1. Many GPs are wary of initiating insulin, for valid reasons. The very act of starting insulin can feel like an admission of failure to control the disease. But the reality is that our efforts to get A1c down to target must be seen in the context of a progressive disease, in which A1c has a natural tendency to climb each year. Eventually the time comes when insulin should no longer be put off. ... Mr. R.J. is a 38-year-old man who presents with a 5-month history of increasing pelvic pain. He describes an intense stabbing pain in the perineum that radiates to the testicles and the tip of the penis. The pain was initially sporadic (initially 3-4 times per week), but while it still waxes and wanes, it’s now becoming more persistent and even debilitating. The patient also reports some increasing urinary frequency and urgency. He recounts a history of good erectile function, but with pain during and after ejaculation. ...

Diagnostic challenge

J.G., a 44-year-old man with history of hypertension and asthma, is referred for assessment of ongoing slow heart rate. Two years ago, his slow heart rate of about 40 beats per minute (bpm) was noted on a pre-operative assessment. At the time, ECG showed junctional bradycardia. Then, he saw an internist and a cardiologist and had an echocardiogram that was reported to be normal with grade 1 LV function except for enlarged left atrium at 50 mm. ...