Hypoglycemia mediated by paraneoplastic production of Insulin like growth factor–2 from a malignant renal solitary fibrous tumor – clinical case and literature review

BACKGROUND: Hypoglycemic episodes are infrequent in individuals without a history of diabetes mellitus or bariatric surgery. When hypoglycemia does occur in such individuals, an uncommon but important diagnosis to consider is non-islet cell tumor hypoglycemia (NICTH). We report a case of NICTH associated with paraneoplastic insulin-like growth factor-2 (IGF-2) production and review current relevant medical literature. CASE PRESENTATION: A 60 year old male with no relevant past medical history was referred to the endocrinology clinic with 18 month history of episodic hypoglycemic symptoms and, on one occasion was noted to have a fingerstick glucose of 36 mg/dL while having symptoms of hypoglycemia. Basic laboratory evaluation was unrevealing. Further evaluation however showed an elevated serum IGF-2 level at 2215 ng/mL (reference range 411–1248 ng/mL). Imaging demonstrated a large right suprarenal mass. A right nephrectomy with resection of the mass demonstrated a malignant solitary fibrous tumor. Post resection, the patient’s IGF-2 levels normalized and hypoglycemic symptoms resolved. CONCLUSION: Due to the structural and biochemical homology between IGF-2 and insulin, elevated levels of IGF-2 can result in hypoglycemia. A posttranslational precursor to IGF-2 known as “big IGF” also possesses biologic activity. Review of recent reported cases of NICTH identified widespread anatomic locations and varied pathologic diagnoses of tumors associated with paraneoplastic production of IGF-2 causing hypoglycemia. Definitive management of hypoglycemia associated with paraneoplastic production of IGF-2 consists of resection of the tumor responsible for IGF-2 production. Accumulating literature provides a firm basis for routine IGF-2 laboratory evaluation in patients presenting with spontaneous hypoglycemia with no readily apparent cause

Welsh Law at the Time of the Edwardian Conquest

Abstract not availabl

Disentangling the Harrisson archive to interpret the spatial and temporal distribution of vertebrate remains at Niah Caves, Sarawak

During the 1950s and 1960s, excavations by the Sarawak Museum at Niah Cave in northwest Borneo produced an enormous archive of records and artefacts, including in excess of 750,000 macro- and micro-vertebrate remains. The excellent state of preservation of the animal bone, dating from the Late Pleistocene (c. 40 kya) to as recently as c. 500 years ago had the potential to provide unparalleled zooarchaeological information about early hunter-gatherer resource procurement, temporal changes in subsistence patterning, and the impact of peoples on the local and regional environment in Island Southeast Asia. However, the coarse-grained methods of excavation employed during the original investigations and the sheer scale of the archaeological record and bone assemblages dissuaded many researchers from attempting to tackle the Niah archives. This paper outlines how important information on the nature of the archaeological record at Niah has now finally been extracted from the archive using a combination of zooarchaeological analysis and reference to the extensive archaeological records from the site

Pilot Evaluation of an Instrument to Measure Quality of Life in British Children With Inflammatory Bowel Disease

The IMPACT questionnaire was developed in Canada to measure quality of life in children with inflammatory bowel disease (IBD). In the present study, 20 children with IBD completed 2 versions of the IMPACT questionnaire with a Likert scale or visual analog scale (VAS), 5 of whom expressed problems with language or phrasing. Difficult words included "restrictions," "moderate," "diarrhea," "school break," and the abbreviation "IBD." Fifteen children preferred the Likert scale to the VAS (chi = 20, P < 0.01). Rewording the difficult words and using a Likert scale should facilitate completion of the IMPACT questionnaire in the United Kingdom. Further validation is needed to ensure that the instrument is reliable and valid