1/36. Painful swelling of the thigh in a diabetic patient: diabetic muscle infarction.A 44-year-old woman with a 5-year history of poorly controlled Type 1 diabetes mellitus presented with a painful, firm and warm swelling in her right thigh. pain was severe but the patient was not febrile, and had no history of trauma or abnormal exercise. Laboratory tests showed ketoacidosis, major inflammation (erythrocyte sedimentation rate (ESR) = 83 mm/h), normal white blood cell count and normal creatine kinase level. Plain radiographs were normal, and there were no signs of thrombophlebitis at Doppler ultrasound. magnetic resonance imaging (MRI) showed diffuse enlargement and an oedematous pattern of the adductors, vastus medialis, vastus intermedius and sartorius of the right thigh. The patient's symptoms improved dramatically, making biopsy unnecessary, and a diagnosis of diabetic muscular infarction was reached. Idiopathic muscular infarction is a rare and specific complication of diabetes mellitus, typically presenting as a severely painful mass in a lower limb, with high ESR. The diabetes involved is generally poorly controlled longstanding Type 1 diabetes with established microangiopathy. Differential diagnoses include deep vein thrombosis, acute exertional compartment syndrome, muscle rupture, soft tissue abscess, haematoma, sarcoma, inflammatory or calcifying myositis and pyomyositis. In fact, physician awareness should allow early diagnosis on the basis of clinical presentation, routine laboratory tests and MRI, thereby avoiding biopsy and its potential complications as well as unnecessary investigations. rest, symptomatic pain relief and adequate control of diabetes usually ensure progressive total recovery within a few weeks. Recurrences may occur in the same or contralateral limb.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/36. Important causes of hypoglycaemia in patients with diabetes on peritoneal dialysis.AIM: Diabetes is now the commonest cause of end-stage renal failure, so there are many diabetic patients receiving dialysis therapy. There are several important ways in which dialysis practice can impinge unfavourably on glucose control. This study focuses on the interaction between maltose-derived metabolites in a new peritoneal dialysis fluid and blood glucose measurements using reagent sticks that depend on the glucose dehydrogenase method. CASE REPORT: We report the cases of three patients, with insulin-treated diabetes and end-stage renal disease treated with peritoneal dialysis, who experienced symptomatic hypoglycaemia with inaccurate glucose readings on reagent strips when converted to icodextrin. CONCLUSION: Careful teamwork between diabetes and renal physicians and specialist nurses is highly desirable to achieve good glucose control in a group of patients at particular risk of microvascular and macrovascular complications.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/36. Postoperative management of the diabetic patient.Diabetic patients are at increased risk for adverse outcomes of surgery. These adverse outcomes are related to pre-existing complications of diabetes, especially atherosclerotic disease, nephropathy (and perhaps increased susceptibility to other renal toxins), and peripheral and autonomic neuropathy. hyperglycemia is associated with likely risks for poorer wound healing, increased susceptibility to infection, and probable loss of administered nutrients through glycosuria. Insulin use has the flexibility of timing and dose in the postoperative management of most diabetic patients. The combinations of intermediate-acting and long-acting insulins and short-acting insulins usually are related to the experience and preferences of the treating physicians and allied health professionals. Intravenous insulin (always R) may be limited to administration in the ICU because of the need for frequent blood glucose monitoring and rapidity of glucose response to intravenous insulin. The use of short-acting insulin analogues has been shown to work well as premeal insulin or for rapidly treating marked hyperglycemia in the outpatient setting. Meal delivery in the hospitalized patient may not be timed as precisely as in the home situation. nurses may be responsible for many patients. The rapid-acting analogues may be associated with increased risk for hypoglycemia in the hospitalized patient if insulin cannot be given immediately before a meal. These rapid-acting insulin analogues usually are limited to circumstances in which the patient can determine the dose and self-administer just before ingestion of the meal. The long-acting insulin analogues may not afford enough flexibility in many situations in which daily dosages changes are occurring in intermediate-acting and long-acting insulins. Oral glucose-lowering agent use in the postoperative state usually is limited to selected patients, including patients who have been on such agents before surgery, who have only mild elevations of blood glucose, who are able to ingest oral medications, and who do not have significant comorbid conditions (or significant risk for such conditions) that may be contraindications to use of such agents (see Table 3). Sulfonylureas and other insulin secretagogues (e.g., meglitinide, nateglinide) lower glucoses acutely. The risk for hypoglycemia is slightly less with the nonsulfonylurea agents. Efficacy and side effects limit the use of carbohydrase inhibitors for hospitalized patients. The glucose-lowering effects of biguanides and thiazolidinediones usually are not rapid enough for hospitalized patients who have never taken these medications. For patients who have been on a biguanide or thiazolidinedione before admission, these agents often are restarted in the postoperative period when oral intake of medications is possible and hepatic and renal function are stable. The hospital period affords an opportunity to review long-term management issues related to diabetes and its complications. Instruction on the importance of medical nutrition therapy, glycemic control, management of hypertension, dyslipidemia, and aspirin use as well as basic guidelines for foot care should be carried out during the hospitalization and at the time of discharge. Similarly, appropriate arrangements for medical nutrition therapy, general diabetes education (especially for newly diagnosed diabetic patients), and regular medical follow-up are important to ensure long-term, excellent surgical and medical outcomes.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/36. Religious/spiritual coping in childhood cystic fibrosis: a qualitative study.OBJECTIVE: To understand the role of religiousness/spirituality in coping in children with cystic fibrosis (CF). methods: Participants were a convenience sample of 23 patients with CF, ages 5 to 12 years, and their parent(s) in an ambulatory CF clinic. The design was a focused ethnography including in-depth interviews with children and parent(s), children's drawings, and self-administered written parental questionnaires. Analysis used grounded theory. RESULTS: Main outcome measures were participants' views on religion/spirituality in coping with illness. Data included 632 quotes organized into 257 codes categorized into 11 themes. One overarching domain emerged from analysis of the 11 themes: Religious/Spiritual Coping, composed of 11 religious/spiritual coping strategies. CONCLUSIONS: Children with CF reported a variety of religious/spiritual coping strategies they nearly always associated with adaptive health outcomes. A preliminary conceptual framework for religious/spiritual coping in children with CF is presented. More study is needed to assess how variability in age, disease type, disease severity, religious/spiritual preference, and religious/spiritual intensity affect religious/spiritual coping in children with chronic illness. Future studies should also investigate whether physician attention to religious/spiritual coping could assist patients in coping with CF and strengthen the doctor-patient relationship.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/36. Severe degree of hyperglycaemia: insights from integrative physiology.We illustrate how the application of principles of integrative physiology at the bedside can reveal novel insights that have been largely overlooked to this day. In this didactic exercise, modern-day physicians seek an imaginary medical consultation with Professor Sir Hans Krebs because of an unusual finding in his area of expertise: a very severe degree of hyperglycaemia. Although Professor Krebs is restricted to data prior to world war ii, this does not prevent him from making novel discoveries. First, he illustrates how an occult factor, rapid absorption of glucose from the intestinal tract, was a critical feature in explaining the basis of the severe degree of hyperglycaemia without obvious ketoacidosis in a 16-year-old patient with type 1 diabetes mellitus in poor control. Second, by examining simple principles of renal and gastrointestinal physiology in a quantitative fashion, Professor Krebs speculates as to how cerebral oedema might occur before therapy in a patient with a severe degree of hyperglycaemia. We hope that readers and educators will appreciate the value of applying principles of integrative physiology in a quantitative fashion at the bedside.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/36. Electrocardiographic manifestations of hypothermia.hypothermia is generally defined as a core body temperature less than 35 degrees C (95 degrees F). hypothermia is one of the most common environmental emergencies encountered by emergency physicians. Although the diagnosis will usually be evident after an initial check of vital signs, the diagnosis can sometimes be missed because of overreliance on normal or near-normal oral or tympanic thermometer readings. The classic and well-known electrocardiographic (ECG) manifestations of hypothermia include the presence of J (Osborn) waves, interval (PR, QRS, QT) prolongation, and atrial and ventricular dysrhythmias. There are also some less known (ECG) findings associated with hypothermia. For example, hypothermia can produce ECG signs that simulate those of acute myocardial ischemia or myocardial infarction. hypothermia can also blunt the expected ECG findings associated with hyperkalemia. A thorough knowledge of these findings is important for prompt diagnosis and treatment of hypothermia. Six cases are presented that show these important ECG manifestations of hypothermia.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/36. Using new insulin strategies in the outpatient treatment of diabetes: clinical applications.Understanding when to use insulin and how to apply the principles of physiologic insulin replacement using existing and new insulins is a key step to improving diabetes care. Insulin analogues and premixed insulins increase physicians' and patients' ability to lower hemoglobin A1C levels with fewer episodes of hypoglycemia. Earlier use of insulin and more aggressive dose escalation are important steps in achieving treatment goals. This article discusses using bedtime insulin with oral agents, basal-prandial insulin strategies, and the new insulin analogues.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/36. Hypothalamopituitary deficiency and precocious puberty following hyperhydration in diabetic ketoacidosis.We report on a 5-year-old child who survived an intracerebral crisis, following ketoacidosis-revealing diabetes (DKA), with visual impairment due to a vascular occipital lesion. Two and 4 months after the initial episode, a unique hypothalamopituitary disorder consisting in GH, ACTH, TSH deficiencies and central precocious puberty, was detected. Cranial magnetic resonance images showed no visible lesion in the hypothalamopituitary region. The most likely hypothesis is the ischemia of hypothalamopituitary and occipital regions following possible cerebral edema after hyperhydration. She survived with low visual acuteness and received a combined replacement therapy for the neuroendocrinological deficiencies. This case emphasizes that the rehydration at the initial period of DKA is critical, especially when risk factors for cerebral edema are present (young age, marked hyponatremia). The neuroendocrinological consequences of acute cerebral edema are rare, but physicians must be attentive in survivors of these accidents.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/36. The many-voiced cultural story line of a case of diabetes mellitus.An ethnographic approach is used to conduct and describe my research into a case of chronic illness and to assist the family physician's interventions. What at first appeared to be a frustrating, difficult-to-control case of diabetes mellitus was later revealed to be an intricate drama involving multiple voices and issues: marital, life stage, family, religious, occupational, regional, economic, and physician family-of-origin. Questions such as who has the disease?, what is the disease?, what keeps the disease going?, who is the patient?, and who is the clinician? are explored in the context of this case. The case was "solved" when the loss and sadness of aging was discovered and accepted during a cathartic session involving the diabetic patient, her husband, their family physician, and myself, a consultant.- - - - - - - - - - ranking = 3keywords = physician (Clic here for more details about this article) |
10/36. Does high blood glucose mean more insulin? Type 1 diabetes management in children and adolescents.BACKGROUND: The growth and development occurring in children and adolescents with type 1 diabetes contributes to many medical and nonmedical factors that may affect diabetic control. OBJECTIVE: This article discusses the assessment of high blood sugar levels in children and adolescents with type 1 diabetes. DISCUSSION: Traditionally, diet, exercise and insulin dose are seen as the determinants of blood glucose levels in type 1 diabetic patients. While these factors are important, other practical, medical and psychosocial factors need to be considered. Appropriate management requires more than just alteration of insulin dose. Insulin injection technique, adherence to insulin and management regimens in general, psychosocial issues, the role of intercurrent infections and the development of other medical problems need to be considered. Children and adolescents may only be seen by specialist physicians at three monthly intervals. Exploring these issues with patients during routine general practitioner consultations is likely to allow early identification of treatable problems and improve long term glucose control.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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