To the Editor: Islamic law exempts pregnant women from fasting during Ramadan [1, 2]. Although women can defer fasting until after pregnancy, they prefer to share the experience during Ramadan. A total of 45–90% of healthy pregnant women fasted during Ramadan [3-5]. Our aims were to examine the practice of fasting among pregnant Muslim women with diabetes and to explore the roles of healthcare professionals and Imams in the decision to fast. Standardised questionnaire-based interviews, based on questions in the EPIDIAR study [6], were conducted at four specialist antenatal centres in London. Forty-eight women completed the questionnaire. Mean age (± SD) was 32 ± 5 years. Sixty-five per cent had gestational diabetes, 31% had type 2 and the remainder had type 1 diabetes. Forty-four per cent were diet-controlled, 25% on oral hypoglycaemic agent(s), 21% on insulin and 10% on insulin and metformin. Ten per cent of women fasted during pregnancy (Table 1). Twenty-three per cent of women who did not fast, had a history of hypoglycaemia. Having diabetes with risk of hypoglycaemia may be why these women did not fast, compared with healthy pregnant women who were keen to fast despite adverse reaction [2]. Urban background may have influenced their decision not to fast, as immigrants and women from rural areas tended to fast [3, 5]. Family members may have been consulted instead, as 63% did not consult healthcare professionals or religious leaders for advice [7]. Husbands tended to discourage fasting when they felt that the women were endangering themselves [4]. In overall, women were just as likely to discuss fasting with their Imams as they were with healthcare professionals (Table 2). Preconception care in Muslim women with diabetes should include education on the risks of fasting during Ramadan and healthcare professionals should work together with Imams to address the medical and religious aspects of fasting. Extending the survey beyond London would provide a more comprehensive view of Muslim women with diabetes. Further research is needed to determine whether fasting during Ramadan affect maternal and foetal outcomes. EH contributed to the concept and design, data collections and preparation of this manuscript; MR,VB, DD and MR are the clinicians responsible for patient follow-up; MR and VB performed data collections; DD and MR helped in critical revision of the article; MH revised and corrected the final version of the manuscript. No competing interest.

Diabet. Med. 29, 828829 (2012)

AIMS:To compare hypoglycaemic events, glycated haemoglobin (HbA1c) and changes in body weight in Muslim patients with Type 2 diabetes receiving Humalog Mix 50 and human Mixtard 30 twice daily during Ramadan fasting. METHODS:Data were collected from Muslim patients with Type 2 diabetes attending primary care practices in North-West London, who were on Mixtard 30 insulin twice daily before Ramadan. Group 1 had their evening insulin changed to Humalog Mix 50 (n = 26) 2 weeks before Ramadan, i.e. taking Mixtard 30 at predawn meal and Humalog Mix 50 at the sunset meal during Ramadan. As the major proportion of the daily caloric intake was consumed at the sunset meal, the rationale of switching the evening dose from human Mixtard 30 to Humalog Mix 50 was to provide more rapid-acting insulin that has shorter time of onset and peak time for the large evening meal to improve the postprandial glucose control without increasing the risk of hypoglycaemia. Group 2 continued on Mixtard 30 twice daily (n = 26). All patients received structured education about how to identify and manage hypoglycaemia during Ramadan. RESULTS:Group 1 had a mean HbA1c reduction of 0.48% (p = 0.0001) before and after Ramadan, whereas group 2 had a mean HbA1c increase of 0.28% (p = 0.007). Group 1 was associated with a small reduction of 0.04 (p = 0.81) in the mean number of hypoglycaemic events during Ramadan compared with before Ramadan, whereas group 2 was associated with an increase of 0.15 (p = 0.43), although these differences between the groups were not statistically significant following adjustment for baseline factors [LSM difference between groups = 0.135, p = 0.36, 95% confidence limits (-0.16, 0.43)]. CONCLUSION:Changing to humalog Mix 50 during Ramadan resulted in improvement in glycaemic control without increasing the incidence of hypoglycaemia.

Diabet. Med. 27, 327–331 (2010)AbstractBackground and Aims During Ramadan, Muslims fast from dawn to dusk for one lunar month. The majority of Muslim diabetic patients are unaware of complications such as hypoglycaemia during fasting. The safety of fasting has not been assessed in the UK Muslim population with diabetes. The aim of this study was to determine the impact of Ramadan‐focused education on weight and hypoglycaemic episodes during Ramadan in a Type 2 diabetic Muslim population taking oral glucose‐lowering agents.Methods We retrospectively analysed two groups. Group A attended a structured education programme about physical activity, meal planning, glucose monitoring, hypoglycaemia, dosage and timing of medications. Group B did not. Hypoglycaemia was defined as home blood glucose < 3.5 mmol/l.Results There was a mean weight loss of 0.7 kg after Ramadan in group A, compared with a 0.6‐kg mean weight gain in group B (P < 0.001). The weight changes observed were independent of the class of glucose‐lowering agents used. There was a significant decrease in the total number of hypoglycaemic events in group A, from nine to five, compared with an increase in group B from nine to 36 (P < 0.001). The majority were in patients treated with short‐acting sulphonylureas (group A—100%, group B—94%). At 12 months after attending the programme, glycated haemoglobin (HbA1c) reduction were sustained in group A.Conclusions Ramadan‐focused education in diabetes can empower patients to change their lifestyle during Ramadan. It minimizes the risk of hypoglycaemic events and prevents weight gain during this festive period for Muslims, which potentially benefits metabolic control.

#### Summary points The holy month of Ramadan is one of five main pillars of being a Muslim. Most Muslims are passionate about fasting during this month. Although the Koran exempts sick people from the duty of fasting,1 2 many Muslims with diabetes may not perceive themselves as sick and are keen to fast. A large epidemiological study of Muslims with diabetes in 13 Muslim countries (n=12 914)—the EPIDIAR study—showed that 43% of patients with type 1 and 79% of those with type 2 diabetes fasted during Ramadan.3 As the month of Ramadan follows the lunar calendar, the fasting month is brought forward by about 10 days each year, which means that over time the season in which Ramadan falls changes. For the next decade Ramadan will fall in the summer in the northern hemisphere. As daylight hours vary considerably between summer and winter months in non-equatorial countries, the length of the fast (which lasts from dawn to sunset) increases in the summer (to about 16-20 hours). People with diabetes who fast are at risk of adverse events, and the risks may increase with longer fasting periods. We review the evidence for optimum management of diabetic patients who wish to fast …

Aims:  To compare hypoglycaemic events, glycated haemoglobin (HbA1c) and changes in bodyweight in metformin‐treated Muslim patients with type 2 diabetes receiving adjunctive treatment with vildagliptin or gliclazide during Ramadan fasting.

To the Editor: Millions of Muslims across the world fast with complete dedication during the month of Ramadan: this is one of the five main pillars of the Muslim faith. During this month, Muslims fast from dawn to dusk. However, as fasting is not meant to create excessive hardship for an individual, the Koran exempts many people from fasting, including anyone who is ill [1]. Consequently, both religious and medical advice is that generally people with diabetes should not fast, as their metabolic condition could be adversely affected [1, 2]. Of the 14 million Muslims living in Europe [3], the number with diabetes is not known. The majority of Muslim patients with diabetes are passionate about the Ramadan fast but are unaware of the possible complications of fasting, which include hyperglycaemia, hypoglycaemia, and increased risk of dehydration and thrombosis [2, 4]. The Epidemiology of Diabetes and Ramadan (EPIDIAR) study showed that in 13 nonEuropean nations, 79% of Muslim patients with type 2 diabetes fasted for more than 15 days during Ramadan. The study also showed that there was a threeto fivefold increase in the incidence of severe hypoglycaemia during this fasting period [4]. Acknowledging this important group of people with diabetes, the American Diabetes Association (ADA) published a consensus statement in 2005 to address the issues surrounding the management of diabetes during Ramadan [5]. The ADA’s objectives were to invite an open dialogue on this topic, offer a set of medical opinions and suggestions, and identify research topics to answer important medical questions on fasting during Ramadan. The safety of fasting has never been studied in the population of European Muslims with type 2 diabetes, and there is no European Association for the Study of Diabetes (EASD) consensus available for the clinical management of these patients during Ramadan. We have recently developed a Ramadan-focused structured education and awareness programme in the UK. It was presented at the EASD conference in Rome in 2008 and was awarded the Diabetes Education Study Group prize [6]. Our aim was to meet the unfulfilled patient need for education and thus enable safer fasting for people with diabetes who choose to fast during Ramadan. We evaluated the impact of the programme on weight and hypoglycaemic episodes during Ramadan in a UK Muslim population with type 2 diabetes. There were three main findings for patients who attended the education programme (n=55): (1) they lost weight (mean 0.7 kg); (2) they were four times less likely to develop hypoglycaemic episodes; (3) they were significantly more empowered to self-manage their diabetes during the month of Ramadan. We would like to recommend that the EASD or local diabetes societies initiate a working group to develop guidelines and consensus for the management of diabetes in Muslim patients who wish to fast during the month of Diabetologia (2009) 52:367–368 DOI 10.1007/s00125-008-1220-8

Annals of the College of Surgeons of Hong KongVolume 5, Issue 3 p. A26-A26 AUDIT OF LICHTENSTEIN’S MESH REPAIR OF INGUINAL HERNIA P. Lam, P. Lam Department of Surgery, Caritas Medical Center, Hong Kong SARSearch for more papers by this authorM. Chan, M. Chan Department of Surgery, Caritas Medical Center, Hong Kong SARSearch for more papers by this authorE. Hui, E. Hui Department of Surgery, Caritas Medical Center, Hong Kong SARSearch for more papers by this authorY.W. Sun, Y.W. Sun Department of Surgery, Caritas Medical Center, Hong Kong SARSearch for more papers by this authorF. Mok, F. Mok Department of Surgery, Caritas Medical Center, Hong Kong SARSearch for more papers by this author P. Lam, P. Lam Department of Surgery, Caritas Medical Center, Hong Kong SARSearch for more papers by this authorM. Chan, M. Chan Department of Surgery, Caritas Medical Center, Hong Kong SARSearch for more papers by this authorE. Hui, E. Hui Department of Surgery, Caritas Medical Center, Hong Kong SARSearch for more papers by this authorY.W. Sun, Y.W. Sun Department of Surgery, Caritas Medical Center, Hong Kong SARSearch for more papers by this authorF. Mok, F. Mok Department of Surgery, Caritas Medical Center, Hong Kong SARSearch for more papers by this author First published: 18 July 2008 https://doi.org/10.1046/j.1442-2034.2001.00106d.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume5, Issue3September 2001Pages A26-A26 RelatedInformation

Annals of the College of Surgeons of Hong KongVolume 5, Issue 3 p. A25-A26 COLONOSCOPY SUCCESS RATE IMPROVED WITH SPECIALIZED SERVICE P. Lam, P. Lam Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this authorE. Hui, E. Hui Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this authorM. Chan, M. Chan Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this authorT.K. Ng, T.K. Ng Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this authorT.L. Kwan, T.L. Kwan Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this authorW.Y. Sun, W.Y. Sun Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this authorF. Mok, F. Mok Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this author P. Lam, P. Lam Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this authorE. Hui, E. Hui Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this authorM. Chan, M. Chan Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this authorT.K. Ng, T.K. Ng Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this authorT.L. Kwan, T.L. Kwan Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this authorW.Y. Sun, W.Y. Sun Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this authorF. Mok, F. Mok Department of Surgery, Caritas Medial Center, Hong Kong SARSearch for more papers by this author First published: 18 July 2008 https://doi.org/10.1046/j.1442-2034.2001.00106c.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume5, Issue3September 2001Pages A25-A26 RelatedInformation

Advances in micromachining technology in many defense and civilian programs make it feasible to design miniature sensors and instruments of the order of 102–103 and 103–104 g, respectively. By applying new signal detection principles, we have designed microspectrometers, microseismometers, microsamplers and other devices, which are now in varying phases of development and testing. Microspacecraft of the order of 10 kg, employing miniature sensors and instruments, are uniquely suited for three types of space science missions: missions that require multiple simultaneous measurements in different locations, missions that require very high launch energy and high risk missions where risk may be reduced by replacing a single large and expensive spacecraft with numerous independent small crafts. Applications examined include seismological and meteorological measurements on planetary surfaces and atmospheres and investigation of the mesoscale plasma structure around the Earth.

A complemental male was found on a solitary specimen of the primitive sessile barnacle Chionelasmus darwini. It was located on the scutal apex of the hermaphrodite and accommodated by a notch in the tergum. Its resemblance to complemental males of Bathylasma adds weight to the classification of the genus in the family Pachylasmidae rather than the Catophragmidae. Phylogenetic implications are discussed.

Elminius modestuscyprids settle readily in contact with adult barnacles in the field, and do not discriminate between conspecific and alien adults. This settlement strategy is contrasted with that previously shown to be employed byBalanus balanoides.

The tendency under field conditions for settlingBalanus balanoideslarvae to space out from conspecific adults but not from adults of other species is reaffirmed. Explanations are advanced for the opposite conclusions reached recently by other workers. The general avoidance byB. balanoideslarvae of settling on top of older barnacles is examined. It is suggested that there must be a strong inhibiting influence, so far unexplained.