Paget's disease in an Omani: long-term improvement following a single injection of zoledronic acid

Paget's disease of bone is a patchy skeletal disorder characterized by an increase in bone resorption and formation in the affected areas. It affects up to 3% of individuals of Anglo-Saxon origin over the age of 40 years but is rare in Arabs. Although most patients are asymptomatic, a variety of symptoms and complications may develop directly from bone involvement or secondarily to compression by bone expansion and increased blood flow. The disease can be treated by using medications that inhibit bone resorption, such as calcitonin and the bisphosphonates. Here we describe the case of an Omani patient with the disease, involving the skull, spine, pelvis, and tibia. He presented to the endocrine clinic in Sultan Qaboos University Hospital with a six-year history of headache, bone pain, progressive skull enlargement, and left-sided deafness. His alkaline phosphatase [ALP] level was 1500 U/L. His disease responded gradually to six months of subcutaneous and nasal calcitonin followed by a single 5 mg intravenous injection of zoledronic acid. This resulted in a further progressive reduction of his bone pain, skull size, and improvement in his hearing, as well as normalization of his serum ALP levels after one-year. This effect has been sustained for 3 years

Adrenocorticotropic hormone-dependent Cushing's syndrome use of an octreotide trial to distinguish between pituitary or ectopic sources

Adrenocorticotropic hormone [ACTH] overproduction is usually due to a pituitary tumour which is often not visible on magnetic resonance imaging [MRI]. However, ACTH overproduction may be due to an ectopic source. This study aimed to develop a simple non-invasive technique to differentiate these sources. This study took place in King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia, and Sultan Qaboos University Hospital, Muscat, Oman, between 1988 and 2012. Serum cortisol levels were measured in nine patients with ACTH-dependent Cushing's syndrome before and during a 72-hour trial of octreotide. All patients underwent computed tomography [CT] scans. MRI scans were performed on six patients. CT scans were abnormal in three patients with ectopic ACTH production. MRI scans showed that three patients had pituitary microadenomas. Serum cortisol levels returned to normal in those with confirmed ectopic ACTH production. No response was found in the other six patients. A 72-hour trial of octreotide is recommended for patients with ACTH-dependent Cushing's syndrome and a normal pituitary MRI. This trial will be a useful alternative to petrosal sinus sampling

Successful management of phaeochromocytoma using preoperative oral labetalol and intraoperative magnesium sulphate report of four cases

Phaeochromocytoma is a rare neuroendocrine catecholamine-secreting tumour. This type of tumour poses multidimensional anaesthetic challenges as it has an unpredictable clinical course during surgical resection. The alpha-blocking agent phenoxybenzamine remained the mainstay in preoperative preparation before the introduction of beta-blocking agents. We report four cases operated between 2009-2012 at Sultan Qaboos University Hospital, Muscat, Oman. The cases were prepared with oral labetalol, as the alpha-blocking drug phenoxybenzamine was not immediately available. Responses to simulated stress were tested in the theatre before surgery. Anaesthesia was induced under invasive arterial pressure monitoring and magnesium sulphate infusion. Rare intraoperative surges in blood pressure during tumour manipulation were treated with sodium nitroprusside infusions and phentolamine boluses. All of the patients had an uneventful postoperative recovery. Preoperative treatment with labetalol has rarely been reported and can be considered as a potential therapeutic option with optimal patient monitoring if phenoxybenzamine is unavailable

Fluctuation in the levels of immunoglobulin m and immunoglobulin g antibodies for cardiolipin and beta[2]-glycoprotein among healthy pregnant women

Antiphospholipid antibodies fluctuate during a healthy normal pregnancy. This study aimed to investigate the levels of both immunoglobulin M [IgM] and Immunoglobulin G [IgG] antibodies for cardiolipin and [beta[2]-glycoprotein [beta[2]GP] among healthy pregnant women. This study was conducted between May 2010 and December 2012. A total of 75 healthy Omani pregnant women with no history of autoimmune disease were investigated during their pregnancy and 90 days after delivery at the Armed Forces Hospital in Muscat, Oman. A control group of 75 healthy Omani non-pregnant women were also investigated as a comparison. Levels of IgM and IgG antibodies for both anti-cardiolipin antibodies [ACAs] and [beta[2]GP were measured using a standard enzyme-linked immunosorbent assay. The ACA IgM levels were significantly higher in the control group compared to the pregnant women [P <0.001]. No significant differences were observed in the ACA IgM levels between the control group and the pregnant women after delivery. In contrast, ACA IgG levels were significantly higher during pregnancy and after delivery compared with those of the healthy control group [P = 0.007 and 0.002, respectively]. The levels of beta[2]GP IgG were significantly higher during pregnancy than after delivery and in the control group [P = 0.001 and <0.001, respectively]. In this study, ACA IgG levels increased during healthy pregnancies and after normal deliveries whereas beta[2]GP IgG levels increased transiently during the pregnancies. Both phenomena were found to be significantly associated with a transient decline in the levels of IgM specific for these antigens. Therefore, the levels of these antibodies may be regulated during a healthy pregnancy

Insulin resistance and its correlation with risk factors for developing diabetes mellitus in 100 Omani medical students

The aim of this study was to assess the prevalence of insulin resistance [IR] in healthy young Omanis and relate this with their body mass index [BMI] and family history [FH] of diabetes mellitus [DM]. This study was conducted between May 2009 and February 2010 at Sultan Qaboos University, Muscat, Oman. A detailed questionnaire was completed by 50 male and 50 female medical students between 20-25 years old. Fasting blood samples were obtained for serum glucose and insulin measurements. IR was calculated using the homeostasis model assessment-estimated insulin resistance [HOMA-IR] formula [fasting insulin x fasting glucose/22.5] and a value above 2.5 was considered elevated. The results were analysed using the Statistical Package for the Social Sciences [SPSS]. Participants were classified into the following BMI categories: 59% were normal [18.5-24.9 kg/m[2]], 26% were overweight or obese [>24.9 kg/m[2]] and 15% were underweight [<18.5 kg/m[2]]. A FH of DM was present in 74%. The HOMA-IR index was elevated in 16% and was directly correlated to the BMI [P = 0.003]. There was no correlation between IR and a positive FH of DM. There is a high prevalence of IR [16%] and obesity [26%] in healthy young Omani medical students. Counselling is recommended for all overweight and obese individuals in an attempt to prevent or delay the onset of DM in the future

Familial clustering of type 2 diabetes among Omanis

The aim of this study was to screen Omani individuals for the familial aggregation of type 2 diabetes mellitus. A random cohort of 1182 Omani individuals visiting the Family Medicine Clinic at Sultan Qaboos University Hospital [SQUH], Muscat, Oman, for regular medical checkup, aged >/= 40 years, were sampled. Patients were categorized into three groups: [1] individuals who claim not to have diabetes and had no family history of diabetes; [2] individuals who claim not to have diabetes but had family history of diabetes; [3] individuals with diabetes. Only 16% of these Omani individuals had no diabetes and no family history of diabetes. Another separate random cohort of 234 Omani type 2 diabetes mellitus patients, from the Diabetes Clinic at SQUH, were interviewed and questioned about their family history of type 2 diabetes mellitus. Ninety five percent of the patients had a family history of diabetes. Eighty percent had first degree relatives with diabetes and 46% had second degree relatives with diabetes. At least one parent with diabetes was reported among 55% of these diabetics, while maternal diabetes [55%] was found to be higher than paternal diabetes [47%]. However, only 15% had both parents with diabetes. Furthermore, almost half of the 234 diabetics were having at least one of the following relatives with diabetes: brother, sister, aunt or an uncle. The findings of this study confirm familial aggregation of diabetes among the Omani population. Compared to other populations, familial aggregation of type 2 diabetes mellitus among Omanis is relatively very high, and is perhaps due to the very high degree of consanguinity among Omanis. Since almost everyone seems to have a genetic predisposition to diabetes, the dramatic lifestyle changes over the past 25 years, could tip the population into an epidemic of type 2 diabetes mellitus

Vitamin D status in pregnant Omanis. A disturbingly high proportion of patients with low vitamin D stores

The objective of this study was to determine the vitamin D status of pregnant Omanis by measurement of their circulating 25 hydroxy vitamin D levels. Blood samples were obtained from a cohort of 103 consecutive healthy pregnant Omanis at the Armed Forces Hospital, Muscat, on their first antenatal visit. The study took place in May, June and July 2010. Vitamin D deficiency was present in 34 [33%] of patients [25OHD3 <25 nmol/L], 'at risk' levels were found in 67 [65%] patients [25OHD3 25-50 nmol/L]; two patients [1.9%] had values between 50 and 75 nmol/L, and no patients in the optimal range >75 nmol/L. If confirmed, these findings indicate the need for vitamin D replacement during pregnancy and lactation. Although not evidence based we recommend at least 1000 IU of cholecalciferol, [vitamin D3] daily

VIPoma Crisis: Immediate and life saving reduction of massive stool volumes on starting treatment with octreotide

We report the case of a 57-year-old male physician who presented with a life threatening secretory and refractory diarrhoea of around 20 L/day. This was complicated by severe hypotension, hypokalaemia, hypercalcaemia, renal failure requiring dialysis, metabolic acidosis, cardiorespiratory arrest and ventilation for 12 days. His diarrhoea responded immediately to the first dose of a therapeutic trial of subcutaneous octreotide 100 mcg 8 hourly which was started on clinical grounds alone before any investigations were carried out. After one day he was extubated and his blood pressure returned to normal. When a functioning neuroendocrine tumour is suspected clinically, the use of octreotide can, as in this case, be life saving

Quality of diabetes care: a cross-sectional observational study in Oman

The objective of this study was to evaluate the quality of diabetes care in Oman. This was a cross-sectional observational study. Fifty percent of all those attending six general health centers in June 2005 were systematically selected for the study. Descriptive statistics were used to describe the data. A total of 430 diabetic subjects were included. Just over 61% percent of the subjects were female [n = 263]. The overall mean age of the cohort was 52 +/- 12 years ranging from 6 to 84 years. Only 40% [n = 171] and 39% [n = 169] of the diabetics had their random blood sugar [RBS] and fasting blood sugar [FBS] documented, respectively. However, 79% [n = 339] had either RBS or FBS done according to the records. Documentation for the other measurements ranged from 74% [n = 317] for HbA1c and low density lipoproteins-cholesterol [LDL] to 95% [n = 409] for systolic and diastolic blood pressure [SBP/DBP] readings. A total of 58% [n = 249] of patients had non-missing values of HbA1c, SBP/DBP, total cholesterol, LDL-cholesterol, high density lipoproteins-cholesterol [HDL], and triglycerides. Only 2.4% [6 out of 249 diabetics] were simultaneously within goal for HbA1c [<7%], SBP/DBP [<=130/80 mmHg], total cholesterol [<5.2 mmol/L], LDL-cholesterol [<3.3 mmol/L], HDL-cholesterol [>1.1 - <1.68 mmol/L], and triglycerides [<1.8 mmol/L]. There was good documentation of values for the indicators used in the assessment of quality. However, the proportion [2.4%] of those meeting internationally recognised goals for the three diabetes-related factors was extremely low

Insulinoma: a rare cause of a common metabolic disorder - hypoglycaemia

We describe the first patient diagnosed with an insulinoma in Oman and successfully managed with a distal laparoscopic pancreatectomy. The importance of obtaining a good history from the patient and/or his family is stressed. All patients with loss of consciousness must have a Reflow check carried out and, if hypoglycaemic, this should be documented in the laboratory and a simultaneous serum sample stored for measurement of insulin, C-peptide proinsulin and sulphonylurea levels, if subsequently indicated. If magnetic resonance imaging fails to locate the tumour, endoscopic ultrasound of the pancreas, or indium 111 labelled octreotide scanning is indicated if the patient's hypoglycaemia has previously responded to treatment with octreotide

Graves' disease following interferon therapy for chronic hepatitis C infection

We describe the first case of Graves' disease occurring at Sultan Qaboos University Hospital, Oman, in a patient who was under treatment with interferon alfa for HCV infection. INF-? is now being widely used to treat patients with a variety of disorders including infection with hepatitis C virus. Clinical thyroid disease, hypo and hyperthyroidism can occur in up to 15% of patients. We emphasize the need for thyroid function screening before and during therapy to identify patients early in the course of their disease