Pelvic Fracture and Risk Factors for Mortality: A Population-Based Study in Taiwan.

OBJECTIVE: To study the incidence, demographics, distribution of fracture sites, associated injuries, and risk factors for the outcomes of pelvic fracture on a population basis. METHODS: An annual claim dataset from 2001 to 2003 was retrieved from the Bureau of National Health Insurance (BNHI) trauma database with any International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) coded as pelvic fracture. Statistical analyses were conducted to discover the association between variables such as age, gender, month of injury, injury mechanisms, associated injuries, and outcome. RESULTS: Pelvic fracture was diagnosed in 10,109 patients (4,693 males, 46.4%) and 384 patients (3.8%) died. The incidence was 14.97/100,000 person-years. The mean length of stay was 9.3 days (females, 8.8 days; males, 9.9 days; p < 0.01) and the average cost per patient was US$1,475. Both were affected by age, gender, and hospital accreditation level and ownership. There were more female cases in the age groups over 44 years old. Head injury (excluding concussion), associated chest and abdominal injuries, open pelvic fracture, and the transfusion of more than four units of blood significantly increased the risk of mortality. CONCLUSIONS: The incidence rate of pelvic fracture was higher in females over 44 years of age, but the average medical resource use was higher in males. Associated injuries were stronger positive factors for the risk of mortality than gender, fracture sites, injury mechanisms, and the characteristics of the treating hospitals.

Primary aldosteronism caused by unilateral adrenal hyperplasia: rethinking the accuracy of imaging studies.

A rare type of aldosteronism, known as unilateral adrenal hyperplasia (UAH), is difficult to diagnose, not only because it fails to conform to the typical common subtypes, but also because imaging results are unreliable. We report 2 Taiwanese patients with UAH. Case 1 was a 44-year-old man with 2 episodes of hypokalemic paralysis. Hypertension and suppressed plasma renin activity (PRA) with elevated plasma aldosterone concentration (PAC) were observed. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) showed a right adrenal mass, but adrenal scintigraphy revealed no definite laterality. The patient underwent a laparoscopic right adrenalectomy. Adrenal cortical hyperplasia was discovered from results of the histologic analysis. Case 2 was a 33-year-old woman referred for hypokalemia, hypertension, and a left adrenal mass found on a CT scan. However, MRI revealed normal adrenal glands. The adrenal vein sampling for PAC showed overproduction of PAC from the left adrenal gland. A laparoscopic left adrenalectomy was done. Pathology results revealed micronodular cortical hyperplasia with central hemorrhage. Blood pressure, plasma potassium, aldosterone, and renin activity levels returned to normal after operation in both cases. Both patients have been well for 3 years and 16 months, respectively, after surgery. We review the literature and discuss the limitations of imaging studies.

Klinefelter's syndrome with seizure, pseudohypoparathyroidism type Ib and multiple endocrine dysfunctions.

Klinefelter's syndrome is rarely associated with hypocalcemia, especially pseudohypoparathyroidism (PHP) type Ib. We describe a case of Klinefelter's syndrome associated with seizure, PHP type Ib and multiple endocrine dysfunctions. A 19-year-old Taiwanese male was admitted due to seizures with loss of consciousness. He had been diagnosed with Klinefelter's syndrome with seizure disorder and hypocalcemia 3 months previously. Physical examination revealed eunuchoidism but no osteodystrophy, while laboratory data revealed severe hypocalcemia, hyperphosphatemia, and elevated parathyroid hormone. Chromosomal study showed 47,XXY. Osteoporosis was found on chest and abdominal radiography. Dense calcification in the cerebrum and cerebellum was shown on brain computed tomography and magnetic resonance imaging. Elevation of the patient's serum calcium level was noted after vitamin D and calcium carbonate supplements were given. Klinefelter's syndrome is rarely associated with PHP type Ib; our patient's hypocalcemia improved after long-term aggressive treatment.

Perioperative hypertensive crisis in clinically silent pheochromocytomas: report of four cases.

Improvements in imaging have resulted in an increase in incidentally discovered adrenal tumors. The adrenal incidentalomas have been identified in at least 2%-3% of patients receiving abdominal computed tomography (CT), and pheochromocytomas are reported to occur in about 5.1%-23.0% of those patients. Only a few case reports of clinically silent pheochromocytomas have been published in the English literature. Herein we present 4 cases of pheochromocytomas as unforeseen adrenal masses on abdominal images. The characteristics of these tumors were that they (1) were noted to have no particular symptoms, (2) were confirmed biochemically and pathologically with immunophenotypic staining, (3) were benign in nature, and (4) produced apparent blood-pressure fluctuations during the operation. Three of these patients underwent a hypertensive crisis during surgery, and antihypertensives were applied transiently for blood pressure control. Two cases suffered from dramatic hypotension after the tumor had been excised, and intravenous fluid expanders and ephedrine were necessary to maintain adequate blood pressure. The above changes in blood pressure had no correlations with the size of the tumors. Although these tumors were clinically silent, they indeed were biologically active. Surgical resection of these tumors was indicated, and the risk of complications, such as hypertensive or hypotensive crises, may be no less than those of other typical tumors. Thus, such tumors should be managed with great caution.

Recurrent pulmonary embolism in an elderly patient with Cushing's syndrome, adrenocortical adenoma, pheochromocytoma and prostate adenocarcinoma.

Pulmonary embolism (PE) is a major health problem. Mortality in untreated PE is high, but with adequate (anticoagulant) treatment, can be reduced. Multiple primary and secondary risk factors are responsible for PE. But there is rare association of mixed adrenal tumor with PE. Here, we report a case of adrenocortical adenoma with Cushing's syndrome coexistent with pheochromocytoma with recurrent PE in an elderly patient with prostate adenocarcinoma. A 78-year-old Taiwanese retired veteran was admitted in July, 2002 with the presentation of syncope. Three years before, he was diagnosed with prostate adenocarcinoma and had received Androcur therapy since then. Five months later, he was admitted with Cushingoid appearance and hypertension. Abdominal imaging studies revealed a left adrenal tumor. Laparoscopic adrenalectomy revealed an adrenocortical adenoma. Two years later, a recurrent left adrenal tumor was found. Repeated laparoscopic adrenalectomy revealed pheochromocytoma. One month after the repeat laparoscopic surgery, the patient was admitted due to syncope. Chest X-ray revealed cardiomegaly with pulmonary venous congestion. Echocardiogram showed impaired right ventricle global systolic function. Perfusion lung scan showed a high probability of PE. Heparin and coumadin were given but stopped 5 weeks later due to the development of severe skin ecchymosis. In December 2002, the patient was admitted again with consciousness disturbance. Chest computed tomography (CT) revealed bilateral PE, and he died 5 hours later due to cardiogenic shock. In conclusion, in elderly patients with Cushing's syndrome with pheochromocytoma and prostate carcinoma, there is probability of pulmonary embolism.

Regression of hepatocellular carcinoma spontaneous or herbal medicine related?

Hepatocellular carcinoma is one of the most common causes of death from cancer in Taiwan. Treatments for this disease include surgical resection, transcatheter arterial embolization, chemoembolization and systemic chemotherapy. Without treatment, the prognosis of hepatocellular carcinoma is poor, and mortality continues to be significant even in patients with small tumors detected during follow-up. For patients in Taiwan with advanced hepatocellular carcinoma, traditional herbal medicine is frequently used. However, neither the overall prevalence of this therapy nor its efficacy has been studied systematically. Spontaneous regression of cancer, although rare, may occur, but the mechanism leading to regression is still far from understood. Here, we report a case of hepatocellular carcinoma with complete regression after taking herbal medicine. We cannot be certain how significant the herbal preparation was in the regression of the hepatocellular carcinoma, but the regression of the tumor provides us a reason and hope for further research.

Mutations in the lipoprotein lipase gene as a cause of hypertriglyceridemia and pancreatitis in Taiwan.

INTRODUCTION: Familial lipoprotein lipase (LPL) deficiency is inherited as an autosomal recessive trait and is characterized by chylomicronemia, eruptive xanthoma, hepatosplenomegaly, and recurrent pancreatitis. AIMS AND METHODOLOGY: Two unrelated Chinese of Han descent with hypertriglyceridemia were enrolled in this study, and another six Han Chinese with no family history of hypertriglyceridemia and diabetes were recruited as normal controls. LPL activity was determined with use of an artificial substrate of 14C-trioleine and Arabic gum, and release of 14C free fatty acid was determined by the liquid-liquid partitioning system. LPL mass was measured by enzyme immunoassay. Genomic DNA was extracted from EDTA-preserved whole blood, and PCR was used to amplify the nine coding exons and the minimal promoter of the LPL gene. RESULTS: DNA sequence analysis revealed that mutations were identified in both patients; one patient had compound heterozygous mutations in codon 252 [CTG(Leu) --> GTG(Val)] and in codon 264 [TGC(Cys) --> TGa(Ter)] of exon 6, and the other patient had homozygous L252V mutation. These subjects had > or =90% reduction in LPL mass and > or =60% reduction in LPL activity. CONCLUSION: The mutated and truncated LPLs caused hypertriglyceridemia in these patients in Taiwan with hypertriglyceridemia and pancreatitis.