this chapter aims to shed light on green hydrogen energy and its varying uses in the Arab region. The study seeks to reveal the types of hydrogen energies and their effectiveness in reducing the volume of emissions resulting from fossil fuel production plants and plants. The study also aims to analyse the negative and positive effects of green hydrogen energy and the extent of its ability to reduce carbon emissions through investments in green hydrogen energy projects. Added to this, the chapter focuses on exploring the economic consequences of green hydrogen energy projects, including their impact on spending and investment rates in this field, and analysing the benefits and challenges that the Arab region may face in adopting this advanced technology.

Mixed presentation of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) has been reported in up to 27% of hyperglycemic emergencies. This 15-year retrospective chart review describes clinical features, risk factors, and outcomes among children presenting with hyperglycemic emergencies at our center. Out of 322 patients, 92% were Afro-Caribbean or Black with a mean age of 13.6 years, comprising 266 (83%) with DKA, 52 (16%) mixed DKA-HHS, and rarely with HHS (1%, n = 4). Most (98%) of DKA and DKA-HHS groups had type 1 diabetes mellitus (T1DM). All 4 patients with HHS had type 2 diabetes mellitus (T2DM). Compared with the DKA group, the mixed DKA-HHS group had higher IV fluid rates ( P < .0001), 4.3-fold greater odds of acute kidney injury (AKI), and 3.3-fold greater odds of altered mental status (AMS). In the HHS group, 50% presented had AMS and AKI and required higher IV fluids rates (≥2× maintenance). Clinicians should recognize mixed cases of DKA-HHS to minimize complications.

This chapter examines how to restructure service provision processes in government organizations using modern ICT. Precisely, the chapter discusses the role of smart governance in improving service delivery by focusing on smart applications. The chapter emphasizes that the practice has gone beyond the traditional e-government. At present, smart governance initiatives focus, in addition to services availability, on the idea of integrating various types of public services. The chapter also emphasizes that the application of the AI-augmented smart government would enhance the process of designing and providing government services. AI-augmented smart government applications also enhance the level of transparency in government agencies and advance the values of accountability and integrity in the various activities of the state's administrative apparatus.

Smart cities represent an emerging trend that may have policy and regulatory implications for telecoms regulators in many countries including Qatar. This paper draws on a review of interdisciplinary literature on regulatory governance and smart cities besides primary data collected from interviews with telecom and urban planning experts as well as regulatory members of staff to offer illustrations of the regulatory challenges and policy implications facing the development of smart cities with special focus on the state of Qatar. The paper emphasizes that regulatory policy-makers are required to go beyond the obvious and immediate benefits of smart cities to capture the full picture of potential impacts on regulatory and policy processes. For the transition towards smart cities to be handled successfully, regulatory policy-makers are required to address the new regulatory challenges by developing proactive rather than reactive approaches in dealing with the implementation of smart city initiatives.

Using a multi-level perspective approach combined with top-down macroeconomic models, we analyze the situation of the GCC countries in the perspective of a global transition to zero-net emissions before the end of the century. Based on these analyses, we propose strategic and political options for these oil and gas exporting countries. We show that it would be unwise for GCC member states to adopt an obstructionist strategy in international climate negotiations. On the contrary, these countries could be proactive in developing international emissions trading market and exploiting negative emissions obtained from CO2 direct reduction technologies, in particular direct air capture with CO2 sequestration, and thus contribute to a global net-zero-emissions regime in which clean fossil fuels are still used.

Abstract Disclosure: I. Gavryutina: None. A. Badran: None. A. Thakkar: None. R. Bargman: None. V. Umpaichitra: None. V. Chin: None. Endothelial dysfunction (ED) was found to be prevalent in women with polycystic ovarian syndrome (PCOS) and was associated with increased leptin and decreased adiponectin levels but has not been studied in children. We performed a cross-sectional study of non-smoking adolescents aged 12-19 years old with PCOS by NIH-criteria (n=20) and controls (n=7) to study the differences in ghrelin, endothelin, anti-mullerian hormone (AMH), leptin, adiponectin and reactive-hyperemia index (RHI) a non-invasive single measure of ED using EndoPAT®. Exclusion criteria were: pregnancy, diabetes, thyroid disease, adrenal disorder, hepatic, cardiovascular disease, hypertension, or medications (other than metformin or oral contraceptive pills which were allowed for the PCOS group). Between PCOS and control groups, there was no difference (mean±SD) in age (16.5±1.8 vs 17.1±2.3 years, p=0.31), BMI (35.7 ±9.7 vs 30.9±10.3 kg/m2, p=0.15) and A1C levels (5.45±0.4 vs 5.37±0.15%, p=0.22). Total and free testosterone was higher in PCOS group (60.7±21.8 vs 34.6±12.8 ng/dl, p=0.00063; 8.51 vs 3.76, p=0.0019, respectively). PCOS group had worse (lower) RHI (1.26±0.43 vs 1.72±0.40, p=0.015, normal RHI >1.67). PCOS group had higher leptin (1085.5±116.9 vs 896.4±176 pg/ml, p=0.014) and lower adiponectin (2.02±0.19 vs 2.27±0.13 µg/ml, p=0.001). There were no differences in endothelin-1 (10.9±1.2 vs 34.3±3.1 pg/ml, p=0.11), ghrelin (6060.1±13057.2 vs 5495.7±5474 pg/dl, p=0.44) and AMH levels (11.86±27 vs 3.8±10.1, p=0.14). HOMA-IR or insulin resistance was not significantly different between the PCOS and control groups (2.05 vs 3.48, p=0.26). Leptin is a proinflammatory product of adipose tissue and via its receptor on the endothelium, likely promotes platelet aggregation, thrombosis and stimulation of free radical production contributing to ED. Adiponectin on the other hand, is known to reduce levels of TNFα and suppress its inflammatory effects on endothelial cells. Low adiponectin has previously been found in women with PCOS when corrected for BMI and even insulin resistance. Our adolescents with PCOS had lower RHI, higher leptin and lower adiponectin levels. These findings suggest increased risk of cardiovascular disease in adolescents which has not been previously reported in children before. Further studies are needed to investigate the relationship between ED and differences in leptin and adiponectin in adolescents with PCOS. Presentation: Friday, June 16, 2023

Following reports of increased new-onset diabetes and worse severity of DKA for children with diabetes following SARS-CoV-2 infection, we studied hospitalization rates for children with type 1 diabetes (T1DM) and type 2 diabetes (T2DM) in our center during the citywide shutdown. Methods. We conducted a retrospective chart review of children admitted to our two hospitals from January 1, 2018, to December 31, 2020. We included ICD-10 codes for diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar syndrome (HHS), and hyperglycemia only. Results. We included 132 patients with 214 hospitalizations: 157 T1DM, 41 T2DM, and 16 others (14 steroid induced, 2 MODY). Overall admissions rates for patients with all types of diabetes were 3.08% in 2018 to 3.54% in 2019 (p=0.0120) and 4.73% in 2020 (p=0.0772). Although there was no increase of T1DM admissions across all 3 years, T2DM admission rates increased from 0.29% to 1.47% (p=0.0056). Newly diagnosed T1DM rates increased from 0.34% in 2018 to 1.28% (p=0.002) in 2020, and new-onset T2DM rates also increased from 0.14% in 2018 to 0.9% in 2020 (p=0.0012). Rates of new-onset diabetes presenting with DKA increased from 0.24% in 2018 to 0.96% in 2020 (p=0.0014). HHS increased from 0.1% in 2018 to 0.45% in 2020 (p=0.044). The severity of DKA in newly diagnosed was unaffected (p=0.1582). Only 3 patients tested positive for SARS-CoV-2 infection by PCR. Conclusion. Our urban medical center is located in Central Brooklyn and serves a majority who are Black. This is the first study investigating pediatric diabetes cases admitted to Brooklyn during the first wave of the pandemic. Despite the overall pediatric admissions declining in 2020 due to the citywide shutdown, overall hospitalization rates in children with T2DM and in new-onset T1DM and T2DM increased, which is not directly associated with active SARS-CoV-2 infection. More studies are needed to elucidate the reason for this observed increase in hospitalization rates.

Background Asthma is known to be a heterogeneous disease that forms a problem in asthma management. Symptom-based asthma phenotyping with endotyping of the proposed phenotype is a trial to solve this problem. Asthma phenotypes and endotypes facilitate research, establish genetic associations, identify biomarkers, and test for new lines of treatment. Aim To clarify the cytokine profile of wheezy asthma phenotype which could pave the way to personalize asthma medicines according to symptom-based asthma phenotypes. Patients and methods A case–control study was conducted in 50 asthmatic patients presented solely with wheezes with a mean±SD of age of 9.54±2.81 years and 50 healthy controls, with a mean±SD of age of 8.98±2.79 years. The studied cases and controls underwent assessment of serum levels of interleukin-10 (IL-10), transforming growth factor-β1 (TGF-β1), total serum immunoglobulin E (IgE), peripheral eosinophilic percent, and pulmonary function tests. Results Wheezy asthma phenotype showed significant increase in parental smoking, positive family history, total serum IgE, peripheral eosinophilic percent, and TGF-β1 compared with controls. However, serum IL-10 showed significant decrease in cases versus controls. Asthmatics with allergic rhinitis showed significant increase in total serum IgE and peripheral eosinophilic percent compared with non-allergic rhinitis asthmatics. Conclusion Wheezy asthma phenotype showed significant increase of serum TGF-β1 as a promoting effect of airway remodeling, significant decrease in serum IL-10, and significant increase of both total serum IgE and eosinophilic percent. This throws a light on the importance of asthma phenotyping according to symptomatology, as a trial toward tailoring asthma medications.

This paper proposes an assessment of long-term climate strategies for oil- and gas-producing countries—in particular, the Gulf Cooperation Council (GCC) member states—as regards the Paris Agreement goal of limiting the increase of surface air temperature to 2°C by the end of the twenty-first century. The study evaluates the possible role of carbon dioxide removal (CDR) technologies under an international emissions trading market as a way to mitigate welfare losses. To model the strategic context, one assumes that a global cumulative emissions budget will have been allocated among different coalitions of countries—the GCC being one of them—and the existence of an international emissions trading market. A meta-game model is proposed in which deployment of CDR technologies as well as supply of emission rights are strategic variables and the payoffs are obtained from simulations of a general equilibrium model. The results of the simulations indicate that oil and gas producing countries and especially the GCC countries face a significant welfare loss risk, due to “unburnable oil” if a worldwide climate regime as recommended by the Paris Agreement is put in place. The development of CDR technologies, in particular direct air capture (DAC) alleviates somewhat this risk and offers these countries a new opportunity for exploiting their gas reserves and the carbon storage capacity offered by depleted oil and gas reservoirs.

Introduction: Hyperglycemic emergencies in children with diabetes traditionally include diabetic ketoacidosis (DKA) predominantly associated with T1DM, whereas hyperosmolar hyperglycemic state (HHS) that is associated with relative insulin deficiency in T2DM, rarely occurs (2%). There have been increasing reports of mixed DKA-HHS affecting up to 27%. The purpose of this study is to identify clinical features, risk factors, complications and outcomes among minority children presenting with hyperglycemic emergencies at our center. Methods: This is a retrospective chart review of children and adolescents (ages 1-21 years) admitted for hyperglycemic emergencies including DKA [defined as glucose >200 mg/dL, metabolic acidosis (pH <7.3 or serum bicarbonate <15 mmol/L) and ketonemia (ß-hydroxybuyrate ≥3 mmol/L) or moderate to large ketonuria], or HHS [defined as glucose >600 mg/dL, effective serum osmolality >320 mOsm/kg, venous pH >7.25 or arterial pH >7.30 or serum bicarbonate >15 mmol/L, absent to mild ketonemia] or mixed DKA-HHS between 2004 and 2019. Descriptive statistics, chi-squared analysis and t-tests were used. Results: Of 322 patients, 92% were African American with mean age 13.6 ± 3.5 years, 39% males, consisting of 266 (83%) with DKA, 52 (16%) mixed DKA-HHS, and 4 (1%) HHS. Ninety-eight of the DKA and DKA-HHS groups had T1DM. All 4 patients with HHS had T2DM. Compared to the DKA group, the mixed DKA-HHS group required higher IV fluids rates (p<0.0001), 4.3-fold greater odds of acute kidney injury (AKI, mean serum creatinine of 1.6 mg/dl vs 1.1 mg/dl; ref 0.5-1.0 mg/dL) and 3.3-fold greater odds of developing altered mental status (AMS). Risk factors such as insulin adherence, and precipitating factors like infection or stress were not different between both groups (p=0.06). There was no significant difference in insulin rates or time to resolution (p=0.4) in both groups. Among the HHS group, 50% presented with AMS and AKI (mean Cr 1.1 mg/dl ± 0.31) due to severe dehydration and required higher IV fluids rates (≥2 x maintenance). Creatinine kinase in 2 patients were slightly elevated (mean 1643 units/L, ± 77; ref 39-309). Insulin drip at 0.05 u/kg/hour was started in all 4 patients. None had venous thrombosis, rhabdomyolysis, cerebral edema, or death. Average time of resolution was 10 ±1.63 hours. Conclusion: In this study, 16% of patients with hyperglycemic emergencies presented with mixed DKA-HHS which was associated with more complications compared to the DKA group. Serum osmolality should be calculated and checked at diagnosis. Identification of hyperosmolality whether with or without DKA in the emergency setting is important because treatment should be focused on the degree of dehydration (usually moderate to severe) and other complications such as AKI and mental status changes.

Abstract Introduction Rickets is a condition that can affect bones of infants and children. It is characterized by growth plate demineralization and can occur secondary to, most commonly, vitamin D deficiency or various problems with vitamin D, Calcium or Phosphate metabolism. Hypophosphatemic rickets (HR) is a type of rickets that is inherited by X linked dominant pattern mainly however it can be also inherited by autosomal dominant and recessive patterns in rare cases. X linked dominant type (XLH) affects about 1 in 20,000 newborns. Each of the other hereditary forms of HR has been identified in only a few families. Clinical features of XLH is similar to other types of rickets including metaphyseal widening, palpable rachitic rosaries, frontal prominence, malformation of the horizontal depression along the lower border of the chest, insufficient weight gain and leg bowing. Case presentation: A 10-month-old infant presented to endocrinology with vitamin D deficiency, low serum phosphorus and hyperparathyroidism. Physical examination showed macrocephaly with frontal bossing, widening of the wrists and rachitic rosaries. His lab results showed low 25 OH vitamin D (11 ng/ml) (N:20-50 ng/ml), low phosphorus (PO4) (3.3 mg/dl) (N:4-6.5 mg/dl), high PTH (113 pg/ml) (N: 20-65pg/ml), high alkaline phosphatase (ALP) (836 IU/L) (N: 135-518 IU/L) and normal calcium (Ca2+) (9.6 mg/dl) (N:9-11 mg/dl). Vitamin D treatment was started however his follow up lab results showed persistent hypophosphatemia for age (2.8mg/dl) and elevated ALP (600IU/l) despite normalization of vitamin D (38 ng/ml). Additional lab tests were done showing high PO4 excretion (19.5 mg/dl)(N:1:3.5 mg/dl), Ca/Cr ratio 0.005 (N <0.14), inappropriately normal FGF23 level (129 RU/ml) (N: >124 RU/mL). Genetic testing showed de novo mutation in PHEX gene (871C>T) which is consistent with XLH. PHEX gene mutation is the most common mutation associated with XLH. Normally this gene can directly or indirectly regulate a protein called fibroblast growth factor 23 (produced from FGF23 gene). This protein normally inhibits renal reabsorption of phosphate into the bloodstream. Gene mutations increase the production or reduce the breakdown of fibroblast growth factor 23 leading to an overactivation of this protein and reduction of phosphate reabsorption by the kidneys, resulting in hypophosphatemia. The patient was maintained on Burosomab (0.4 mg/kg biweekly); a recombinant human monoclonal antibody (IgG1) that binds to and inhibits the activity of fibroblast growth factor 23 (FGF23) and increases the phosphate reabsorption in the renal tubules. Conclusion: XLH due to PHEX gene mutation should be considered in rachitic children who have persistently low phosphate levels despite treating vitamin D deficiency.

Abstract Introduction The extracellular calcium-sensing receptor (CaSR) expressed mainly in the parathyroid gland and kidneys regulates calcium (Ca+2) homeostasis through parathyroid hormone (PTH) secretion. Activating mutations of CaSR can lead to autosomal dominant hypocalcemia and severe congenital hypoparathyroidism. Constitutively activated CaSR receptors blocks PTH release leading to hypocalcemia, hyperphosphatemia and decreased Ca+2 reabsorption from the kidney. Case 1: 14 year old male presented for an evaluation of hypocalcemia and hyperphosphatemia found on routine blood work. He denied symptoms of hypocalcemia. He had normal vital signs, positive Chovstek sign but rest of exam was unremarkable. His lab results showed low Ca+2 8.1 mg/dl (8.6–10 mg/dl), high phosphorus 6 mg/dl (2.7–4.5 mg/dl) and inappropriately normal PTH 26.8 pg/ml (10–65 pg/ml). FISH was negative for DiGeorge. Genetic testing showed heterozygous CaSR gene mutation I822T, variant of uncertain significance. His father with primary hypoparathyroidism has the same CaSR gene mutation; mother is healthy and tested negative for this variant. Given the inheritance pattern of the mutation, it is likely a pathologic mutation. He is maintained on Calcium (1500 mg BID) and Calcitriol (0.5 mcg PO BID) and is doing well. Case 2: One day old premature 32-week old infant girl was found to have early onset neonatal hypocalcemia 6.1 mg/dl (6.2–11 mg/dl) during NICU admission for respiratory distress, inappropriately normal PTH 18.5 pg/ml and high phosphorus 8.8 mg/dl (4.6–7.9 mg/dl). She had no symptoms of hypocalcemia in the NICU or at home. She did not have any dysmorphic features. FISH was negative for DiGeorge. Genetic testing to sequence genes including AIRE, AP2S1, CASR, GNAS, HADHA, HADHB, PTH1R, SOX3, STX16, TBCE was done and revealed a novel heterozygous mutation in the CaSR gene for a missense variant c.2495T>C (p.lle832Thr) and STX16 c.644A>T, possibly benign variant. Unfortunately, the parents have not consented to testing yet. Further familial and functional characterization of this new variant is necessary to confirm its possible pathogenetic role in this hypocalcemic patient. Currently she is maintained on ergocalciferol 800 IU, calcitriol 0.25 mcg and sevelamer 3 packets daily and is doing well. Conclusion: In the workup for primary hypoparathyroidism without dysmorphic features and tests negative for DiGeorge, CaSR mutations should be investigated as part of the differential as we have identified variants in the CaSR gene in 2 children with asymptomatic hypocalcemia, one of which is a novel mutation which has never been reported before.