin Glargine at 7 pm (after Maghreb) versus 12 midnight (bed time) during Ramadan. The primary outcome being rates of hypoglycemia. Methods: 30 patients with T1DM planning on fasting Ramadan were recruited from the Diabetes clinic at Imam Abdulrahman bin Faisal Hospital National Guards Hospital, Dammam, Saudi Arabia. Glucose data collected using self-monitoring via the Abbott Freestyle Libre © 14-day device. Patients were instructed to continue taking their insulin glargine at bedtime for two weeks of Ramadan then to change timing to 7pm for the other two weeks of Ramadan in a treatment timing cross-over design. Results: Out of the 30 patients recruited 19 completed both phases of the study. Total number of sensor data captured was 79.84 for the 7pm timing vs. 72.82 for the 12am timing, and the total daily scans recorded were 9.79 vs. 8.18 respectively. The percentage of time spent within target (70-180mg/dl) for the 7pm timing vs. the 12 am timing respectively was 24.53% vs. 21.24%, above target 63.31% vs. 65.76%, and below target 12.16% vs. 13%. The average blood glucose for the 7pm timing vs. for the 12 am timing was 193.63 mg/dl vs 198.59 mg/dl and the HbA1c for the two weeks as calculated by Abbott Libre software was 8.24 vs 8.34% (p more than 0.05 for all values). Average number of hypoglycemic episodes (<70mg/dl) was 9.3 during the 7pm timing vs. 8.1 during the 12 am timing (p=0.05), and average duration spent in hypoglycemia was 128.3 minutes vs. 125.8 minutes (p=0.89). Conclusion: In patients with T1DM who fast Ramadan there is no advantage of changing basal insulin Glargine timing to earlier evening hours in regards to difference in rates of hypoglycemia. Larger randomized trials are needed to answer this question.

Disclosure: R.M. Alamoudi: None. S.M. Nawar: None. H.S. Alharbi: None. A.A. Al Qarni: None. A. Alzahrani: None. A.K. Almulla: None. W.T. Busaad: None. N.F. Alahmari: None. N.D. Alshamrani: None. L. Alkhalifa: None. Y.M. Saleh: None. M. Ramadan: None. A. Borai: None. Background: The effect of Ramadan fasting on the thyroid profile, and the best time for L-thyroxine (LT4) intake in relation to fasting during Ramadan remains undetermined. Objectives: To compare two different time points of taking LT4 therapy during fasting the month of Ramadan in regards to thyroid profile and patient satisfaction. Methods: A multicenter open-label randomized controlled trial. Patients with primary hypothyroidism were recruited from three centers in three cities in Saudi Arabia (Jeddah, Riyadh, and Alhasa). Patients with thyroid cancer were excluded. TSH and FreeT4 (FT4) were measured two weeks before Ramadan, and four to six weeks after Ramadan. Results: 303 patients with primary hypothyroidism were randomized; 156 to take the LT4 dose at sunset with sips of water at the time of breaking fast and wait 30-60 minutes to eat the main Iftar meal (pre-Iftar), and 147 to take the LT4 dose just before the start of fasting (pre-dawn) regardless of their last meal intake. There were no significant differences between the two groups in demographics or comorbidities. The mean age was 49 ±12 years, 87% were female, and the average duration of hypothyroidism was 9.7 ±8.25 years. The mean weekly LT4 dose in the pre-Iftar vs. pre-dawn group was 753.3 ±349.4 vs. 733.2 ±265.6 mcg, p=0.001, and the Pre-Ramadan thyroid profile was: TSH 2.56 ±2.16 vs. 2.46 ±1.72 mIU/L, p=0.3, FT4 13.45 ±2.1 vs 13.08 ±2.4 pmol/L, p=0.16. Post-Ramadan thyroid profile values were: TSH 3.64 ± 4.1 vs. 4.07 ±4.17 mIU/L, p=0.78, FT4 12.96 ±0.1 vs. 12.64 ±0.22 pmol/L, p=0.003. The estimated difference within the group means post-Ramadan was - 0.41 ±0.51 mIU/L, p=0.43 for TSH, and 0.32 ±0.28 pmol/L, p=0.24 for FT4. Generalized linear model repeated measures analysis of variance showed no significant difference over time in TSH or FT4 within or between groups (p = 0.47 vs. 0.81). Patient compliance and satisfaction with the regimens were similar between groups. Conclusion: There is no significant change nor difference in thyroid profile between the two regimens related to the change in LT4 intake during the fasting months of Ramadan. Both regimens can be utilized depending on patient preferences. ClinicalTrials.gov: NCT05421468. Saudi FDA: SCTR # 22041002 Presentation: Friday, June 16, 2023

Background: Fasting Ramadan is practiced by Muslims globally. Compliance with health team advice on ability to fast or not, medication and lifestyle adjustments are the corner stone of achieving optimal diabetes control and avoiding complications with fasting. We aimed in this study to evaluate the attitudes and practice of Muslim patients with diabetes during fasting Ramadan, and to assess their compliance with the medical instructions provided by their healthcare team. Methods: A cross-sectional study conducted in four Medical Centers under the Ministry of National Guard health affairs in four cities: Al-Ahsa, Dammam, Jeddah and Riyadh. All patients with diabetes followed in the diabetes clinics within three months post Ramadan and who met the study inclusion and exclusion criteria were approached and consented for participation in the study, and then filled a self-administered validated 15 items questionnaire. Results: Data for 1438 diabetics were analyzed; 1207 (83.9%) T2DM and 231 (16.1%) T1DM. The mean age was 57.9 ± 14.9 years. 270 (18.8%) suffered multiple comorbidities. 559 (46.3%) of T2DM vs 22 (9.5%) of T1DM were not familiar with the type of their diabetes. 883 (73.2%) of T2DM were on combination therapy. There was a significant difference between T1DM and T2DM in health education received from the treating physician 168 (72.7%) vs 574 (47.6%) and from a dietician 165 (71.4%) vs 613 (50.8%) (p<0.0001), but education received from diabetes educators was not significantly different 189 (81.8%) vs 936 (77.6%) (p=0.15). Patients who followed diet advise were only 55 (23.8%) vs 43 (36.4%), respectively, (p=0.0002). 1191 (82.8%) reported fasting the full month, 162 (11.3%) were advised by their physicians to not fast. Patients who did not fast full Ramadan were 247 (17.2%), one third 92 (37.25%) of them based on physician advise with a compliance rate of (56.8%). Blood sugar was not well controlled before Ramadan and did not change significantly after Ramadan with a mean HbA1c (8.41 ± 2.0 and 8.40 ± 2.1) respectively, p-value 0.53. Multivariate analyses revealed that being on insulin, and prior hospitalization for diabetes were significant predictors of compliance with physicians advice related to fasting Ramadan [(OR 4.5, 95% CI, 1.7 - 12.2, p-value 0.003), (2.3, 95% CI, 1.2 - 5.1, p-value 0.048)] respectively, while lack of receiving education, type of diabetes, and degree of glycemic control did not predict compliance with statistical significance [(OR 1.9, 95% CI, 0.8 - 4.6, p-value 1.5), (1.06, 95% CI, 0.4 - 2.6, p-value 0.89), (1.3, 95% CI, 0.5 - 3.5, p-value 0.56)] respectively. Majority of patients were aware of a religious “Fatwa” on fasting with diabetes but their understanding of it varied. Conclusion: The study shows low level of patient awareness and compliance to health providers advice. Results indicate prior hospitalization and being on insulin treatment as predictors of patient compliance. This signifies the need for better structured diabetes and fasting education programs. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Background: Thyroid dysfunction in pregnancy is associated several adverse outcomes. This has triggered a debate about whether universal screening should be implemented. Despite recommendations against universal screening, the clinical practice of many caregivers may differ. We aimed to assess the sensitivity of using targeted high-risk case finding for diagnosing thyroid dysfunction in pregnancy compared to routine screening in pregnant Saudi women, and to evaluate if gestational diabetes (GDM) specifically affected the risk. Methods: A cross-sectional study in two hospitals under the Ministry of National Guards Health affairs of Saudi Arabia; King Abdulaziz Hospital, Al-Ahsa, and Imam Abdulrahman bin Faisal Hospital, Dammam. Pregnant ladies attending the Family medicine, Obstetrics and Gynecology, and Endocrinology clinics in both hospitals were assessed by the caring physician based on a check list for risk stratification for thyroid dysfunction as per the 2012 Endocrine society clinical practice guidelines for management of thyroid dysfunction in pregnancy. Presence of one risk factor defined high risk. All patients had a routine serum TSH measured as universal screening is commonly practiced in both institutions, the physician doing the risk stratification was not aware of the TSH result. Sensitivity and specificity for the case finding approach was calculated using and abnormal TSH value as the gold standard for presence of thyroid dysfunction. The institutions lab reference TSH 0.35 – 4.94 mIU/L was used as cutoff. Results: 1571 pregnant women were included in the study; mean age 29.3± 6.2 years, 396 (23.5%) were primigravida. The mean TSH value was 1.898 ± 1.459 mlU/L. 1178 (75%) pregnant women had an indication for screening based on presence of at least one risk factor, of which 95 (8.1%) tested abnormal for TSH. 393 women had no risk factors, of which 379 (96.4%) had normal TSH, (Chi square 9.3, p-value 0.002). [Sensitivity 87.2%, (95%CI 79.4% – 92.8%), Specificity 25.9%, (95%CI 23.7% – 28.3%)]. Total abnormal TSH values was 109 (6.9%), 43 were abnormal high (i.e. hypothyroid); of which 40 screened positive by case finding approach [Sensitivity 93.02%, (95%CI 80.9% – 98.5%), Specificity 25.52%, (95%CI 23.4% – 27.8%)]. Moreover, 178 (11.3%) women screened positive for GDM at some stage in pregnancy out of which only 5 (2.8%) had an abnormal TSH value, while of the 1393 pregnant women who screened negative for GDM 1289 (92.5%) had a normal TSH value, (Chi square 5.3, p-value 0.02). [Sensitivity 4.6%, (95%CI 1.5% – 10.4%), Specificity 88.2%, (95%CI 86.4% – 89.8%)]. Conclusion: Targeted high-risk case finding predicts thyroid dysfunction in pregnant Saudi women with high sensitivity supporting its utility in screening our pregnant population. Gestational diabetes is highly prevalent in Saudi women, but does not increase risk of thyroid dysfunction in pregnancy.

Background: For a whole month, every year Muslims fast daily from dawn to sunset. Those with health conditions that put them at risk are exempted from fasting, yet most of patients with diabetes choose to fast. Clinical and metabolic complications of diabetes during this month are issues of concern for patients and their managing physicians. This study is designed to evaluate the impact of fasting Ramadan on safety of patients. Methods: A multicentercross-sectional survey was conducted in four hospitals under the Ministry of National Guard Health Affairs; King Abdulaziz Hospital,Al-Ahsa, Imam Abdulrahman bin Faisal Hospital, Dammam, King Abdulaziz Medicalcities, Riyadh and Jeddah. All patients with diabetes followed in the diabetes clinics of all four centers who fulfilled the study inclusion and exclusion criteria were approached within three months post Ramadan and consented for participation in the survey, then filled a self-administered validated questionnaire that consisted of 15 items. Results: Socio-demographic,clinical, and laboratory characteristics of 1438 patients with diabetes were analyzed. The majority 1207 (83.9%) had type II diabetes, and 828 (57.6%) were females.The mean age was 57.9 ± 14.9 years, and mean BMI 25.25 ± 5.39.The majority 1060 (73.7%) had concomitant diseases. 36 (2.5%)were on diet therapy alone, 147 (10.2%) on metformin monotherapy, and 261 (18.2%) on insulin therapy alone. The remaining 994 (69.1%) were on combination of insulin and oral agents. Health education was received on average by 688 (57.8%) of patients. Out of the 1191 (82.8%) who fasted the full month, 497 (41.7%) experienced acute glycemic complications. Multivariate analyses revealed that significant predictors for unsafe fasting were: type I diabetes [OR 1.8 (95%CI 1.2 - 2.8), p-value 0.007], insulin therapy [OR 1.8 (95% CI 1.4 - 2.3), p-value0.0001], previous history of breaking fast for glycemic reasons [OR 2.1 (95% CI1.5 - 2.9), p-value 0.0001], and not receiving health education [OR 1.6 (95% CI1.2 - 2.0), p-value 0.0006]. Blood sugar control, presence of concomitant diseases, and history of diabetes related hospitalization were not statistically significant predictors [(OR 1.25, 95% CI, 0.9 - 1.7, p-value 0.15),(1.3, 95% CI, 0.9 - 1.8, p-value 0.14), (1.1, 95% CI, 0.8 - 1.6, p-value 0.45)] respectively. Conclusion: A significant proportion of patients with diabetes do not receive specific education pertinent to fasting Ramadan. Lack of health education, in addition to; type I diabetes, insulin therapy, and previous experience of complications are predictors for unsafe fasting. This highlights the need for better structured educational programs and further research in the field.