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It is well known that an islet cell tumor can secrete multiple hormones depending on its cell type. We report the case of a 70-year-old woman who initially presented with peptic ulcer symptoms, an elevated serum gastrin level, and multiple liver tumors. Liver biopsy and distal pancreatectomy were performed, and the pathological diagnosis was malignant islet cell tumor. Additionally, the immunohistochemical staining revealed scattered positivity for gastrin, and then also positivity for insulin 14 months later. A subsequent hypoglycemic episode and elevated serum gastrin and insulin levels suggested that the disease had developed into a condition of multiple hormone secretion. The plasma gastrin and insulin levels decreased from 584 pg/ml and 90.8 microIU/ml to 49.1 pg/ml and 20.9 microIU/ml, respectively, 5 days after treatment with subcutaneous octreotide 100 micrograms every 6 to 8 hours. In addition, follow-up computed tomography showed shrinkage of the metastatic liver tumors. In conclusion, we found a case of malignant islet cell tumor with variable hormone secretion which could be effectively controlled with octreotide.

Background: A retrospective analysis of enterovesical fistula treated at Chang Gung Memorial Hospital was conducted to determine the optimal diagnosis and management of this disease.

Methods: The records of 41 patients who presented from 1984 to 1996 and had a final diagnosis of enterovesical fistula were retrospectively reviewed. The etiology, symptoms on presentation, diagnostic tools, and modality of treatment were analyzed.

Results: The majority of these cases were associated with malignancy (38, 92.7%), and the others with diverticulitis (2, 4.9%) and iatrogenic causes (1, 2.4%). In those with malignancy, 15 patients (39.5%) were found to have tumor recurrence. The most frequent symptom in enterovesical fistula was fecaluria (58.5%), followed by abdominal pain (22%) and dysuria (14.6%). Diagnostic tools included the barium enema, cystography, and cystoscopy; these methods could identify the fistula in 63.2%, 60%, and 53.8% of the patients, respectively. Methods of management included diversion only (39%), one-stage fistula repair (36.6%), and watchful surveillance (24.4%).

Conclusion: Enterovesical fistula should be considered if fecaluria, pneumaturia, or persistent non-specific urinary tract infection present as the initial complaint. A thorough surgery for a possible underlying malignancy is mandatory when confronted with enterovesical fistula, since the incidence of inflammatory bowel disease is low in this area. An abdominal computer tomography (CT) scan, barium enema, and cystogram can be useful diagnostic tools. Treatment of this entity should be individualized according to each patients clinical status.

Background: Internal rigid fixation for mandibular fractures has been recognized as a reliable method for obtaining osteosynthesis. It may allow for early active physiotherapy and resumption of normal function. However, few studies have compared the various fixation methods.

Methods: From January 1993 through December 1997, 101 patients with mandibular fractures, who were selected for study, received treatment using various fixation methods at the Craniofacial Center, Chang Gung Memorial Hospital. The fixation methods included plate fixation in 44 patients, lag screw fixation in 30, combined plate and lag screw fixation in 15, and wire fixation in 12. Clinical data assessment was performed by reviewing hospital records. For assessment of the long-term surgical results, the patients were asked to complete a questionnaire including questions which specifically targeted history regarding occlusion, mastication, facial asymmetry, width of mouth opening, and general appearance.

Results: The outcome assessment showed statistically different results among the groups. The wire group required intermaxillary fixation more often and for a longer duration compared to the groups using plates and/or lag screws. The plate, lag screw, and combined plate and lag screw fixation groups had better total outcome scores, in particular for long-term dental occlusion and mastication function.

Conclusion: This study shows that for mandible fractures, the more rigid types of fixation methods, i.e., plates and screws or lag screws, can offer better short and long-term outcomes.

The prognosis of recurrent endometrial carcinomas is generally poor, except for isolated vaginal relapse. We report a case of recurrent endometrial cancer in a 58-year-old woman who initially received a type I extended hysterectomy with bilateral salpin-go-oophorectomy and bilateral para-aortic and pelvic lymph node dissection. The first recurrence occurred in the left parametrium 7 months after the primary surgery. The salvage therapy consisted of radiotherapy combined with hormonal therapy (tamoxifen and Megace). Complete remission was achieved initially. Subsequently, the patient accepted six courses of chemotherapy (cisplatin and Adriamycin) for progressive elevation of cancer antigen 125 (CA-125). The CA-125 levels remained elevated with titers fluctuating around 100 U/ml until a second recurrence at the left iliac 75 months following salvage therapy. The second salvage treatment consisted of maximal debulking of the pelvic mass and intraoperative radiotherapy (IORT) followed by four courses of chemotherapy with paclitaxel and carboplatin. Complete remission was again accomplished, with clinical investigations and molecular markers returning to normal. The patient has been clinically free of disease for more than 2 years since the second relapse of cancer. In this particular case, we found that repeated recurrence could occur after a long complete remission following salvage therapy; however, the disease could be recontrolled with further aggressive salvage efforts. A multimodality approach with combinations of radical resection, IORT, and paclitaxel-based chemotherapy can be offered to patients with localized recurrent or repeatedly recurrent endometrial carcinoma after previous cisplatin-based chemotherapy and pelvic radiation.

Background: This study measured morphological and hemodynamic changes and renin-angiotensin responsiveness of the left ventricle (LV) to beta-agonist stimulation in a Sprague-Dawley rat model of myocardial dysfunction produced by coronary artery ligation.

Methods: The LV function and papillary muscle mechanics were measured after 12 weeks of captopril treatment (2 g/l in drinking water) following left coronary artery ligation or a sham operation. Fifty-two rats were divided into three groups: those with sham operations, those with small infarcts (infarct size [IS] < 30% LV) and those with large infarcts (IS > or = 30% LV).

Results: The results showed that LV end-diastolic pressures were elevated in the large-infarct group regardless of treatment with the angiotensin-converting enzyme inhibitor (ACEI), and the LV weight was reduced in the ACEI-treated rats. In addition, the uninfarcted LV posterior papillary muscle of the large-infarct rats showed an impaired response to isoproterenol stimulation, including the developed tension, positive and negative rate of tension development, time to peak tension, and time to half relaxation.

Conclusion: Chronic captopril treatment improved isoproterenol-stimulated muscle isometric function in rats following myocardial infarction, possibly through the beta-receptor pathway.

Background: A retrospective study was undertaken to evaluate the results of phacoemulsification, intraocular lens implantation, and trabeculectomy in patients with cataracts coexisting with glaucoma.

Methods: This study consisted of 20 eyes from 19 patients. Fifteen eyes had chronic angle-closure glaucoma and 5 eyes had primary open-angle glaucoma. All cases were followed for a minimum of 6 months (range, 6 to 16 months). The mean preoperative intraocular pressure (IOP) was 17.3 +/- 4.5 mmHg. The mean preoperative visual acuity was 0.05 +/- 0.19. The mean number of preoperative antiglaucoma medications per patient was 2.3.

Results: Postoperatively, all patients except for one no longer required antiglaucoma medication. The mean IOP was 10.7 +/- 3.7 mmHg one month postoperatively and 13.7 +/- 4.3 mmHg at the final follow-up visit. Vision improved in 80% of the patients and remained unchanged in 20%. The failure to achieve improvement was due to advanced optic atrophy. The mean level of surgically induced astigmatism at the final visit was 0.98 +/- 0.91 diopters as calculated by vector analysis. Various extents of fibrin exudate was found in 10 eyes (50%). The most serious postoperative complication, occurring in one eye (5%), was temporary hypotony with moderate choroidal effusion, which later resolved spontaneously.

Conclusion: Combined phacoemulsification and trabeculectomy is an effective and safe approach for obtaining good visual rehabilitation and glaucoma control.

Citrobacter is a distinct group of Gram-negative bacilli belonging to the Enterobacteriaceae family. Central nervous system (CNS) infections due to Citrobacter are uncommon, though they occur more frequently in neonates and young children. In adults, Citrobacter meningitis is extremely unusual with only 6 cases reported in the literature before 1998. This rare CNS infection has been seen in patients with head trauma, following neurosurgical procedures, and in those who are immunocompromised. Of the patients in the 6 reported cases, only one developed multi-antibiotic resistant Citrobacter CNS infection. Adding to this small number of reported cases, we report an adult case of post-neurosurgical meningitis and subdural empyema caused by multi-antibiotic resistant Citrobacter freundii and also review the literature related to this infection. Antimicrobial therapy with imipenem and third-generation cephalosporins failed to result in cerebrospinal fluid sterilization in our patient. Because of the use of broad-spectrum antibiotics, multi-antibiotic resistant Citrobacter species have developed in this nosocomial CNS infection and now present a therapeutic challenge. Therefore, further clinical studies are needed to determine updated therapeutic modalities for treating this life-threatening infection.

Virchow-Robin spaces normally surround the perforating arteries that enter the brain. These spaces are a well-defined sites where immunological reactions take place and they may have implications in the pathogenesis of a number of neuropathological conditions. We present the case of a 52-year-old woman who had a history of complex partial seizures for 30 years. Her routine neurological examinations and mini-mental tests had normal results. Magnetic resonance images of this patient revealed unusual widening of the Virchow-Robin spaces up to 1.5 cm in diameter along the perforating medullary arteries in the white matter, more so in the left hemisphere. Although it has been concluded that these large spaces are a phenomenon of the normal aging brain and are unrelated to neurological diseases, our patient had had epileptic seizures for 30 years. The large Virchow-Robin spaces of our patient might have been an incidental radiologic finding. Their pathogenesis remains unclear, and their possible clinical relationship to epilepsy deserves further pathological studies.