Background Médecins Sans Frontières (MSF) has been providing primary care for non-communicable diseases (NCDs), which have been increasing in low to middle-income countries, in the Shatila refugee camp, Beirut, Lebanon, using a comprehensive model of care to respond to the unmet needs of Syrian refugees. The objectives of this study were to: 1) describe the model of care used and the Syrian refugee population affected by diabetes mellitus (DM) and/or hypertension (HTN) who had ≥ one visit in the MSF NCD clinic in Shatila in 2017, and 2) assess 6 month treatment outcomes. Methods A descriptive retrospective cohort study using routinely collected program data for a model of care for patients with DM and HTN consisting of four main components: case management, patient support and education counseling, integrated mental health, and health promotion. Results Of 2644 Syrian patients with DM and/or HTN, 8% had Type-1 DM, 30% had Type-2 DM, 30% had HTN and 33% had DM + HTN. At intake, patients had a median age of 53, were predominantly females (63%), mostly from outside the catchment area (70%) and diagnosed (97%) prior to enrollment. After 6 months of care compared to intake: 61% of all patients had controlled DM (HbA1C < 8%) and 50% had controlled blood pressure (BP: < 140/90 mmHg) compared to 29 and 32%, respectively ( p < 0.001). Compared to intake, patients with Type-1 DM reached an HbA1C mean of 8.4% versus 9.3% ( p = 0.022); Type-2 DM patients had an HbA1C mean of 8.1% versus 9.4% ( p = 0.001); and those with DM + HTN reached a mean HbA1C of 7.7% versus 9.0%, ( p = 0.003). Reflecting improved control, HTN patients requiring ≥3 medications increased from 23 to 38% (p < 0.001), while DM patients requiring insulin increased from 21 to 29% (p < 0.001). Loss-to-follow-up was 16%. Conclusions The MSF model of care for DM and HTN operating in the Shatila refugee camp is feasible, and showed promising outcomes among enrolled individuals. It may be replicated in similar contexts to respond to the increasing burden of NCDs among refugees in the Middle-East and elsewhere.

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A substantial minority (16%) of pituitary macroadenomas treated surgically are corticotroph adenomas. Of these, 40% are clinically silent but can be recognized by elevated plasma ACTH and/or 24-h UFC. Recognizing these adenomas may influence the surgical approach and provide a marker by which to follow the response to treatment.

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Background : The overwhelming majority of insulinomas are intrapancreatic, but rare cases have been described outside the pancreas. The course of extrapancreatic insulinoma is unclear as there are no reported cases with follow-up beyond 3 months. We present a case of extrapancreatic insulinoma with recurrence as metastatic disease at 5-year follow-up. Clinical Case : In June 2013 a 36-year-old woman presented with Whipple’s triad and 40-pound weight gain. Her serum glucose was 49 mg/dL (normal range 70-99 mg/dL) with insulin level 8.1 uIU/mL (2.6 - 24.9 uIU/mL) and C-peptide 2.2 ng/mL (1.1 - 4.4 ng/mL) prior to receiving dextrose. 72-hour fast confirmed hyperinsulinemic hypoglycemia at 26 hours. Abdominal CT with IV contrast showed a 1.1 x 1.6 x 2 cm hypervascular mass in the second portion of the duodenum and a normal pancreas. OctreoScan did not show uptake in the area of the mass. Esophagogastroduodenoscopy found a mass in the duodenal sweep and endoscopic ultrasound (EUS) showed a 1.6 x 1.6 cm duodenal mass and 3 hypoechoic well-defined lymph nodes up to 1 cm in length distal to the mass. She underwent exploratory laparotomy with duodenotomy and neuroendocrine tumor (NET) enucleation in August 2013. Pathology showed a well-differentiated intermediate grade 1.5 cm NET with Ki-67 index 3-4%. 4/4 lymph nodes were negative for disease. After surgery, she had 30-pound weight loss and resolution of hypoglycemia at her 6-month follow-up. In September 2015 she had mild hypoglycemia (60-70 mg/dL) during exercise. 7-day continuous glucose monitoring (CGM) showed no glucose values <60 mg/dL, and abdominal CT with IV contrast did not show evidence of disease. Due to more frequent hypoglycemia symptoms, she had another 7-day CGM placed in July 2017 which showed 29% of glucose values <60 mg/dL and a pattern of hypoglycemia overnight. Abdominal CT was negative, but PET-CT with Ga68-DOTATATE showed a 1.5 x 1.3 cm soft tissue nodule adjacent to the inferior pancreatic head and wall of the 2nd portion of the duodenum with max SUV of 41. A 72-hour fast was not repeated. EUS showed normal duodenum and pancreas but found peripancreatic lymphadenopathy. Lymph node fine needle aspiration confirmed NET. Repeat surgery found metastatic well-differentiated NET to 5/12 lymph nodes with Ki-67 index 3.8%. Her hypoglycemia resolved after surgery. Follow-up Ga68-DOTATATE scan in January 2018 did not show evidence of disease. Conclusions : Extrapancreatic insulinoma is rare, and while few cases have been described there has not been long-term follow-up reported. This is the first known case of extrapancreatic insulinoma recurrence. Current evidence shows lymph node metastases of intrapancreatic insulinoma do not change prognosis (Krampitz, et al. Arch Surg 2012). It is unclear if this applies to extrapancreatic insulinoma. More long-term outcome data are needed to help determine how these patients should be monitored and managed.

INTRODUCTION: The sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS) are the cornerstones of cardiovascular adaptation.Autonomic dysfunction produces symptoms that overlap with hypofunction of the RAAS, namely hypoaldosteronism. The simultaneous presence of both disorders is not uncommon, especially in patients with CAD undergoing CABG surgery. Objective: This is the case of a patient with recurrent episodes of syncope and severe bradycardia, found to have both hyporeninemic hypoaldosteronism and carotid sinus hypersensitivity. We describe those interrelated phenomena and their association with CAD and CABG surgery. Case presentation: Our patient is a 63-year-old male with a history of hypertension (On Bisoprolol, Valsartan and Hydrochlorothiazide) and hyperlipidemia presenting for coronary artery bypass grafting for triple vessel disease. On the day of admission, the patient lost consciousness briefly and was transiently hypotensive (60/30 mm Hg) with a heart rate of 65 bpm. He reported having had similar self resolving episodes in the past at times of emotional stress. The next day, the patient underwent CABG surgery that was uneventful. Four hours later he developed another episode of unprovoked hypotension that resolved with the administration of neosynephrine. On postoperative day 3, while removing the central line from the right IJ vein, he lost consciousness and had a cardiac pause of 5 seconds. His blood pressure was 70/45 mm Hg. He regained consciousness immediately afterwards upon leg elevation. A carotid massage resulted in a 7 seconds cardiac pause, confirming the presence of carotid sinus hypersensitivity, necessitating the insertion of a pacemaker. However the patient lost consciousness again the next morning despite a normal functioning device. Endocrinology work up was initiated to rule out adrenal insufficiency. It revealed an undetectable aldosterone level with a low-normal renin level, ie hyporeninemic hypoaldosteronism.No hyponatremia, hyperkalemia, renal insufficiency or hypocortisolism were noted. Patient was started on fludrocortisone 0.1 mg daily, and his hemodynamics improved.He remained free of symptoms with normal electrolytes and vital signs on follow up since then. Conclusion: This case describes coexistence of hyporeninemic hypoaldosteronism and carotid sinus hypersensitivity. Although both entities might seem unrelated, a review of the literature and the physiology of cardiovascular hemodynamics revealed that CAD leads to autonomic dysfunction, which can present as carotid sinus hypersensitivity as in our case. In turn, the impaired adrenergic function blocks the activation of renin, leading to hypoaldosteronism and hypofunctioning RAAS. CABG surgery unmasked those interrelated entities. Patient was treated successfully with pacemaker placement and fludrocortisone replacement.

The sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS) are the cornerstones of