Objective: Alpelisib-induced DKA is a rare, but life-threatening adverse event. There have been only two reported cases in the literature. We describe such a case, with emphasis on the importance of screening and achieving adequate glycemic control prior to and after initiation of therapy. Methods: A 49-year-old woman, known to have advanced breast cancer, presented with a 3-day history of nausea, vomiting and diffuse abdominal pain. She started alpelisib 300 mg/d two months prior to presentation, after failing other options. She was diagnosed with DKA using her clinical and laboratory features, leading to treatment with hydration and IV insulin therapy. Results: Laboratory data showed high anion gap metabolic acidosis, hyperglycemia and ketonemia with negative GAD-65 antibodies, leading to the diagnosis of alpelisib-associated DKA. Alpelisib was held, and she was treated with IV insulin and hydration. When DKA and hyperglycemia resolved, alpelisib was resumed at a lower dose (200 mg/d) and her blood glucose (BG) managed using a regimen combining insulin and metformin. Conclusion: PI3K signaling is important for the metabolic actions of insulin and alpelisib has been associated with severe hyperglycemia. Metformin is the first line treatment, however when DKA is the presenting syndrome, insulin needs to be considered. BG and HbA1c should be checked prior to treatment initiation and monitored closely after drug initiation. DKA, albeit rare, must be considered in an acutely ill, alpelisib-treated patients presenting with metabolic acidosis, and if drug discontinuation is not an option, insulin treatment may be required to control glycemia.

Surgical advancements are focusing currently on minimally invasive techniques, the latest of which is natural orifice transluminal endoscopic surgery. Though this approach is feasible through different natural orifices, the vaginal approach is the one which gained attention the most, given the vaginal flexibility and the ability to access pelvic and abdominal organs. Compared to gynecologists, general surgeons were precedents for using the vaginal orifice as a port of surgical entry. However, this vaginal approach is being more frequently implemented during gynecological surgeries nowadays. Advantages of natural orifice transluminal endoscopic surgery include scarless surgery, better exposure, reduced pain scores, less peri-operative complications, shorter hospital stay and improved patient satisfaction. This article provides an idea on the application of vaginal natural orifice transluminal endoscopic surgery in gynecology along with future potentials.

Context Diabetic peripheral neuropathy (DPN) is a common complication. Objective To re-evaluate the role of vitamin B supplementation on reducing the signs and symptoms of DPN. Data Sources Electronic databases such as PubMed, Cochrane Library, and Medline. Data Extraction An Excel spreadsheet was used to report the extracted relevant data. Data Analysis Fourteen randomized controlled trials were selected, comprising a pooled sample of 997 study subjects. The pooled odds ratio values were 3.1 (95%CI, 1.197–8.089) and 3.04 (95%CI, 1.556–5.937) for pain and dysesthesia outcomes, respectively. For the amplitude change in electromyography of the sensory sural nerve, the weighted difference from 2 studies was 0.37 (95%CI, 0.034–0.709) in favor of intervention. Peak latency changes were in favor of the intervention group. Two studies yielded a weighted difference of 0.571 (95%CI, 0.310–0.831) for the velocity outcome in favor of intervention. Unlike the fibular nerve, the electromyographic motor outcomes of the tibial nerve were in favor of vitamin B supplementation. Conclusion Vitamin B supplementation could improve many symptoms and signs of DPN.

IntroductionWorldwide, women perform a variety of vaginal practices to enhance their intimate hygiene and sexual health.ObjectiveTo conduct a systematic review to assess the different kinds of intimate hygiene practices and their association with reproductive tract infections and complications.MethodsPubMed, Medline and The Cochrane Library were used. Both observational and interventional studies targeting the urogenital infections and their association with hygiene practices were included. Exclusion criteria included studies that assessed the knowledge and attitudes towards intimate hygiene practices rather than their relation to infections. The design of this systematic review complied with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).ResultsFifteen articles were included. Intravaginal practices were found to be associated with reproductive tract infections. Reusable absorbent material used during menstruation increased the risk of Candida infection with an adjusted proportional reported ratio (aPRR) of 1.54 (95% CI 1.2–2.0), but no association with bacterial vaginosis ortrichomonas vaginalisinfection was noted. Bathing or vaginal washing during menstruation with water only showed a higher association with symptoms of urogenital infections when compared with washing with both soap and water during menstruation. Drying reusable pads inside the house and storing them inside the toilet was found to be associated with a higher candida infection prevalence. Moreover, bathing in sitting position during menstruation, not drying the genital area or using cloth for drying it, and not paying attention to hand washing, were all associated with a higher risk of genital infections. Finally, postpartum use of native homemade vaginal preparations might be a risk factor for ascending vaginal infections, and the use of inappropriate material for menstrual blood absorption was associated with secondary infertility.ConclusionSeveral hygiene practices put women at higher risk for reproductive tract infections. We should continue to increase awareness to counter the misinformation resulting from marketing campaigns and common misconceptions.

Background Androgen insensitivity syndrome is a rare X-linked disorder of sex development, caused by mutations in the androgen receptor. In this case, a 13-year-old child, reared as female, presenting for primary amenorrhea, was diagnosed with complete androgen insensitivity syndrome. Case presentation A 13-year-old Caucasian child, reared as female, presents with primary amenorrhea. Physical examination revealed female appearance and a short vagina with blind-ended pouch. Laboratory examination showed high levels of testosterone and anti-Müllerian hormone; uterus and ovaries were absent. Karyotype confirmed a 46,XY pattern. Deoxyribonucleic acid analysis of the androgen receptor gene revealed a homozygous mutation p.R856C in exon 7. Gender was assigned as female, and she was started on hormonal therapy and underwent gonadectomy. Conclusion Androgen insensitivity syndrome comprises a large spectrum of presentations. High index of suspicion is needed. Investigation of girls with bilateral inguinal hernia is critical.