Three Cases of Non-islet Cell Tumor Hypoglycemia Highlighting Efficacy of Glucocorticoid Treatment.

Non-islet cell tumor hypoglycemia (NICTH) is a rarely encountered cause of hypoglycemia. It is most often caused by tumor secretion of precursor insulin-like growth factor-2 (IGF-2) which, in high concentrations, binds to insulin receptors exerting insulin-like metabolic effects. It is often associated with mesenchymal and hepatic tumors. We describe 3 cases of NICTH: a 60-year-old man with an unresectable pelvic sarcoma and two women ages 43 and 57 with metastatic hemangiopericytoma. Biochemical assessment identified hypoglycemia associated with suppressed insulin, c-peptide, and beta-hydroxybutyrate levels. Each patient was treated with oral glucocorticoids, which effectively prevented recurrence of hypoglycemia and this effect was sustained long-term. These cases highlight a rarely encountered but important cause of hypoglycemia and demonstrate the long-term efficacy of glucocorticoid treatment in preventing hypoglycemia in cases of NICTH related to surgically unresectable tumors.

Induction of lactation in a patient with complete androgen insensitivity syndrome.

Summary: With rising rates of adoption and surrogacy, induced lactation is likely to become increasingly relevant, allowing women who did not undergo pregnancy to breastfeed. We describe the case of a woman with complete androgen insensitivity syndrome (CAIS) on conventional oestrogen therapy who was expecting a child via surrogacy and who wished to breastfeed. The woman was commenced on supplementary oestrogen therapy, domperidone and breast stimulation by mechanical breast pump 8 weeks prior to the delivery of her child. Following delivery, the patient produced a small, unquantified amount of milk, allowing her to suckle the infant for a short period of time. Induced lactation is possible in chromosomally XY individuals. It has been most successful in cis-women and transwomen, both of whom have had progesterone/progestogen exposure to the breast. We suggest that the addition of a progestogen to our patient's treatment regimen, either as part of her original hormone therapy or part of the lactation induction program, would have improved her changes of establishing successful lactation. Learning points: Induced lactation is possible in chromosomally XY individuals with the use of pharmacological and non-pharmacological therapies. There are no standardised guidelines regarding the optimal regimen for induced lactation. Progesterone exposure to the breast is essential for ductal branching and alveolar maturation. In the published literature, induced lactation is more successful in transwomen and other XY individuals who have had prior progesterone exposure. The addition of progestogen to our patient's treatment regimen would have improved her chances of establishing successful lactation.

Routine bacterial culture of proximal bone specimens during minor amputation in patients with diabetes-related foot infections has little clinical utility in predicting re-operation or ulcer healing.

BACKGROUND: Trans-phalangeal and trans-metatarsal amputation, collectively termed 'minor amputations' are important procedures for managing infections of diabetes-related foot ulcers (DFU). Following minor amputation, international guidelines recommend a prolonged course of antibiotics if residual infected bone on intra-operative bone samples are identified, but the quality of the evidence underpinning these guidelines is low. In this study, we examined the concordance of microbiological results from proximal bone cultures compared to results from superficial wound swabs in relation to patient outcomes; with the aim of determining the utility of routinely obtaining marginal bone specimens. METHODS: Data was retrospectively collected on 144 individuals who underwent minor amputations for infected DFU at a large Australian tertiary hospital. Concordance was identified for patients with both superficial wound swabs and intra-operative bone samples available. Patient outcomes were monitored up to 6 months post-amputation. The primary outcome was complete healing at 6 months; and secondary outcome measures included further surgery and death. Mann Whitney U testing was performed for bivariate analyses of continuous variables, Chi-Squared testing used for categorical variables and a logistic regression was performed with healing as the dependent variable. RESULTS: A moderate-high degree of concordance was observed between microbiological samples, with 38/111 (35%) of patients having discordant wound swab and bone sample microbiology. Discordant results were not associated with adverse outcomes (67.2% with concordant results achieved complete healing compared with 68.6% patients with discordant results; P = 0.89). Revascularisation during admission (0.37 [0.13-0.96], P = 0.04) and amputation of the 5th ray (0.45 [0.21-0.94], P = 0.03) were independent risk factors for non-healing. CONCLUSION: There was a moderate-high degree of concordance between superficial wound swab results and intra-operative bone sample microbiology in this patient cohort. Discordance was not associated with adverse outcomes. These results suggest there is little clinical utility in routinely collecting proximal bone as an adjunct to routine wound swabs for culture during minor amputation for an infected DFU.

Xbox Kinect™ based rehabilitation as a feasible adjunct for minor upper limb burns rehabilitation: A pilot RCT.

INTRODUCTION: Rehabilitation following burns is integral to improving physical and psychological outcomes. Interactive video game consoles are emerging as therapeutic adjuncts due to their ease of use, affordability, and interactive gameplay. The Xbox Kinect™ has advantage over similar consoles, with controller free interaction utilising three dimensional motion capture software. Player movements during gameplay have been shown to be comparable to completing daily tasks and therefore the Xbox Kinect™ has potential for use as a rehabilitation tool. AIM: The objectives of this pilot study were to compare the efficacy of the Xbox Kinect™ with conventional physiotherapy as an adjunctive tool to promote activity and, to explore their efficacy in influencing functionality and pain. METHOD: A randomised controlled clinical trial design was used. Intervention group participants were asked to complete two daily 30min exercise sessions consisting of 15min of self-directed physiotherapy exercise followed by 15min of Xbox Kinect™ activities, based on location of burn. Control group participants were asked to complete two daily 30min exercise sessions of self-directed physiotherapy exercises involving two 15min sets of exercises, standardised for location of burn. Participants were recruited for a maximum of 7 days. Outcomes assessed included daily activity time, treatment satisfaction, upper limb disability, pain, and self-reported fear of movement (kinesiophobia). RESULTS: A sample of 30 burn patients admitted to Royal Perth Hospital was randomised into intervention and control groups. The intervention group demonstrated significantly greater total activity time compared to control group (median 49.4 and 26.7min respectively, p<0.0001), irrespective of total burns surface area (TBSA). Significantly greater satisfaction scores were also demonstrated in the intervention group compared to controls (median 8.53 vs 7.8 respectively, p<0.0001). There was no evidence to support differences between group measures for upper limb disability, pain and fear avoidance of movement. CONCLUSION: The Xbox Kinect™ is a useful tool in increasing rehabilitation exercise time and patient satisfaction compared to conventional physiotherapy without indication of concurrent negative effects on patient recovery.