Summary Aims: Increases in the prevalence of type 2 diabetes will likely be greater in the Middle East and other developing countries than in most other regions during the coming two decades, placing a heavy burden on regional healthcare resources. Methodology: Medline search, examination of data from major epidemiological studies in the Middle Eastern countries. Results: The aetiology and pathophysiology of diabetes appears comparable in Middle Eastern and other populations. Lifestyle intervention is key to the management of diabetes in all type 2 diabetes patients, who should be encouraged strongly to diet and exercise. The options for pharmacologic therapy in the management of diabetes have increased recently, particularly the number of potential antidiabetic combinations. Metformin appears to be used less frequently to initiate antidiabetic therapy in the Middle East than in other countries. Available clinical evidence, supported by current guidelines, strongly favours the initiation of antidiabetic therapy with metformin in Middle Eastern type 2 diabetes patients, where no contraindications exist. This is due to its equivalent or greater efficacy relative to other oral antidiabetic treatments, its proven tolerability and safety profiles, its weight neutrality, the lack of clinically significant hypoglycaemia, the demonstration of cardiovascular protection for metformin relative to diet in the UK Prospective Diabetes Study and in observational studies, and its low cost. Additional treatments should be added to metformin and lifestyle intervention as diabetes progresses, until patients are receiving an intensive insulin regimen with or without additional oral agents. Conclusions: The current evidence base strongly favours the initiation of antidiabetic therapy with metformin, where no contraindications exist. However, metformin may be under-prescribed in the Middle East.

The degradations of gaseous toluene (2-20 ppmv) by solar irradiation (solar), solar irradiation and ozone (solar + O3), solar photocatalytic reaction (solar + TiO2) and solar photocatalytic reaction in the presence of ozone (solar + O3 + TiO2) were studied in a pilot plant. The effects of the inlet concentration of toluene, flow rate and relative humidity on the decomposition of toluene were followed. The experimental results showed that the solar process alone did not eliminate a significant amount of toluene. However, the combination of solar irradiation with either O3 or TiO2 improved the decomposition rate of toluene. A significant toluene conversion, at a high toluene inlet concentration, was achieved by the solar + O3 + TiO2 process. Toluene decomposition was found to be affected by the inlet flow rate; a high flow rate resulted in low conversion. The solar + O3 process was found to be more affected by gas relative humidity; the optimal humidity was found to be around 50%. The products from the photo-degradation of toluene were found to be water-soluble organics. The water-soluble organics were found to have high biodegradability. Thus, a post treatment consisting of a washing technique followed by biological treatment can be proposed.

OBJECTIVE: To estimate the prevalence and severity of erectile dysfunction (ED) and its correlations among Jordanian men with diabetes. METHODS: We conducted this study at the National Center for Diabetes, Endocrinology and Genetics, Amman, Jordan, between January and August 2004. The study included 988 married diabetic men. Patients were interviewed by one of our medical staff based on a health care questionnaire and an Arabic translation of the 15-item International Index of Erectile Function. Scores of the questions in each of the 5 sexual function domains were summed up. Dysfunction was categorized as absent, mild, moderate or severe. RESULTS: The overall prevalence of ED was 62%; and we found that 30.3% had severe ED. The prevalence increased with age from 26.5%(13 out of 49) of patients <40 years of age to 91%(87 out of 96) in the age group >/= 70 years. Severity of ED increased with age as well. Multivariate logistic regression analysis identified age, glycemic control, hypertension, coronary artery disease, retinopathy and neuropathy as independent risk factors of ED. Among patients with ED, 7% reported having treatment for ED. CONCLUSION: Prevalence of ED among Jordanian diabetic patients is high. It increases with age and poor glycemic control. Other independent risk factors include: hypertension, coronary artery disease, retinopathy and neuropathy.

OBJECTIVE: To report several cases of hyperthyroidism in patients presenting with the unusual symptom of sleepwalking and to discuss the possible pathophysiologic basis for this novel association. METHODS: After encountering and reporting the first case of new-onset somnambulism in a patient presenting with thyrotoxicosis at our institution, we routinely inquired about the sleep history of patients with thyrotoxicosis, questioning both the patients and family members when applicable. Those patients who actually had sleepwalking episodes coinciding with the onset of thyrotoxicosis underwent close follow-up, and the relationship between the sleepwalking and the results of thyroid function tests was analyzed. In addition, we reviewed the literature on psychiatric disorders and sleep problems, and the pathophysiologic rationale for a cause-and-effect relationship is discussed. RESULTS: We collected 8 cases of patients with new-onset sleepwalking episodes that coincided with the start of thyrotoxicosis. The disappearance of the sleepwalking with successful achievement of euthyroidism supports a cause-and-effect relationship. This hypothesis is further supported by the absence of a family history, the adult onset, and the relapse of sleepwalking in 2 of the patients when their thyrotoxicosis became poorly controlled as a result of noncompliance with medications and its subsequent disappearance with reachievement of euthyroidism. Of note, such a presentation was seen only in patients with thyrotoxicosis caused by diffuse toxic goiter or Graves' disease and never in patients with other causes of thyrotoxicosis. CONCLUSION: New-onset sleepwalking could be caused by thyrotoxicosis or, more specifically, by thyrotoxicosis resulting from diffuse toxic goiter. The mechanism is hypothesized to be related to the combination of prolongation of non-rapid eye movement sleep and the associated fatigue. Specific inquiry about this unusual presentation of thyrotoxicosis is encouraged, and more studies are needed to confirm and evaluate its extent.

BACKGROUND: Proper management of patients with Kallmann syndrome (KS) allows them to attain a normal reproductive health. The purpose of this study is to demonstrate the presentation modalities, phenotypes and the modes of inheritance among 32 patients with Kallmann syndrome in Jordan. Recognition of the syndrome allows for prompt proper management and provision of genetic counselling. SUBJECTS: Over a period of five years (1999-2004), the clinical and inheritance profiles of 26 male and 6 female patients with Kallmann syndrome from 12 families were evaluated at the National Center for Diabetes, Endocrinology and Genetics in Jordan. RESULTS: The patients belonged to twelve Jordanian and Palestinian families and their age at presentation ranged from 4 - 46 years. Nine boys aged 4-14 years presented with cryptorchidism and microphallus, all other males presented with delayed puberty, hypogonadism and/or infertility. The main presentation among six female patients was primary amenorrhea. Intrafamilial variability in clinical phenotype was specifically evident for renal abnormalities and sensorineural hearing impairment. Familial KS was diagnosed in 27 patients belonging to five families with the X-linked mode of inheritance and two families with the autosomal recessive mode of inheritance. CONCLUSIONS:(1) the majority of cases in this study represented the X-linked form of KS, which might point to a high prevalence of Kal 1 gene in the population.(2) Genetic counselling helps these families to reach a diagnosis at an early age and to decide about their reproductive options.(3) Children presenting with cryptorchidism and microphallus in our population should be investigated for KS.

OBJECTIVE: To determine the precise radiologic findings in Wolfram syndrome (WFS) patients using objective techniques in order to better define the reference population for the clinical evaluation. METHODS: Sixteen patients (6 males and 10 females) with WFS found in 4 families were included in this study. Fourteen patients with WFS-2 came from 3 families while 2 patients with WFS-1 from one family. All patients were studied at Jordan University Hospital, Amman, Jordan, from January 2001 through to January 2003 by definite radiologic techniques as part of a thorough clinical comprehensive assessment. These include intravenous urography, abdominal and pelvic ultrasonography, barium meal, upper gastrointestinal endoscopy and magnetic resonance imaging with and without contrast to the brain and the pituitary glands. RESULTS: Five of the female patients had a small uterus. Spina bifida was found in 7, hydronephrosis in 9 and hydroureter in 5 patients. Peptic ulcer was detected in 10 out of 14 available patients and helicobacter pylori in 7 out of 16 patients. Atrophy was detected in all brains, 9 brain stems, 12 cerebellums and 14 optic tracts of all patients. The size of the pituitary glands was variable CONCLUSION: The particular radiologic assessment of patients with WFS proofed that, urinary tract dilatation was detected in WFS-1 and WFS-2 patients though all WFS-2 patients have no diabetes insipidus. Peptic ulcer was frequently higher in WFS-2 patients. No significant radiologic difference was found between patients with WFS-1 and WFS-2.

A 22-year-old patient presented with abdominal pain and massive ovarian enlargement secondary to severe long standing hypothyroidism, mimicking an ovarian cancer. Treatment with L-thyroxin caused marked regression of the tumor.

OBJECTIVE: To detect feet changes and to identify risk factors leading to amputation among type 2 diabetics. METHODS: A total of 1142 patients with type 2 diabetes mellitus; 595 males (52%), and 547 females (48%) were seen between January and December 2001 at the National Center for Diabetes, Endocrinology, and Genetics (NCDG) Amman, Jordan. The mean age was 56.1 years (SD=10.2) and the mean duration of diabetes was 9 years (SD=7.1). All patients had a complete medical assessment including history, physical examination, glycosylated hemoglobin (HbA1c)(the mean of the last 4 readings) and microalbuminuria. Statistical analysis were performed to identify significant risk factors leading to amputation using Epi info, version 6 software. RESULTS: Mean HbA1c was 7.4%(SD=1.4). The prevalence of hypertension was 52%, retinopathy 45% and microalbuminuria 33%. Impaired vibration, position and protective sense were found in 19%, 13%, and 18%. The prevalence of all amputations was 5%. The following were strong predictors of amputation; duration of diabetes (P= 0.04), smoking (P=0.01), microalbuminuria (P=0.02), retinopathy (P=0.008), legs hair loss (P=0.003), neurological deficit (P=0.0001), ulceration (P=0.00001) absent dorsalis pedis (P=0.0006) and insulin therapy (P=0.0001). The rate of amputation was directly proportional to high HbA1c >= 8%(P=0.01). Age and gender were not found to have an impact on prevalence of amputation. CONCLUSION: Prevalence of amputation correlates with duration of diabetes, poor glycemic control, smoking, neurological impairment, peripheral vascular disease and microalbuminuria.