103秋季會

目

錄

理監事名單 .......................................................................................3 會場資訊 .........................................................................................4 理事長致詞 ......................................................................................6 大會程序表 .......................................................................................8 節目表 ..............................................................................................9

演講摘要 Lunch Symposium

LS-1 Optimized Approach for Type 2 Diabetes Treatment: The Case of Oral Incretin Therapies.....................................................................................14 （林慶齡 醫師） LS-2 New Armamentarium in T2DM Treatment: SGLT2 Inhibitor......................15 （朱志勳 醫師）

Plenary Lecture

糖尿病預防往何處去 --- 大慶 20 年隨訪研究的啟示 ..................................16 （李光偉 教授）

Special Lecture

New Era of Thyroid Cancer Management.................................................18 （Prof. Francis Paul Worden）

Symposium

Sym1 內分泌專題論壇 ........................................................................................19 （王治元 醫師） Sym2 內分泌專科醫師制度研討 ..........................................................................20 （黃天祥 教授） Sym3 糖尿病專題論壇 ........................................................................................21 （莊峻鍠 教授）

Oral Presentation

OP-1 以口服葡萄糖耐量實驗測量第二期胰島素分泌的準確性評估 ...................22 1 2 2 （裴馰 ，林俊佃 ，吳忠擇 ）

1

OP-2 氟 18- 去氧葡萄糖正子斷層掃描對於碘 131 全身掃描陽性與血清甲狀腺球蛋 白升高的分化型甲狀腺癌病患之處置與臨床預後的影響 ...........................23 1 1, 2 1 （張雁翔 ，王佩文 ，黃淑華 ） OP-3 一新變異血色素「血色素高雄榮總」使用陽離子高壓液相色層分析法檢測糖 化血色素不干擾糖化血色素的測定 ...........................................................24 1 2 3 4 1 1 1 （王玫君 ，林興中 ，蔡國旺 ，李鎮堃 ，孫群欽 ，莊琬琦 ，朱志勳 ） OP-4 淋巴球性腦垂體炎 - 兩例報告及文獻回顧 .................................................25 1 1 1 （潘筱芳 ，葉振聲 ，翁錦興 ）

Poster Presentation

PP-1 PROPYLTHIOURACI (PTU) 誘發抗嗜中性球細胞質抗體血管炎 : 病例報告 .................................................................................................26 1

1

1

1

1

1

（劉欣岳 ，周劍文 ，楊純宜 ，嚴逢杰 ，葉美成 ，田凱仁 ） PP-2 以兩周空腹血糖預估一週一次 1.5MG DULAGLUTIDE 的效果 ..................28 1 2 3 4 5 （劉偉翰 ，G Grunberger ，S Gough ，T Forst ，V Pechtner ， R Shaginian6，H Wang7，L Fernandez8） PP-3 比較長效一週一次的 DULAGLUTIDE 和短效一天兩次的 EXENATIDE 在第 二型糖尿病病患的效果 : 起始 HBA1C 的影響，AWARD-1 的後續分析 .....29 1 2 3 4 5 4 （劉偉翰 ，SC Bain ，Z Skrivanek ，A Tahbaz ，V Pechtner ，O Adetunji ） PP-4 修改後的 CAUMO 公式在國人的運用 ........................................................30 1

1

（夏德霖 ，裴馰 ）.

PP-5 混雜皮質與髓質之腎上腺瘤 : 病例報告和文獻回顧 ....................................31 1

2

1

1

2

3

1

1

1

（莊立倫 ，蔡善茵 ，洪薇雯 ，林昆德 ，辛錫璋 ，蕭璧容 ） PP-6 糖尿病病人足部截肢後情緒與相關因子之探討 ..........................................32 （楊惠美 ，黃禹堯 ，蔡秀鸞 ） PP-7 高血糖合併跳躍舞蹈、基底核症候群 .........................................................33 1 1 1 1 （黃芳專 ，蔡東華 ，蘇矢立 ，郭仁富 ）

PP-8 腎上腺皮質癌合併庫欣氏症候群及嚴重低血鉀 ..........................................34 1 1 1 （沈弘偉 ，蔡東華 ，王舒儀 ）.

PP-9 甲促素使用的罕見併發症 ...........................................................................35 1 1 1 （莊武龍 ，蔡東華 ，許上人 ）

2

中華民國內分泌暨糖尿病學會

中華民國內分泌暨糖尿病學會理監事名單 中華民國內分泌學會

第十二屆理監事名單

理 事 長

葉振聲

常務理事

翁錦興、黃天祥

理 事

王佩文、王治元、李亭儀、張慶忠、曾芬郁、 蔡克嵩、鄧錦泉、簡銘男

常務監事

林仁德

監 事

林宏達、張天鈞

秘 書 長

陳涵栩

副秘書長

林興中、郭錦松、林亮羽、黃建寧、陳雁玲、 林慶齡

中華民國糖尿病學會

第十二屆理監事名單

理 事 長

許惠恒

常務理事

蔡世澤、陳榮福

理 事

杜思德、江怡德、黃禹堯、郭清輝、裴 馰、 謝明家、莊峻鍠、胡啟民

常務監事

莊立民

監 事

何橈通、戴東原

秘 書 長

林時逸

副秘書長

洪乙仁、李弘元、李奕德、王俊興、朱志勳、 林昆德

3

會場資訊 高 雄 國 際 會 議 中 心 坐 落 於 高 雄 市 鹽 埕 區 著 名 的 愛 河 精 華 段 內， 就是 中外人 士訪高 雄必 遊之 處 。鹽埕 區 有 許 多 傳 統 商 家 與 產 業 聚 落 ， 如銀 樓飾品 業 、傳 統小吃 業等 ，為 高 雄 最 具 人 文 歷 史 特 色 的 行 政 區 。 緊 鄰 高 雄 市 立 歷 史 博 物 館 與 高 雄 音 樂 館， 面 對 廣 闊 的 仁 愛 公 園 和 愛 河 徒 步 區。 駁 2 藝 術 特 區、 真 愛 碼 頭、 香 蕉 碼 頭、 傳 統 小 吃 店 及 特 色 商 店 都 在 步 行 1 5 分鐘的 範圍 內 。

高雄國際 會 議 中 心 電 話 ： + 88 6- 7- 5 6 1- 8 6 66

交通工具 高鐵 火車 捷運 市區公車

地 址 ： 8 0 3 4 7 高雄市鹽 埕區中 正四路 2 7 4 號

交通方式 搭乘高鐵至左營站 → 轉乘捷運至美麗島站換橘線 → 鹽埕埔站 02 號出口 → 步行約 3 至 5 分鐘即可抵達 搭乘火車至高雄火車站 → 轉乘捷運至美麗島站換橘線 → 鹽埕埔 站 02 號出口 → 步行約 3 至 5 分鐘即可抵達 橘線鹽埕埔站 02 號出口 → 步行約 3 至 5 分鐘即可抵達） 歷史博物館 0 南 ( 單邊停靠 )、0 北 ( 單邊停靠 )、11、25、33、 56、60、76、77、82、建國幹線、91、214、219、248

4

中華民國內分泌暨糖尿病學會

7 0 4 室 議 會

403A 會議室

諾華 武田

默沙東

諾和諾德

5

喬

海

茶點區

402 海報 展示區

秘書處

拜耳 輝瑞

禮

來

會場圖

中華民國內分泌學會 理事長致詞

各位理監事、會員女士先生，大家好： 歡迎各位蒞臨高雄國際會議中心，參加中華民國內分泌暨糖尿病學會 2014 年秋季暨兩岸學術研討會。今年度秋季會榮幸邀請到對岸專家學者共 同參與，本人謹代表全體會員表示竭誠歡迎！ 學術節目包含 Plenary Lecture 由大陸阜外心血管醫院專家李光偉教 授主講「糖尿病預防往何處去 - 大慶 20 年隨訪研究的 示」；及兩岸共同 研討之「 內分泌專題論壇 」、「 內分泌專科醫師制度研討 」、「 糖尿病專 題論壇」。特別演講有來自美國的 Prof. Francis Paul Worden 主講「New Era of Thyroid Cancer Management」。 旅遊方面，9 月 27 日（ 六 ） 學會安排了「 高雄駁二特區 / 旗津老街 」 及「紅毛港文化園區 / 淨園咖啡休閒農場」；9 月 28 日（日）上午參訪「佛 光山佛陀紀念館」。歡迎會員及眷屬參加！ 感謝兩會秘書處精心籌畫！感謝外賓蒞臨演講，增進兩岸及國際醫學 知識交流！感謝各位理監事的協助及各位會員女士先生的參與。敬祝大家 身體健康，本次秋季會圓滿成功！

中華民國內分泌學會 理事長

敬上

民國 103 年 9 月 27 日 6

中華民國內分泌暨糖尿病學會

中華民國糖尿病學會 理事長致詞 各位會員女士先生大家好： 歡迎各位會員來參加 2014 年度的秋季暨兩岸學術研討會。首先非常感 謝內分泌學會在節目、住宿及休憩活動的精心安排。 今 年 的 秋 季 會， 除 了 安 排 精 闢 的 專 題 演 講， 另 有 來 自 美 國 的 Prof.

Francis P. Worden 主講 New era of Thyroid Cancer Management 及會員 投稿論文， 分別安排口頭論文報告和壁報論文展示。 此外，也有來自大陸 的專家學者與會，增加兩岸學術交流的機會。 今年糖尿病學會有幾項重要工作正在進行中，包括： 1. 糖尿病臨床照護指引改版，目前已接近完成階段，預計明年 3 月年會 出版。 2. 今年 UNWDD 宣傳活動將在 11 月 1-2 日在彰化舉行點燈及園遊會， 相關訊息會在網站公告，請各位會員鼓勵病友踴躍參加。 3. 11 月 9 日在高雄 DUA Hotel 將有一場 Post EASD 研討會，歡迎各位 會員踴躍報名。 4. 2016IDF-WPR 會議將在台北舉行， 目前正在進行網站等相關規劃； 11 月 21-24 日在新加坡舉行之 IDF-WPR Meeting， 也會進行相關宣 傳活動。 最後， 感謝各位會員熱列參與， 祝福大家身體健康， 事事如意， 秋季 會圓滿成功。

中華民國糖尿病學會 理事長

敬上

民國 103 年 9 月 27 日 7

中華民國內分泌暨糖尿病學會

大會程序表 時間：103 年 9 月 27 日（星期六） 地點：高雄國際會議中心 地址：80347 高雄市鹽埕區中正四路 274 號

Program Time

Program

Room

Lunch Symposium-1 林慶齡 醫師 Lunch Symposium-2 朱志勳 醫師

403A 407

13:20-13:30 Opening Remarks 葉振聲 理事長

403A

13:30-14:00 Plenary Lecture 李光偉 教授

403A

14:00-15:00 Special Lecture Prof. FP Worden

403A

12:00-13:00

15:00-15:30 Poster Presentation & Tea Break & Booth Exhibition 15:30-15:50 內分泌專題論壇 王治元 醫師

403A

15:50-16:10 內分泌專科醫師訓練制度研討 黃天祥 教授

403A

16:10-16:30 糖尿病專題論壇 莊峻鍠 教授

403A

16:30-17:10 Oral Presentation

403A

17:20-17:50 Dinner Lecture Prof. FP Worden

5F

17:50-20:00 Welcome Dinner

5F

8

中華民國內分泌暨糖尿病學會

Lunch Symposium-1（Sep 27, 2014 12:00~13:00） Room 403A 主持人：吳達仁 12:00~13:00（LS1）

Optimized Approach for Type 2 Diabetes Treatment : The Case of Oral Incretin Therapies 林慶齡 國泰醫院新陳代謝科

Lunch Symposium-2（Sep 27, 2014 12:00~13:00） Room 407 主持人：蕭璧容 12:00~13:00（LS2）

Opening Remarks

New Armamentarium in T2DM Treatment: SGLT2 Inhibitor 朱志勳 高雄榮民總醫院新陳代謝科 （Sep 27, 2014 13:20~13:30） Room 403A

致 Plenary Lecture

詞：葉振聲

（Sep 27, 2014 13:30~14:00） Room 403A

主持人：許惠恒 13:30~14:00（PL）

糖尿病預防往何處去 --- 大慶 20 年隨訪 研究的啟示 李光偉 阜外心血管病醫院新陳代謝科

Special Lecture

（Sep 27, 2014 14:00~15:00） Room 403A

主持人：葉振聲 14:00~15:00（SL）

New Era of Thyroid Cancer Management 諶鴻遠 三軍總醫院核子醫學科 Francis Paul Worden Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan

9

Symposium 15:30-15:50（Sym1）

（Sep 27, 2014 15:30-16:30） Room 403A

主持人：李光偉 內分泌專題論壇 王治元 台大醫院內分泌新陳代謝科

15:50-16:10（Sym2）

主持人：張慶忠 內分泌專科醫師制度研討 黃天祥 台大醫院內分泌新陳代謝科

16:10-16:30（Sym3）

主持人：李光偉 糖尿病專題論壇 莊峻鍠 林口長庚醫院內分泌新陳代謝科

Oral Presentation

（Sep 27, 2014 16:30-17:10） Room 403A

16:30~16:40（OP1）

主持人：林宏達、簡銘男

以口服葡萄糖耐量實驗測量第二期胰島素 分泌的準確性評估 裴馰 1、林俊佃 2、吳忠擇 2 耕莘醫院內科部輔仁大學醫學院 1、 雙和醫院內科部台北醫學大學醫學院 2

16:40~16:50（OP2）

主持人：王佩文、郭清輝

氟 18- 去氧葡萄糖正子斷層掃描對於碘 131 全身掃描陽性與血清甲狀腺球蛋白升高的分 化型甲狀腺癌病患之處置與臨床預後的影響 張雁翔 1、王佩文 1, 2、黃淑華 1 高雄長庚醫院核子醫學科 1、 高雄長庚醫院內科部新陳代謝科 2

10

中華民國內分泌暨糖尿病學會

16:50~17:00（OP3）

主持人：曾芬郁、陳涵栩

一新變異血色素「血色素高雄榮總」使用 陽離子高壓液相色層分析法檢測糖化血色 素不干擾糖化血色素的測定 王玫君 1、林興中 2、蔡國旺 3、李鎮堃 4、 孫群欽 1、莊琬琦 1、朱志勳 1 高雄榮民總醫院內科部 新陳代謝科 1、高齡醫學中心 2、教學研究部 3、 高雄榮民總醫院生物化學科 4

17:00~17:10（OP4）

主持人：蔡克嵩、李亭儀 淋巴球性腦垂體炎 - 兩例報告及文獻回顧 潘筱芳 1、葉振聲 1、翁錦興 1 台北榮民總醫院內分泌新陳代謝科 1

Dinner Lecture

（Sep 27, 2014 17:20-17:50） 5F

主持人：葉振聲 17:20-17:50（DL）

Clinical Implication of TKI for DTC Management Francis Paul Worden Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan

11

Poster Presentation （PP1）

（Sep 27, 2014 13:00~17:00） Room 402 PROPYLTHIOURACI (PTU)

誘發抗嗜中性球細胞質抗體血管炎 : 病例報告

（PP2）

以兩周空腹血糖預估一週一次 1.5MG DULAGLUTIDE 的效果

劉欣岳 1、周劍文 1、楊純宜 1、嚴逢杰 1、葉美成 1、田凱仁 1 台南永康奇美醫院內科部新陳代謝科 1

（PP3）

劉偉翰 1、G Grunberger2、S Gough3、T Forst4、 V Pechtner5、R Shaginian6、H Wang7、L Fernandez8 僅代表禮來公司 1、印第安納波利斯、美國作報告、 Grunberger 糖尿病學院 2、密西根州 Bloomfield Hills、 美國、牛津大學和牛津大學醫院 3、NHS 信託、英國牛 津大學、Profil 美因茨 4、美因茨、德國、禮來糖尿病部 5、 禮來公司、塞納河畔塞納河、法國、禮來糖尿病部 6，禮 來公司、豪滕、荷蘭、禮來公司 7、印第安納波利斯、印 第安那州、美國、禮來糖尿病部 8、禮來公司、印第安納 波利斯、印第安那州、美國

比較長效一週一次的 DULAGLUTIDE 和短效一天 兩次的 EXENATIDE 在第二型糖尿病病患的效果 : 起始 HBA1C 的影響，AWARD-1 的後續分析

劉偉翰 1、SC Bain2、Z Skrivanek3、A Tahbaz4、 V Pechtner5、O Adetunji4 僅代表禮來公司 1、印第安納波利斯、美國作報告、 生命科學學院 2、斯旺西大學和 ABMU 健康委員會、 斯旺西、英國、禮來公司 3、印第安納波利斯、印第安 那州、美國、禮來公司 4、貝辛斯托克、英國 、禮來公司 5、 塞納河畔塞納河、法國 （PP4）

修改後的 CAUMO 公式在國人的運用 夏德霖 1、裴馰 1 耕莘醫院內科部輔仁大學醫學院 1

12

中華民國內分泌暨糖尿病學會

（PP5）

混雜皮質與髓質之腎上腺瘤 : 病例報告和文獻回顧

（PP6）

糖尿病病人足部截肢後情緒與相關因子之探討

（PP7）

高血糖合併跳躍舞蹈、基底核症候群

（PP8）

腎上腺皮質癌合併庫欣氏症候群及嚴重低血鉀

（PP9）

莊立倫 1、蔡善茵 2、洪薇雯 1、林昆德 1、辛錫璋 1、蕭璧容 1 高雄醫學大學附設醫院內分泌新陳代謝內科 1、 高雄醫學大學附設醫院病理部 *2 楊惠美 1、黃禹堯 2、蔡秀鸞 3 林口長庚內分泌暨新陳代謝科專科護理師 1、林口長庚醫 師內科部內分泌暨新陳代謝科 2、大葉大學護理系院長 3 黃芳專 1、蔡東華 1、蘇矢立 1、郭仁富 1 彰化基督教醫院內科部內分泌新陳代謝科 1 沈弘偉 1、蔡東華 1、王舒儀 1 彰化基督教醫院內科部內分泌暨新陳代謝科 1

甲促素使用的罕見併發症 莊武龍 1、蔡東華 1、許上人 1 彰化基督教醫院 1

13

LS-1

Optimized Approach for Type 2 Diabetes Treatment: The Case of Oral Incretin Therapies Cheering Lin Division of Endocrinology and Metabolism, Department of Internal Medicine, Cathay General Hosptital

The management of patients with type 2 diabetes has become more complex in recent years. In general, the foundational use of metformin and lifestyle interventions has simplified clinicians' selection of initial therapy for most patients. However, eventually, it is conceivable that more medication will be needed in addition to metformin glycemic management with the progressive nature of type 2 diabetes. The step-up strategies after metformin monotherapy most widely used in community medicine are either addition of a sulphonylurea or addition of a dipeptidylpeptidase-4 inhibitor or others . It is at this juncture that treatment has become more complex because of the diverse treatment options now available, as reflected in the most recent American Diabetes Association/ European Association for the Study of Diabetes and American Association of Clinical Endocrinologists/American College of Endocrinology guidelines. Following those guidelines, it is noteworthy that incretin-based therapies (i.e., GLP-1 receptor agonists and DPP-4 inhibitors) have become fundamental treatment options. DPP-4 inhibitors, belonging one of OHAs and acting in inhibition of DPP4 on the incretin system to regulate glucose homeostasis, are useful in the management of patients with T2DM over the spectrum of A1C levels, including drug-naive patients as well as those treated with other glucose-lowering therapy.

Although the efficacy of these treatments is well established in randomized controlled clinical trials, effectiveness in everyday care under real world conditions is less well characterized. Moreover, since T2DM is a progressive disease, an important therapeutic issue is to ensure that each stage of treatment is as effective as possible to delay escalation of treatment intensity to the next line of treatment as long as possible.

Maintaining a patient on an unchanged treatment is a pragmatic outcome criterion which combines notions of both effectiveness and tolerability.

14

中華民國內分泌暨糖尿病學會

LS-2

New Armamentarium in T2DM Treatment: SGLT2 Inhibitor Chih-Hsun Chu Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Veterans General Hospital

In conventional epidemic of Diabetes Mellitus, the therapeutic strategies usually try to treat or prevent chronic complications. The chronic complications could be divided into two entities, one is macrovascular, and the other is microvascular complication.

Particularly, cardiovascular disease is the chief cause of morbidity and mortality in diabetic patients. The latent stage of cardiovascular disease may correlate to insulin resistance and postprandial hyperglycemia, which may begin 10 years before the onset of Diabetes Mellitus.

The legacy effect of UKPDS suggests that the early intervention for hyperglycemic control is the pivotal factor for preventing micro/macrovascular complications, including myocardial infarction. Moreover, the postprandial hyperglycemia is defined by a rapid increase in blood glucose levels in diabetes, and the postprandial hyperglycemic fluctuating may be relevant to the onset of cardiovascular complications.

Epidemiological studies and preliminary intervention studies have shown that fluctuated postprandial hyperglycemia is a direct and independent risk factor for cardiovascular disease. The majority of cardiovascular risk factors are directly enhanced by an acute increase of glucose. Controlling the postprandial hyperglycemia may become the important therapeutic strategy for the prevention and management of cardiovascular diseases in type 2 diabetes, and HbA1c should be closely controlled and monitored.

Most standard in different countries even suggested HbA1c should be lower than 6.5% for prevention of macro/microvascular complications.

Type 2 diabetes is a complex multifactorial disease with a complex pathophysiology.

Traditional therapies have very much targeted insulin resistance and inadequate insulin secretion. Increasingly the role of the incretin pathway but also the kidney are now recognised with new therapies having novel mechanisms of action.

In this talk we will over view the recent guidelines with regard to the management of type 2 diabetes including the ADA and EASD Position Statement which talks about the importance of tailoring therapy to the individual. We will consider the variability in different classes of drugs, both in their ability to lower HbA1c but also their effects on hypoglycaemia, weight and risk benefit profile. In particular we will focus on the incretin based therapies including both the DPP-4 and the GLP-1 receptor analogues but also consider the contribution of the new class of SGLT-2 inhibitors to the treatment paradigm.

15

大會 Plenary Lecture 演講者 李光偉教授簡介

主任醫師，博士生導師 阜外心血管醫院內分泌首席專家，中日友好醫院國際 醫療部名譽主任，內分泌專業首席專家，衛生部心血管防 治研究中心專家組成員，國家藥品監督局新藥、進口藥評 審委員，中華內分泌代謝雜誌副主編和多個中華系列醫學 雜誌編委和審稿人。 「大慶糖尿病 20 年前瞻性研究」的主要組織者和執行 者之一。其 20 年研究結果證明 6 年生活方式可在 20 年間 減少糖尿病發生 43%，並減少嚴重視網膜病變 47%，主要 成果發表於世界頂級雜誌《柳葉刀》。該研究與美國及芬 蘭同類糖尿病預防一起被譽 世界 2 型糖尿病的一級預防 里程碑式的研究。 在 1993 年提出胰島素敏感性指數目前在國內胰島素抵 抗研究中廣泛應用。在國內外核心雜誌共發表文章 200 餘 篇。曾榮獲 1995 年衛生部科技進步獎，1998 年獲吳階平醫 學研究獎。2000 年起 2006 年獲中國胰島素分泌研究組。 2007 年獲國家科技進步獎。2000 年起入選國務院有貢獻專 家，享受政府特殊津貼。

16

中華民國內分泌暨糖尿病學會

P-L

糖尿病預防往何處去 --- 大慶 20 年隨訪研究的啟示 李光偉 阜外心血管病醫院新陳代謝科

中國大慶糖尿病預防研究、芬蘭糖尿病預防研究和美國糖尿病預防研究 3 個 大型隨機試驗已經表明，飲食和運動干預能推遲或預防糖耐量減低進展為糖尿病。 大慶研究則首次證明此種獲益可持續很久。是受試者多年繼續堅持了他們改善了 的生活方式，抑或是 6 年的干預已經足以長久獲益尚不清楚，但兩者無不證明將 這種研究結果轉化為實踐是正確的。該項研究雖然尚沒有足夠的證據證明生活方 式干預能降低心血管事件或死亡，但它顯示了與以往藥物干預研究同樣的趨勢， 即延緩糖耐量減低進展為糖尿病可能改善心血管疾病的後果。該研究最為驚人之 處是 20 年後對照組中有 93％的受試者發生了糖尿病，儘管干預組 80％最終也發 生了糖尿病，但被推遲了 3.6 年。這些發現表明，一線內科醫師儘早發現糖耐量 減低者並在這一階段給予強化干預具有重要的臨床意義。

17

S-L

New Era of Thyroid Cancer Management Daniel Hueng-Yuan Shen Departments of Nuclear Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

Francis Paul Worden Associate Professor, Clinical Track; Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan

The DECISION (stuDy of sorafEnib in loCally advanced or metastatIc patientS with radioactive Iodine refractory thyrOid caNcer) trial was an international, multicenter, placebocontrolled study. A total of 417 patients with locally advanced or metastatic, RAI-refractory, differentiated thyroid cancer (papillary, follicular, Hürthle cell and poorly differentiated) who had received no prior chemotherapy, tyrosine kinase inhibitors, monoclonal antibodies that target VEGF or VEGF receptor, or other targeted agents for thyroid cancer were randomized to receive 400 mg of oral sorafenib twice daily (207 patients) or matching placebo (210 patients). Ninetysix percent of randomized patients had metastatic disease.

The primary endpoint of the study was progression-free survival, as defined by Response Evaluation Criteria in Solid Tumors (RECIST). Secondary endpoints included overall survival, time to progression, response rate and duration of response. Safety and tolerability were also evaluated. In the trail, sorafenib significantly extended progression-free survival (PFS), the primary endpoint of the study, compared to placebo.

18

中華民國內分泌暨糖尿病學會

Sym1

內分泌專題論壇 王治元醫師 台大醫院內科部代謝內分泌科主治醫師 / 台大醫學院內科臨床副教授

It is not an easy job to describe such a research career for endocrinologist physicians in Taiwan. We had a world-wide and well-known health insurance system; this system was built under the instruction of government only, without delicate suggestions from clinical practitioners. About one more decades ago, the hospital accreditation system was also established, and all clinical practitioners need to be responsible to complete all the provisions given by the accreditation. However, such systems forgot one thing, i.e. humanity, which should be the real driving force for every practitioner in daily work.

The endocrinologist physicians really deserved to have the lowest income among all sub-specialties of internal medicine in Taiwan, because we endocrinologists just pay the efforts in studying research and some bench work. We had no core-competence, like endoscope, cardiac catheterization, and high insurance payment ultrasonography. We are named as “dermatologist” in internal medicine, because people said, endocrinologists did not earn more money for our hospitals but earn more leisure time for ourselves.

We endocrinologist physicians did deserve low payment in this insurance system, utile younger endocrinologist physicians chose to be a real general practitioner in one local clinic because there could be expected more salary payment from daily work in local clinic. Whether we need having really researches in Taiwan or we just need to obtain information from international conferences or guidelines and to be a follower.

I wonder that how to achieve “Making others followers” in the future for Taiwanese younger endocrinologists……..

To be continued… my younger endocrinologist physician fellows, we need to know how do you think….

19

Sym2

內分泌專科醫師訓練制度研討 台灣的內分泌暨新陳代謝次專科訓練 黃天祥教授 台大醫院內分泌暨新陳代謝科主任

台灣自 1988 年開始內分泌暨新陳代謝科次專科的認證， 內科專科醫師完訓 後得進入內分泌暨新陳代謝科次專科訓練 2 年，經過筆試及口試及格後取得次專 科醫師資格，此 2 年訓練包括： 1. 行政管理訓練：受訓醫師須輪流管理內分泌暨新陳代謝科病房，安排病人 出、住院；輪值醫師排班；實習醫學生實習病例安排；安排全科迴診；出 席內科部相關行政會議；公文處理如健保署申覆、申請特殊藥材、學會公 文、醫院評鑑相關事宜。 2. 教學訓練 ：主持晨會並教學含實習醫學生、住院醫師、PGY 醫師；實習 醫學生病歷修改、回饋、臨床指導；主持內分泌、糖尿病病例討論會；參 加師資培訓（optional），每年一次內科演講 內分泌暨新陳代謝新知。 3. 技能訓練：糖尿病併發症篩檢、甲狀腺超音波檢查、甲狀腺、淋巴結、腫 瘤細針穿刺、細胞學檢查判讀。 4. 臨床訓練： 熟悉各種內分泌暨新陳代謝科疾病之診斷、 鑑別方法（ 含試 驗）、判讀並在迴診、教學、討論會、臨床照護反覆操作運用，熟悉各種 內分泌暨新陳代謝疾病治療指引，並了解個人化治療之差異。除住院病人 照護外，並每週一次或不定時（代診）照護門診病人。訓練期間必須完成 學會設定之學習護照。 5. 研究訓練：每位受訓醫師參與主治醫師研究計劃並於受訓期間參加國內、 外學會年會，發表論文或提交心得報告，每位受訓醫師須於完訓前完成一 篇論文發表。

20

中華民國內分泌暨糖尿病學會

Sym3

糖尿病專題論壇 以貝他細胞為標靶的糖尿病治療新趨勢 莊峻鍠教授 長庚大學醫學院及長庚紀念醫院內科部內分泌暨新陳代謝科

雖然過去認為第 1 型糖尿病是肇因於其胰臟貝他 (beta) 細胞無可回復的減 損，而第 2 型糖尿病則主要是因為體內胰島素作用降低所致，現在有越來越多證 據顯示這兩型糖尿病均與貝他細胞質量減少和胰島素分泌障礙有關。第 1 型糖尿 病患貝他細胞質量約減少 98%，而第 2 型糖尿病患則約減少 65%。前者主因為自 體免疫破壞貝他細胞 ,，後者則包括葡萄糖毒性、脂肪毒性、氧化壓力、內質網壓 力、發炎細胞激素和人胰島澱粉樣多胜肽 (human islet amyloid polypeptide) 等多 重因素導致貝他細胞凋亡。近年來的研究指出成人貝他細胞亦有再生的潛能，這 引發學者將未來糖尿病治療的標靶指向貝他細胞，研發增加糖尿病患貝他細胞質 量及促進其貝他細胞分泌胰島素功能的療法。 以貝他細胞為標靶的治療， 在第 1 型糖尿病病人旨在避免自體免疫破壞以 維持貝他細胞的方法包括自體抗原療法、抗細胞激素療法、抗 T 淋巴細胞療法及 抗 B 淋巴細胞療法。 再生療法則包括類昇糖素胜肽 -1 類似物、 胰島新生相關蛋 白、上皮生長因子及胃泌素。至於治療第 2 型糖尿病的降血糖藥物，metformin、 thiazolidinediones 及 ATP 敏感鉀離子通道開啟劑在離體可抑制貝他細胞凋亡， 而類昇糖素胜肽 -1 類似物及二肽基肽酶在離體及糖尿病鼠，則除抑制貝他細胞凋 亡外尚可促進貝他細胞增生。然而這些研究結果仍需進一步在人體印証。我們預 期今後降血糖藥物的發展，除了能控制糖尿病病人的血糖外，更能遏阻糖尿病的 進展。

21

OP-1

VALIDATION OF SECOND PHASE INSULIN SECRETION DERIVED FROM ORAL GLUCOSE TOLERANCE TEST DEE PEI1, JIUNN-DIANN LIN2, CHUNG-ZE WU2 Department of Internal Medicine, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan.1; Division of Endocrinology and Metabolism, Department of Medicine, Shuang-Ho Hospital, Taipei Medical University, New Taipei, Taiwan2

Abstract:

Although important, second phase insulin secretion (2nd ISEC) is less discussed and often overlooked partly because the difficulty in measuring it. To accurately quantify 2nd ISEC, c-peptide measurement and a special mathematical method-deconvolution are both needed. In this study, there are two goals: first, to validate the 2nd ISECderived from the oral glucosetolerance test (OGTT), i.e. Φs,against the 2nd ISEC derived from the low dose graded glucose infusion (LDGGI) which is regarded as gold standard; second, to evaluate whether to use deconvolution in calculating 2nd ISEC with LDDGI will make a difference.

Methods:

Fourteensubjects (3 with normal glucose tolerance, 8 with pre-diabetes and 3 with diabetes) were enrolled. Theyreceived both 180 min OGTT and 200 min LDGGI proposed byPolonsky et al. Three different 2nd ISEC were measured. First, Φs from OGTT. Second, 2nd ISEC measured by insulin without deconvolution (2nd ISEC-IN) and, third, by c-peptide with deconvolution (2nd ISEC-CP).

Results:

Φs was significantly related to 2nd ISEC-DE (r = 0.867, p = 0.000) and to 2nd ISEC-IN (r = 0.792, p = 0.002). In the same time, the correlation between 2nd ISEC-IN and 2nd ISEC-CP was also significant (r = 0.637, p = 0.019).

Conclusion:

Our results showed that Φsderived from OGTT could be reliable a measurement for 2nd ISEC. Whether to use deconvolution only has minimal effect on the measurement of 2nd ISEC.

22

中華民國內分泌暨糖尿病學會

OP-2

IMPACT OF F-18 FDG PET/CT ON THE MANAGEMENT AND CLINICAL OUTCOME OF DIFFERENTIATED THYROID CANCER PATIENTS WITH POSITIVE I-131 WHOLE BODY SCAN AND AN ELEVATED THYROGLOBULIN YEN-HSIANG CHANG1, PEI-WEN WANG1, 2, HSU-HUA HUANG1 Department of Nuclear Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.1 ; Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.2

Background:

Although the value of 18F-fluoro-deoxyglucose positron emission tomography and computed tomography (18F-FDG PET/CT) in the surveillance of differentiated thyroid cancer (DTC) patients with thyroglobulin (Tg)-positive and a negative radioiodine whole body scan ( 131I WBS) is well recognized, its usefulness in DTC patients with positive 131I WBS had seldom been discussed. The aim of this study was to evaluate the impact of 18F-FDG PET/CT on DTC patients with positive 131I WBS and an elevated serum Tg level.

Methods: From 2005 to 2013, a total of 27 DTC patients with positive 131I WBS and a detectable stimulated-Tg who underwent 18F-FDG PET/CT study were retrospectively evaluated. All of the patients had undergone total or near-total thyroidectomy followed by radioiodine ablation. The 18 F-FDG PET/CT findings were analyzed, with disease progression as a primary endpoint.

Results:

Among the 27 patients, twenty (74%) patients had positive 18F-FDG PET/CT findings.

In 12 (44%) patients, 18F-FDG PET/CT provided additional information than 131I WBS and conventional imaging; eight (30%) of them resulted in a change of clinical management. The sensitivity, specificity, and diagnostic accuracy of 18F-FDG PET/CT for detecting recurrent/ residual lesions were 86.3%, 80%, and 85%, respectively.

During follow-up, twelve (44%) patients experienced disease progression after 18F-FDG PET/CT study. The maximal standard uptake value (SUVmax) of the lesion with the strongest 18 F-FDG uptake was significantly higher in patients with progression than those without progression. Patients with lesion SUVmax over 4.5 were suggestive for disease progression with sensitivity of 90% and specificity of 87.5%. Of the 7 (26%) patients with negative 18F-FDG PET/ CT result, 6 patients achieved undetectable Tg at the end of follow-up.

Conclusion: 18

F-FDG PET/CT plays a crucial role in the management of DTC patients with positive 131I WBS and elevated Tg. The lesion 18F-FDG uptake provides prognostic information in identifying DTC patients with disease progression, while a negative 18F-FDG PET/CT result suggests a favorable prognosis

23

OP-3

A NEW HEMOGLOBIN VARIANT (HB–KSVGH) THAT DOES NOT INTERFERE IN HBA1C MEASUREMENT BY ION-EXCHANGE HPLC METHOD MEI-CHUN WANG1, HING-CHUNG LAM2, KUO-WANG TSAI3, JENN-KUEN LEE4, CHUN-CHIN SUN1, WAN-CHI CHUANG1, CHIH-HSUN CHU1 Division of Endocrinology and Metabolism, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan1; Elderly Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan2; Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan3; Laboratory of Biochemistry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan4

Hemoglobin variants may interfere in measurement of HbA1c by ion-exchange HPLC method. In our hospital, we routinely used Tosoh HLC-723 G7 (ion-exchange HPLC method) in HbA1c measurement. Among total 41267 subjects, the DNA sequence detected 17 different Hemoglobin variants in 81 subjects: Hb Phnom penh (1), Hb G-taichung (24), Hb J-meinung (24), Hb–F (9), Hb E (1), Hb H (4), Hb Constant Spring (1), Hb Owari (1), Hb QUEEN (1), G-Hsin chu (1), Hb montfermeil (1), Hb Ube-2 (1), Hb GH (1), Hb G-Chinese (3), α-thalassemia (3), β-thalassemia (4), and one subject with an insertion of 24 bp between 57th and 58th amino acids of α1 subunit of hemoglobin [Gly57_His58insSerHisGlySerAlaGlnValLys]. The last one was the first identified hemoglobin variant. We therefore named it Hemoglobin-KSVGH. The HbA1c was 5.2% by our routinely used Tosoh HLC-723 G7. The measurement of HbA1c by affinity HPLC method was not interfered by the existence of hemoglobin variants. We therefore used Boronate affinity HPLC method (Trinity Biotech’s ultra2,USA)for comparison, which revealed 5.4 %. Our findings demonstrated that Hb–KSVGH does not interfere in HbA1c measurement by ion-exchange HPLC method.

24

中華民國內分泌暨糖尿病學會

OP-4

LYMPHOCYTIC HYPOPHYSITIS – TWO CASES REPORT AND LITERATURE REVIEW SHEAU-FANG PAN1, TJIN-SHING JAP1, JUSTIN GING-SHING WON1 Division of Endocrinology and Metabolism, Department of Medicine Taipei Veterans General Hospital, Taipei, Taiwan1

Background: Lymphocytic Hypophysitis was first described in 1962 as an inflammatory condition of the pituitary gland of presumed autoimmune in etiology that leads to dysfunction of the pituitary gland.

A 47 year-old gentleman came to hospital because of general weakness and cold intolerance for 2 years. At the same time, the body weight lost about 15 kg and muscle weakness over both lower limbs in recent 6 months. He had history of Type-2 Diabetes for 3 years. The endocrine profile showed prolactin of 21.6 ng/mL (2.5-18.1), testosterone <0.08 ng/mL, FSH of 0.9 mIU/mL (0.9-11.9), LH of 0.05 (0.6-12),alpha fetoprotein of 3.19 ng/mL (0-20), Beta HCG <1.2 mIU/mL (<10), free T4 of 1.0 ng/dL (0.8-1.9), TSH of 0.09mIU/mL (0.4-4), cortisol of 0.1 ug/dL (5-25) and ACTH of 8.7 pg/mL (<46). The MRI of sella showed a 1.5 cm homogeneous enhancing tumor in the pituitary fossa with stalk extension. The pathology following transphenoid endoscopic hypophysectomy disclosed a picture of Lymphocytic Hypophysitis.

A 37 year-old housewife came to hospital because of intermittent headache for 2 months. The pattern of headache was over the left retro-orbital area and sometimes interrupted her sleep pattern which was also associated with nausea. The physical examination showed body height of 159.4cm, body weight of 52.2Kg and BMI of 20.5kg/m2. The endocrine profile showed serum prolactin of 67.31 ng/mL (2.5-18.1), FSH of 1.44 mIU/mL (0.9-11.9), LH of 2.71 (0.6-12), E2 of 36 pg/mL, free T4 of 2.31 ng/dL (0.8-1.9), TSH of 0.004mIU/mL (0.4-4), TSH receptor antibody showed 50 pg/ mL (normal <1.5), cortisol of <0.5 ug/dL (5-25) and ACTH of <5 pg/mL (<46). The MRI of sella showed a 23 x 13 x 13 mm tumor growth in pituitary fossa, more on left side. After the thyroid function test returned to normal and adequate steroid replacement, the pathology following transphenoid endoscopic hypophysectomy also demonstrated a picture of Lymphocytic Hypophysitis.

In conclusion, we have found two rare cases of lymphocytic hypophysitis with histologic confirmation.

25

PP-1

PROPYLTHIOURACIL (PTU) -INDUCED ANTINEUTROPHIL CYTOPLASMIC ANTIBODY (ANCA) -ASSOCIATED VASCULITIS: A CASE REPORT HSIN-YUEH LIU1, CHIEN-WEN CHOU1, CHWEN-YI YANG1, FENG-CHIEH YEN1, MEI-CHEN YEH1, KAI-JEN TIEN1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwann1

PURPOSE: ANCA was associated with vasculitis which refers to a group of potentially life threatening autoimmune diseases. The drug most often implicated in causing this disease was the antithyroid agent PTU. Here we present a case with hyperthyroidism on PTU treatment for 2 years, presenting with p-ANCA associated diffuse crescentic glomerulonephritis and acute pulmonary hemorrhage.

METHOD: This 58-year-old female patient suffered from urinary frequency, hematuria, decreased urine output for one month. She had a past history of hyperthyroidism on PTU (50mg 1 tab bid) treatment for 2 years. Besides, fever and hemoptysis were also noted. After admission, patient was found to have dyspnea and acute pulmonary edema due to acute kidney injury was suspected. Emergent dialysis was arranged. Acute respiratory failure happened during dialysis and emergent intubation was done. She was sent to ICU for further management. In ICU serum Hb dropped to 5.9 g/dL, blood transfusion was administrated. CCR showed 2.5 mL/min. Chest X-ray showed diffuse consolidation of bilateral lungs. Bronchoscopy showed pulmonary hemorrhage. Cardiac echo showed adequate LV global performance. Abdominal echo showed chronic renal parenchymal disease. Serum data showed higher titer of both P-ANCA and C-ANCA. Renal biopsy revealed p-ANCA associated diffuse crescentic glomerulonephritis. Pulse steroid treatment was given. Plasmapheresis was also performed for 2 weeks. She was transferred to the ward after 10 days in ICU and discharged 2 weeks later. The patient kept regular hemodialysis and there was no antithyroid agents use since then and for more than 8 months. Thyroid function was within normal range.

RESULT: The treatment protocol for PTU-induced ANCA associated vasculitis tailored to the individual and based on an assessment of disease activity and severity. PTU might

26

中華民國內分泌暨糖尿病學會

directly participate in the pathogenesis of PTU-induced ANCA-associated vasculitis so it is crucial to withdraw PTU immediately after diagnosis. In those with seriously endorgan damage, they should also receive corticosteroid and immunosuppressive agents.

If patients with rapidly progressive glomerulonephritis and massive pulmonary alveolar hemorrhage, they should receive intravenous pulse methylprednisolone therapy or even plasmapheresis. The duration of immunosuppressive therapy depending on the severity of end-organ damage. According to current literature, maintenance therapy in PTUinduced vasculitis might not be necessary.

CONCLUSION: Patients undergoing treatment with PTU or other drugs that can induce ANCA associated vasculitis should be monitored closely during long term therapy. ANCAs are a useful tool to diagnose PTU induced vasculitis. PTU should be discontinued immediately after diagnosis and immunosuppressive therapy should be considered only to patients with end-organ involvement. The duration of immunosuppressive therapy was related to the severity of disease, and maintenance therapy in PTU-induced vasculitis might not be necessary.

27

PP-2

THE 2-WEEK FASTING GLUCOSE AS A PREDICTOR OF RESPONSE TO ONCE-WEEKLY DULAGLUTIDE 1.5 MG T LEW1, G GRUNBERGER2, S GOUGH3, T FORST4, V PECHTNER5, R SHAGINIAN6, H WANG7, L FERNANDEZ8 Presenting on behalf of Eli Lilly and Company, Indianapolis, IN, USA1. Grunberger Diabetes Institute, Bloomfield Hills, MI, USA2. University of Oxford and Oxford University Hospitals NHS Trust, Oxford, UK3. Profil Mainz, Mainz, Germany4. Lilly Diabetes, Eli Lilly and Company, Neuilly-Sur-Seine, France5.

Lilly Diabetes, Eli Lilly and Company, Houten, Netherlands6. Eli Lilly and Company, Indianapolis, IN, USA7. Lilly Diabetes, Eli Lilly and Company, Indianapolis, IN, USA8

OBJECTIVE To assess whether laboratory fasting blood glucose (FBG) in patients with type 2 diabetes mellitus (T2DM) measured early in treatment with the once-weekly glucagon-like peptide-1receptor agonist dulaglutide (DU) 1.5 mg predicts treatment response.

MATERIALS AND METHODS Post-hoc analyses were conducted separately for 2 Phase 3 studies (AWARD-5, in combination with metformin, and AWARD-1, in combination with metformin and pioglitazone) in T2DM patients receiving once-weekly DU 1.5 mg. In AWARD-5, FBG values were categorized at baseline and week 2 as: Low (L, <142 mg/dL); Intermediate (I, ≥142 to <185 mg/dL); and High (H, ≥185 mg/ dL). Treatment response was assessed at week 12 (AWARD-5) or 13 (AWARD-1) and 26 (AWARD-5, AWARD-1) by composite efficacy endpoint (CEE): A1c <7.0% or A1c reduction from baseline >0.8% (if baseline A1c <8.0%); >1.1% (if baseline A1c ≥8.0% and <9.0%); or >1.6% (if baseline A1c ≥9.0%).

RESULTS In AWARD-5, mean baseline A1c for DU 1.5 mg (N=304) was 8.1%. At baseline, mean FBG was 176 mg/dL, and 33% (n=99), 32% (n=97), and 36% (n=108) of patients had FBG in L, I, and H categories, respectively. After 2 weeks of treatment, mean FBG was 129 mg/dL, and 68% (n=208), 21% (n=64), and 11% (n=32) of patients had FBG in L, I, and H categories, respectively. At week 26, mean A1c was 6.9%.

There was a strong association between FBG at week 2 and achieving CEE at week 26 (p<0.001). A higher percentage of patients in FBG category L (83% [172/208]) at week 2 met CEE at week 26 vs patients in FBG categories I (61% [39/64]), p<0.001, and H (34% [11/32]), p<0.001. Similar findings were seen using AWARD-1 data.

CONCLUSION FBG values at week 2 may be an early and useful measurement for predicting response to once-weekly DU 1.5 mg in patients with T2DM

28

中華民國內分泌暨糖尿病學會

PP-3

EFFICACY OF LONG-ACTING ONCE-WEEKLY DULAGLUTIDE COMPARED WITH SHORT-ACTING TWICE-DAILY (BID) EXENATIDE IN PATIENTS WITH TYPE 2 DIABETES MELLITUS (T2DM): A POST-HOC ANALYSIS TO DETERMINE THE INFLUENCE OF BASELINE HBA1C IN THE ASSESSMENT OF WEEKLY ADMINISTRATION OF DULAGLUTIDE IN DIABETES-1 (AWARD-1) TRIAL T LEW1, SC SC BAIN2, Z SKRIVANEK3, A TAHBAZ4, V PECHTNER5, O ADETUNJI4 Presenting on behalf of Eli Lilly and Company, Indianapolis, IN, USA1. Institute of Life Science, Swansea University & ABMU Health Board, Swansea, UK2. Eli Lilly & Co, Indianapolis, IN, USA3. Eli Lilly & Co, Basingstoke, UK4. Eli Lilly & Co, Neuilly-sur-Seine, France5.

OBJECTIVE To investigate the response to long- and short-acting glucagonlike peptide-1 receptor agonists based on baseline HbA1c levels. The AWARD-1 trial compared once-weekly dulaglutide 1.5mg and dulaglutide 0.75mg to placebo and exenatide 10µg bid in patients with T2DM on metformin and pioglitazone.

MATERIALS AND METHODS The changes from baseline in HbA1c and percentages of patients reaching HbA1c targets (<7.0%, ≤6.5%) with dulaglutide 1.5mg and dulaglutide 0.75mg at 26 weeks were analysed by baseline HbA1c (<8.5%, ≥8.5%) and compared with placebo and exenatide. Results are presented (LS mean [SE]) for the change from baseline in HbA1c and percentages achieving glycaemic targets, the <8.5% group followed by the ≥8.5% group.

RESULTS The LS mean changes from baseline in HbA1c for dulaglutide 1.5mg (–1.16 [0.07]%; –2.37 [0.10]%) were greater compared with placebo (0.17 [0.10]%; –0.76 [0.16]%) and exenatide (–0.64 [0.07]%; –1.86 [0.11]%) (p < 0.001, all comparisons). For both baseline groups, significantly more dulaglutide 1.5mg patients reached targets of <7% (92%, 47%) and ≤6.5% (80%, 26%) compared with placebo (<7%: 55%, 10%; ≤6.5%: 32%, 3%) and exenatide (<7%: 65%, 21%; ≤6.5%: 50%, 9%) (p < 0.05, all comparisons). Dulaglutide 0.75mg also demonstrated significant changes for both baseline groups vs placebo (p < 0.05, both outcomes; all comparisons).

Statistical significance was not achieved when comparing dulaglutide 0.75mg with exenatide in the baseline HbA1c ≥8.5% groups.

CONCLUSION Regardless of baseline HbA1c, once-weekly dulaglutide 1.5mg and dulaglutide 0.75mg showed a robust reduction in HbA1c in this population of patients with T2DM.

29

PP-4

ESTIMATION OF INSULIN SENSITIVITY BY CAUMO’S EQUATION DERIVED FROM ORAL GLUCOSE TOLERANCE TEST TE-LIN HSIA1, DEE PEI1 Department of Internal Medicine, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University1

Abstract: Decreased insulin sensitivity (SI) is important in the pathogenesis of type 2 diabetes (T2DM). Caumo et al. developed an equation calculating SI from 300 mins-75 g oral glucose tolerance test (OGTT300). The aim of the study was to assess the accuracy of SI estimation using Caumo’s equation by 120 and 180 min OGTT (OGTT120, OGTT180, respectively).

Methods:Fifty subjects were enrolled (17 normal glucose tolerance, 14 pre-diabetes and 19 T2DM). They underwent both frequently sampled intravenous glucose tolerance test (FSIGT) as a standard for SI and OGTT180. In Caumo’s original hypothesis, the plasma glucose and insulin at 300 min (G300 and I300) should all return to the basal state (Gb, Ib). Whilst in the OGTT180, the plasma glucose and insulin levels at 180 min (G180, I180) would be either higher or lower than Gb and Ib, respectively. To solve this problem, estimation of both G300 and I300 must be done. If they were higher than basal, extrapolation was done to estimate G300 and I300 and the area under curve (AUC) was calculated and added (area a). In the meanwhile, if they were lower than basal at 180 min, the G300 and I300 must be further lower and a minus AUC was also formed (area b). Dependent on whether to add the area a or b into the original equation, four methods were investigated: 1.

Method 1: add area a and minus area b 2.

Method 2: add area a only 3.

Method 3:minus area b only 4.

Method 4: neither area a or b is added The similar methods were also applied to the OGTT120. Finally, the correlations between FSIGT (SIFSIGT) and either SI derived from OGTT180 and OGTT120 (SI180 and SI120, respectively) was calculated.

Results:By using the aforementioned method, both SI180and SI120 were only significantly correlated with SIFSIGT with method 3 (r = 0.623, p = 0.000 and r = 0.559, p = 0.000, respectively). All other methods were unable to estimate the SI correctly.

Conclusion:Our results showed that SI could be accurately calculated in subjects with a varying degree of glycemia using Caumo’s equation in shorter OGTT with our particular method. We hoped this finding could be widely used in clinical settings.

30

中華民國內分泌暨糖尿病學會

PP-5

ADRENAL CORTICOMEDULLARY MIXED ADENOMA: CASE REPORT AND LITERATURE REVIEW L-L CHUANG1, S-Y TSAI2, W-W HUNG1, K-D LIN1, S-J SHIN1, P-J HSIAO1 Division of Endocrinology and Metabolism, Kaohsiung Medical University Hospital1 ; Department of Pathology*, Kaohsiung Medical University Hospital2

The adrenal gland is composed of cortex and medulla, each comes from distinct embryologic origin exhibiting discrete anatomic and physiologic characteristics.

Corticomedullary mixed tumor is a single adrenal tumor containing cortical and medullary cells intermixed throughout the entire neoplasm. It is extremely rare and should be distinguished from other disease entities.

We reported a 32-year-old female who manifested with typical Cushing’s syndrome within half a year. She also suffered from puffy face, acnes, easy bruising, palpitation, unsteady gait, hand tremor, headache, mildly elevated blood pressure and rapid body weight gain for 10 kg within this period. She was admitted and diagnosed with diabetes mellitus, hypertension and metabolic alkalosis. Hypercortisolism was demonstrated with baseline cortisol 38.08mg/dL at 8 am and 41.62 mg/dL at 4 pm. Her hypercortisolemia failed to be suppressed by low dose and high dose dexamethasone test. The 24-hour urine collection for vanillylmandelic acid rose nearly 10 folds (74.03 mg/d) of normal reference range.

Abdominal CT scan demonstrated a huge hypervascular tumor sized 8.8 cm with central necrosis over right adrenal gland. Wide adrenectomy was performed soon by cooperation of urologist and hepatobiliary surgeon based on the concerns of malignant potential. The pathology displayed equal distribution of pheocromocytes and adrenal cortical cells in an intimately intermingled arrangement. The immunohistochemical study presented with strongly positive Chromogranin and Synaptophysin for pheochromocytoma, intermixed with intensely reactive to Melan A and inhibin for cortical tissues. However, the ACTH stain was negative in the tumor.

This exceptionalyl rare disease has been described among less than 20 cases until now. It should be distinguished from cases coexistent with pheochromocytoma and adrenocortical adenoma in unilateral or contralateral adrenal gland. It is also different from the cases of ACTH-secreting pheochromocytoma.Physiologically, there exists a paracrine effect that catecholamines may stimulate glucocorticoids synthesis, whereas glucocorticoids could regulate the expression of the key enzymes for catecholamine synthesis. The “collision” theory or an early genetic defect of the above paracrine interference was speculated to explain the co-expression of the cortical and medulla cells.

31

PP-6

EMOTION AND RELATED FACTORS IN DIABETIC FOOT AMPUTATION PATIENTS HUI-MEI YANG1, YU-YAO HUANG2, SHIOW-LUAN TSAY3 Nurse Practitioner of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Taiwan, R.O.C.1; Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taiwan, R.O.C.2; School of Nursing, DA-YEH University of Nursing and health Science, Taiwan, ROC3

Aim: Foot amputations in diabetic patients can not only substantially affect patients’ daily lives but also trigger emotional distresses. This study aims to investigate the emotional status in diabetic patients with amputation.

Methods: This study applied a cross-sectional design, with a sample of patients treated in diabetic foot care center in Chang Gung Memorial Hospital at Linkou. Those patients discharged with outcome amputations were enrolled for emotional factors analysis using Emotion Thermometers (Mitchell, A.J.). Patients were grouped according to major amputation (above ankle) and minor amputation (below ankle).

In the case of questionnaires received, including demographic characteristics, disease-related information, perceived health status and emotion thermometers. Data were analyzed with descriptive statistic, Student's t-test, Pearson’s chi-squared test, Wilcoxon rank sum test, analysis of variance, Fisher's exact test and logistic regression.

Results: From year 2011 to 2013, Sixty patients with amputation as treatment outcomes were enrolled. The mean age was 66.8± 13.6 y/o. Male gender is predominant (68.3%). The diabetic duration was 13.7± 9.3years. For patients suffered from distress, anxiety, depression, and angry was 45%, 25%, 43.3%, and 18.3%, respectively. Patients with left ventricular dysfunction or bed ridden after amputation were the two major risks for experienced emotional suffering. Patients received major amputation had more anxiety and depression than those receive minor amputation (40% v.s. 10%, p<0.05; 56.7% v.s. 30%, p<0.05 ).

Conclusion: Amputations results in severe emotional disorders in patients with diabetic foot ulcers. Emotional evaluation and subsequently psychological supports is mandatory for this high risk group of patients.

32

中華民國內分泌暨糖尿病學會

PP-7

CHOREA, HYPERGLYCEMIA, BASAL GANGLIA SYNDROME FANG-CHUAN HUANG1, DONG-HWA TSAI1, SHIH-LI SU1, JENG-FU KUO1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan1

This 85-year-old Taiwanese woman, with a history of 1. type 2 DM under premixed insulin control (18,0,12,0 U) 2. hypertension 3. dyslipidemia.

She had bilateral progressive involuntary movement over bilateral upper limb (especially left hand then right hand) in recent 3 days. She was admitted to neural ward for further survey.

Neurological examination: Consciousness clear but chorea like involuntary movement over bilateral upper limb. There was no limb weakness nor barbinski sign.

Lab: blood sugar: 357 and then 600 mg/dl. Serum osmolality: 326, and ketone body in serum/urine: all negative. Electrolyte: sodium: 135mmol/L, potassium: 3.7 mmol/ L. Renal and hepatic function, were all within normal range. Patient and her families mentioned of omitting premixed insulin recently.

Brain CT: No ICH, no CT evidence of large acute infarction nor mass effect lesion.

Brain MRI: Hyperintensity of T1W image over bilateral striastumsis noted, the diabetic striatopathy is considered.

According to neurological examination, laboratory exam, image studies, Chorea, hyperglycemia, basal ganglia syndrome(C-H-BG) is highly suspected.

Initial insulin pump and then basal bolus insulin regimen were prescribed for blood sugar control. After blood sugar was under control , symptoms of chorea, ballism got improved gradually. She was discharged and received outpatient department follow up

33

PP-8

ADRENAL CORTICAL CARCINOMA WITH CUSHING'S SYNDROME AND SEVERE HYPOKALEMIA HONG-WEI SHEN1, DONG-HWA TSAI1, SHU-YI WANG1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan1

This 67-year-old Taiwanese woman, with a history of L3-4 HIVD operation about 10 years ago.

She complained to have body weight gain about 20Kilogram in five months. She was admitted to endocrinology ward for further survey.

Physical examination: central obesity, abdominal striae, general edema, alopecia, and hirsutism.

Lab: afternoon ACTH< 5 pg/ml and cortisol level:31.44 μg/dL. Serum potassium: 2.6 mmol/L, and serum glucose: 262 mg/dL. 1mg dexamethasone suppression test: 31.44 μg/dL, 24-hours urine cortisol level: 253 μg/day (normal: 20~90). Testosterone: 0.77 ng/ mL (normal range <0.1~0.75).

Chest X-ray: two nodules in the LUL and another one in the RLL. Abdominal CT: enhanced lobulated mass at right lobe of liver about 5-6cm in size; mass lesion at right adrenal gland region about 2.5cm in size with punctate calcification.

Chest CT: Multiple varying size, parenchymal nodules are noted scattering in both lungs Pathology: compatible with metastatic adrenal cortical carcinoma According to clinical manifestation, laboratory exam, and image studies, the adrenal cortical carcinoma with Cushing's syndrome and severe hypokalemia is diagnosed.

Initial potassium supplement from drug and food were performed. The general surgeon and systemic therapy was suggested due to multiple metastatic lesions. She started mitotane therapy during outpatient department follow up. But the symptoms, complications of Cushing’s syndrome persisted and worsened. The patient then received supportive care and expired on 2014-6-21.

34

中華民國內分泌暨糖尿病學會

PP-9

HEMIPARESIS AFTER THYROTROPIN ALFA USE IN A PATIENT WITH THYROID PAPILLARY CARCINOMA WU-LUNG CHUANG1, DONG-HWA TSAI1, SHANG-REN HSU1 Changhua Christian Hospital, Changhua, Taiwan1

We report a rare complication afte administration of Thyrotropin Alfa.A 67-year-old man developed hoarseness, dyspnea and hemoptysis for 3 years.

Chest CT scan revealed tumor at right thyroid gland with direct invasion to the trachea which caused airway obstruction.

Right near-total thyroidectomy,left total thyroidectomy and central lymph node dissection were performed on 2011-10-12.Because of upper airway stenosis , metallic stent placement in the trachea was performed on 2011-09-26 . Radiotherapy was arranged from 2011-11-08 to 2011-12-16.

He received first radioiodine (131I) therapy on 2012-06-28. After radioiodine treatement, whole body scan revealed uptake in thyroid bed, mediastinum, and right femur which was suggestive of bone metastais.

Thyrotropin Alfa were administered at two days before admission for second radioiodine treatment. In the morning of admission, he was treated with radioiodine (131I), 150 mCi. He developed left leg numbness in the night of admission and then became left hemiparesis in the next morning. Brain CR showed multifocal nodular lesions in both cerebral hemispheres, with peri-tumor edema.Dexamethasone (4 mg four times daily) was administered and he had had improvement in his symptoms.

A month after this episode, he developed dyspnea due to progressive airway compression.

The patient was transitioned to hospice care and died several weeks later.

35

ATION R OCI OC S AS 中華民國

糖尿病 學

N) WA AI (T

DIAB ET ES

MEMO

會

1980

36