Synopsis: Insulinoma is the most common cause of hyperinsulinemic hypoglycemia. We report a 23 year-old male with a five-year history of seizures, documented hyperinsulinemic hypoglycemia with negative imaging studies. Clinical Presentation: We report a 23- year old male nursing student with 5-year history of seizures. Five years prior to admission, patient was found unconscious and diaphoretic at dawn. Capillary blood glucose (CBG) was noted to be 28 mg/dl with reversal of symptoms after intravenous glucose administration. Subsequently, hypoglycemic episodes with glucose levels ranging between 20-30 mg/dl, which were unrelated to food intake. The episodes occurred thrice weekly (midnight - 6a.m.) predominantly after hospital duties, Which abated with carbonated drinks. He had three admissions for unconsciousness and seizures. Pancreatic insulinoma was considered. On the 10th hour of 72-hour fast, he was diaphoretic with blood glucose (28-35 mg/dl), and inappropriately elevated insulin 66.1 (NV < 7.1uU/ml) and C-peptide 6.68 (NV 1.1-5ng/ml). Abdominal ultrasound and magnetic resonance imaging (MRI) revealed normal pancreas. Physical Findings: Examined an obese patient with BMI 31.6 kg/m2, and waist-hip-ratio 0.97 with normal vital signs, unremarkable physical and neurologic findings. Diagnostics: Intra-arterial calcium gluconate stimulation test with hepatic venous sampling was performed stimulating the hepatic, gastroduodenal, superior mesenteric, proximal and distal splenic arteries with calcium gluconate (0.025mEq/kgBW). Baseline insulin levels in all arteries were 8.9 - 10.8 fold elevated (313.2 - 375.4 uIU/mL). A 1.4- fold increase at 60 seconds was noted in the superior mesenteric artery. Treatment: Patient underwent exploratory laparotomy where a 2 cm mass posterior to the pancreatic neck was palpated. Intraoperative ultrasonography revealed a 1.2x1.9cm sonolucent mass in the transverse and longitudinal planes. He underwent near-total pancreatectomy and splenectomy. Intraoperatively, CBGs ranged between 120-150 mg/dL with a linear rise to 200 mg/dL 60 minutes after resection of the pancreatic tumor. Serum insulin decreased to 51.1uIU/mL post-operatively. Histopathology revealed pancreatic islet cell tumor (insulinoma) confirmed by synaptophysin and chromogranin A staining. Outcome: One month post-surgery, he weighed 64kg and required 18 units of basal insulin to maintain euglycemia. He has had no recurrence of seizure since after surgery.

children with femur fractures. This study compares the outcomes of spica cast application, in terms of quality of fracture reduction and hospital charges when performed in operating theatre versus outpatient clinics at a local institution. Materials and Methods: A total of 93 paediatric patients, aged between 2 months to 8 years, who underwent spica casting for an isolated femur fracture between January 2008 and March 2019, were identified retrospectively. They were separated into inpatient or outpatient cohort based on the location of spica cast application. Five patients with metaphyseal fractures and four with un-displaced fractures were excluded. There were 13 and 71 patients in the outpatient and inpatient cohort respectively who underwent spica casting for their diaphyseal and displaced femur fractures. Variables between cohorts were compared. Results: There were no significant differences in gender, fracture pattern, and mechanism of injury between cohorts. Spica casting as inpatients delayed the time from assessment to casting (23.55 ± 29.67h vs. 6.75 ± 4.27h, p<0.05), increased average hospital stay (41.2 ± 31.1h vs. 19.2 ± 15.0h, p<0.05) and average hospital charges (US$1857.14 vs US$775.49, p<0.05). Excluding the un-displaced fractures, there were no significant differences in the period of cast immobilisation and median follow-up length. Both cohorts had a similar proportion of unacceptable reduction and revision casting rate. Conclusion: Both cohorts presented similar spica casting outcomes of fracture reduction and follow-up period. With spica cast application in operating theatre reporting higher hospital charges and prolonged hospital stay, the outpatient clinic should always be considered for hip spica application.