Hyperinsulinemia and insulin resistance form an intrinsic component of diabetes, hyperlipidemia, and atherosclerotic vascular disease (syndrome X). The induction of hyperinsulinemia and insulin resistance by medication may therefore counteract intended benefits. An extensive review of recent medication in patients with disorders of glucose tolerance and the avoidance of polypharmacy are recommended. It is prudent to monitor plasma glucose values when it is not possible to avoid prescription of medication with known effects on carbohydrate metabolism.

To develop a predictive model identifying perioperative conditions associated with postoperative pulmonary complications (PPCs).Design: A prospective survey of patients whose preoperative history and physical examination, spirometric, PaO 2 and PaCO 2 analysis, and operative results were recorded. These patients underwent postoperative cardiopulmonary examinations until they were discharged from the hospital; their medical records were also reviewed until they were discharged from the hospital.

Background. A patient was diagnosed with an extramedullary plasmacytoma of the lung after complete resection of the mass at thoracotomy. Immunoperoxidase staining of the mass revealed monoclonal lambda chains. Screening for multiple myeloma identified a small amount of M‐protein in the blood, but no other evidence of multiple myeloma was found. Methods. A literature search was conducted to determine the prognosis and the best way to manage the patient. Results. Nineteen cases of primary pulmonary plasmacytoma were found in the literature. The age range was 3–79 years. Most of these cases were diagnosed at thoracotomy and treated by surgical excision. Immunohistochemical evaluation of the lesion is essential for diagnosis but was done in only three cases. Conclusions. Surgery and radiation therapy seem to be equally effective forms of treatment. The role of adjuvant chemotherapy is unknown. Local recurrences are rare. Follow‐up data were inadequate to determine disease‐free survival, progression to multiple myeloma, and overall survival in primary pulmonary plasmacytoma. Close follow‐up is needed to detect progression.

SummaryThe case is a 34-year-old woman with long-standing type 1 diabetes mellitus with existing follow-up in the outpatient clinic at the Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, UHCW. She had maintained good glycaemic control and glycaemic stability with basal bolus regimen for many years. She had not developed any diabetes-related complications and had no other co-morbidities. Six months ago, she presented to A&E with sudden-onset, well-localised and severe pain in the right iliac fossa, just lateral to the para-umbilical area. Her biochemistry was normal. Ultrasound scan, however, revealed a right-sided ovarian cyst, which was thought to have caused pain to her. She was discharged from A&E with simple analgesia. On subsequent gynaecological follow-up 4 weeks later, her pain remained severe and examination revealed an exquisitely tender subcutaneous nodule at the same location measuring 2 cm in diameter. Magnetic resonance imaging (MRI) scan at the time revealed a 1 cm mass in the subcutaneous adipose tissue, which co-localised to her pain. The mass demonstrated a central fat signal surrounded by a peripheral ring: observations consistent with fat necrosis. There were other smaller subcutaneous nodules also observed in the left para-umbilical area. Subsequent surgical resection of the main area of fat necrosis was performed. The patient made an excellent recovery and her pain resolved post-operatively. Histology confirmed the presence of fat necrosis. Fat necrosis is a rare complication of s.c. insulin injection. This case illustrates the importance of considering this diagnosis in patients who inject insulin and develop localised injection-site pain.Learning points Fat necrosis is a rare complication of insulin injections that can manifest with severe, persistent and well-localised pain.Fat necrosis can masquerade as other pathologies causing diagnostic confusion.The imaging modality of choice for accurate diagnosis of fat necrosis is MRI.Histological confirmation of fat necrosis is important.Appropriate management of localised fat necrosis is surgical excision, with avoidance of further insulin injections into the affected area.

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