Case Study: using a continuous glucose monitoring system in a patient with diabetes and beta-thalassemia hemoglobinopathy.

Optimum glycemic control is extremely important in patients with diabetes mellitus to avoid long-term complications. Glycemic control relies mainly on the use of hemoglobin A1c, which unfortunately showed inaccurate results in patients with hemoglinopathies. The authors describe a case of beta-thalassemia with poorly controlled diabetes mellitus that has misleading low levels of HbA1c. The use of a continuous glucose monitoring system was useful in documenting her poor glycemic control, with prolonged periods of hyper- and hypoglycemia. Based on these results, her insulin regimen was adjusted and the blood glucose levels were greatly improved throughout and the patient was able to meet her target blood glucose range (72-140 mg/dL [4-7.8 mmol/L]) in 70% of the time.

An application of educational theories and principles of teaching and learning communication skills for general practitioners in oman.

This article discusses the crucial role of teaching and learning communication skills for general practitioners, based on the theory of experiential and self-directed learning. It also outlines the proposed ways and methods to teach these communication skills in this project.The patient-doctor interview or what is known as office visit in some countries and consultation in others is the cornerstone of the entire General Practice (GP) or Family Medicine. It is from this process and outcome that the reputation is gained or destroyed. The analysis of the consultation is complicated and varied but is most usefully employed to assess effecacy in terms of achieving the means that are mutually desired by patients and their carers.

Control and management of hypertension at a university health centre in oman.

OBJECTIVES: To evaluate the prevalence of hypertension, its control and management at Sultan Qaboos University (SQU) Health Centre, Oman. METHODS: This was a retrospective cross-sectional study, in which were enrolled all the subjects (≥18 years), with the diagnosis of essential hypertension, who attended the SQU Health Centre between 1998 and 2002. The systolic and diastolic blood pressure (BP) values of the last three visits were used for analysis. BP control was defined using the Joint National Committee (JNC-7) criteria, <140 mmHg and <90 mmHg for systolic and diastolic BPs, respectively. Analyses were performed using univariate statistics. RESULTS: Among the 7,702 medical records reviewed, the prevalence of hypertension was 2.4% (n = 187). The overall mean age of the cohort was 55±11 years, 54% (n = 101) were females, and majority of the subjects were Omanis (n = 123; 66%). The proportion of subjects who had their BP controlled was 41% (n = 77) with Omanis significantly less likely to have their BP controlled compared to non-Omanis (53% versus 35%; p = 0.017). The majority of the subjects were on mono (n = 131; 70%) followed by dual (n = 50; 27%) anti-hypertensive therapies. The most frequent mono anti-hypertensive therapies were B-blockers (n = 64; 34%) and angiotensin-converting enzyme (ACE) inhibitors (n = 47; 25%). Among the dual combination therapies, the most common prescribed regimens were ACE inhibitor plus B-blocker (n = 14; 28%) and B-blocker plus diuretic (n = 12; 24%). CONCLUSION: The prevalence of hypertension in this patient population was low compared to the national average. This study shows that control of hypertension is not optimal, but higher than those reported elsewhere.

Intravenous Lidocaine for Refractory Chronic Orofacial Pain: Two case reports and a literature review.

This report presents the results of treatment of two adults, at the Pain Center of Montreal General Hospital, Canada, with intravenous lidocaine for intractable orofacial pain. Repeated lidocaine infusions (1mg/kg in a bolus, followed by 4mg/kg infused over 1 hour) resulted in satisfactory pain relief in both patients, and the drug was well tolerated. Intravenous lidocaine therapy may be considered for intractable orofacial pain; further research is warranted.

Chronic adreno-cortical insufficency associated with a unilateral adrenal mass.

Adreno-cortical insufficiency in the context of an adrenal mass can be a challenging clinical problem. The two main possibilities are either a benign mass or a malignant pathology. We describe here a patient who was investigated for chronic adreno-cortical insufficiency and was found to have a left adrenal mass that was later confirmed histopathologically to be tuberculous in nature.

Subcutaneous administration of testosterone. A pilot study report.

OBJECTIVE: To investigate the effect of low doses of subcutaneous testosterone in hypogonadal men since the intramuscular route, which is the most widely used form of testosterone replacement therapy, is inconvenient to many patients. METHODS: All men with primary and secondary hypogonadism attending the reproductive endocrine clinic at Royal Victoria Hospital, Monteral, Quebec, Canada, were invited to participate in the study. Subjects were enrolled from January 2002 till December 2002. Patients were asked to self-administer weekly low doses of testosterone enanthate using 0.5 ml insulin syringe. RESULTS: A total of 22 patients were enrolled in the study. The mean trough was 14.48 +/- 3.14 nmol/L and peak total testosterone was 21.65 +/- 7.32 nmol/L. For the free testosterone the average trough was 59.94 +/- 20.60 pmol/L and the peak was 85.17 +/- 32.88 pmol/L. All of the patients delivered testosterone with ease and no local reactions were reported. CONCLUSION: Therapy with weekly subcutaneous testosterone produced serum levels that were within the normal range in 100% of patients for both peak and trough levels. This is the first report, which demonstrated the efficacy of delivering weekly testosterone using this cheap, safe, and less painful subcutaneous route.

Prevalence and predictors of microalbuminuria in patients with type 2 diabetes mellitus: a cross-sectional observational study in Oman.

AIM: To evaluate the prevalence and predictors of microalbuminuria in type 2 diabetics in Oman. METHODS: All patients attending an outpatient diabetic clinic at the Sultan Qaboos University Hospital between 2002 and 2003 were enrolled in the study. RESULTS: A total of 261 patients were included in this study. The mean overall age of the cohort was 50+/-13 years, and 57% were male. The proportion of subjects who had microalbuminuria was 27% (n=70; N=261). The logistic regression model indicated that significant predictors for the development of microalbuminuria include HbA(1c), log creatinine, and the presence of hypertension. A one unit increase in HbA(1c) was associated with a 23% increase in the odds of developing microalbuminuria (OR 1.23; 95% CI: 1.10-1.37; p<0.001). Additionally, patients that had a one unit increase in log creatinine were 5.72 times more likely to develop microalbuminuria (OR 5.72; 95% CI: 1.86-17.59; p=0.002). Furthermore, patients who were hypertensive were 2.37 times more likely to have microalbuminuria (OR 2.37; 95% CI: 1.11-5.09; p=0.026). CONCLUSIONS: The prevalence of microalbuminuria in patients with type 2 diabetes in this study was 27%. Significant predictors of microalbuminuria included HbA(1c), creatinine, and the presence of hypertension.

Universal precautions in pain medicine: a rational approach to the treatment of chronic pain.

The heightened interest in pain management is making the need for appropriate boundary setting within the clinician-patient relationship even more apparent. Unfortunately, it is impossible to determine before hand, with any degree of certainty, who will become problematic users of prescription medications. With this in mind, a parallel is drawn between the chronic pain management paradigm and our past experience with problems identifying the "at-risk" individuals from an infectious disease model. By recognizing the need to carefully assess all patients, in a biopsychosocial model, including past and present aberrant behaviors when they exist, and by applying careful and reasonably set limits in the clinician-patient relationship, it is possible to triage chronic pain patients into three categories according to risk. This article describes a "universal precautions" approach to the assessment and ongoing management of the chronic pain patient and offers a triage scheme for estimating risk that includes recommendations for management and referral. By taking a thorough and respectful approach to patient assessment and management within chronic pain treatment, stigma can be reduced, patient care improved, and overall risk contained.

Clinical profile of rheumatic disease patients referred to a multidisciplinary pain center.

OBJECTIVE: Good pain control is a prerequisite for success in the management of many rheumatological diseases. However, some rheumatology patients may present challenges in terms of pain management and be subsequently referred to a specialized pain clinic. We examined the characteristics and assessed the outcome of patients with rheumatic diseases who were referred to a tertiary care pain center. METHODS: All new patients with a primary rheumatological diagnosis referred over a 9 year period to the McGill University Pain Centre were studied. Patients were identified through a computer search according to both diagnoses and symptoms. Demographic information, clinical and pain characteristics, and subsequent management and final outcome were assessed. RESULTS: Out of a total of 1120 new patients, 60 (5%) had a primary rheumatologic diagnosis to account for pain and referral. The diagnoses were as follows: fibromyalgia in 26 (43%), inflammatory arthritis 17 (28%), degenerative arthritis 9 (15%), and soft tissue rheumatism 8 (13%). The median age at presentation was 52 years and 47 (78%) were female. The median duration of pain was 5 years. The mean pain scores according to the McGill Pain Questionnaire and the visual analog scale were 27 +/- 15 and 7 +/- 2, respectively. Patients were followed a mean duration of 10.6 +/- 15 months. Seventy-two percent were assessed by a psychologist and 52% by a physiotherapist or occupational therapist. New pharmacologic treatments were prescribed for 47 (78%) patients, with 47% receiving opioids, 37% antidepressants, 12% nonsteroidal antiinflammatory drugs, 8% tranquillizers, and 18% other medications. Final outcome was described as follows: improved in 55%, no change in 43%, and worsened in 2%. CONCLUSION: Although patients with a primary rheumatologic process to account for pain constituted a small proportion of patients evaluated, improvement was considerable in over half. Further study should address the selection of patients that are most likely to benefit from referral to multidisciplinary pain centers and the longterm outcome of such interventions.

Methadone in the treatment of neuropathic pain.

BACKGROUND: Methadone, being an N-Methyl-D-Aspartate receptor antagonist, may have a potential role in the treatment of neuropathic pain. OBJECTIVES: To evaluate the effect of methadone in the treatment of neuropathic pain and to estimate the possible dose ranges needed for pain control. METHODS: Methadone was offered as a treatment option to consecutive cancer and noncancer patients with neuropathic pain. Pain intensity was measured by the visual analogue scale (VAS) (0-10 cm where 0 = no pain and 10 = worst possible pain). Mechanical allodynia and paroxysmal (shooting) pain were assessed clinically. All assessments were collected prospectively before treatment and once a stable dose of methadone was reached. RESULTS: A total number of 18 patients met our inclusion criteria. The mean pretreatment VAS +/- SD was 7.7+/-1.5 cm and this dropped significantly to 1.4+/-1.7 cm on a stable dose of methadone (P<0.0001). Nine of 13 patients (70 %) had a complete resolution of mechanical allodynia and all eight patients (100%) with shooting pain reported a complete response. The median stable dose of methadone was 15 mg per day. CONCLUSION: Methadone at relatively low doses seems to be useful in the treatment of neuropathic pain.