99年度年會(彰化基督教醫院)

目

錄

交通位置圖 ······················································································ 1 會場圖 ······························································································ 2 會長致詞 ·························································································· 3 理事長致詞 ······················································································ 4 程序表 ······························································································ 6 節目表 ······························································································ 7 演講摘要 特別演講 ················································································· 13 經典案例討論 ········································································· 19 論文口頭發表 ········································································· 25 論文壁報發表 ········································································· 34

作者中文索引 ················································································ 48 作者英文索引 ················································································ 50

中華民國內分泌學會

中華民國糖尿病學會

第十一屆理監事名單

第十一屆理監事名單

理 事 長： 張慶忠

理 事 長： 莊立民

常務理事： 王佩文

常務理事： 許惠恒

黃天祥

陳榮福

理

事： 王治元

理

事： 杜思德

翁錦興

辛錫璋

陳思達

莊峻鍠

曾芬郁

黃禹堯

劉瑞川

葉振聲

蔡克嵩

裴

鄧錦泉

蔡世澤

簡銘男

謝明家

常務監事： 林仁德

常務監事： 何橈通

監

監

事： 林宏達

馰

事： 李洮俊

張天鈞

戴東原

秘 書 長： 陳沛隆

秘 書 長： 江怡德

副秘書長： 施翔蓉

副秘書長： 李弘元 張恬君

九十九年度秋季學術研討會 會

長： 郭 守 仁

院長

協 辦 單 位 ： 彰化基督教醫院

交通位置圖

彰化基督教醫院 四期 教學研究大樓 12 樓【蘭大衛國際會議廳】 地址：500彰化市南校街135號 電話：04-723-8595

自行前往-交通資訊 1. 搭台鐵、國光號、統聯的會員：請在彰化站下車，再轉乘彰化客運或計程車至彰基。 2. 搭高鐵的會員：請在烏日站下車，從 3 號出口進入台鐵新烏日站，轉乘台鐵區間 快車/區間車（約每 10 分鐘一班）至台鐵彰化站，車程約 15 分鐘。再轉乘彰化 客運或計程車至彰基。 3. 搭計程車的會員：彰化火車站出口右前方計程車招呼站，每趟約為 100 元左右， 請告訴運將先生：往彰基急診方向（旭光路），再往前過紅綠燈口，右手邊星巴 克那棟大樓（研究大樓） 。 4. 搭彰化客運公車：每位學員需自備零錢 22 元/單趟。 搭乘地點：彰化火車站出口左斜前方 30 公尺（三民路口，警察局對面）。 5. 開車的會員 a.

中一高走法： 下彰化交流道，中華西路右轉中央路，走到底左轉中山路，再右 轉旭光路直走。過彰基急診，再往前過紅綠燈口，右手邊星巴克 那棟大樓。

b.

中二高走法： 請接中一高走法。

c.

台一線走法： 台中往彰基方向，中山路直走，進入彰化市依序在路的左邊看到 縣議會、縣政府，過了縣政府之後再直走過華山路曉陽路，第一 路口左轉旭光路，過彰基急診處，再往前。

請停於教學研究大樓地下室之【第四停車場】 ，本會備有免費停車卷， 請於會場【12 樓蘭大衛國際會議廳-報到處】索取。 1

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

彰化基督教醫院

教學研究大樓 12 樓蘭大衛國際會議廳

2

會長致詞

會長致詞 內分泌及糖尿病學會的會員朋友們大家好，歡迎各位光臨彰化基督教醫 院。回想民國八十九年，也就是貴學會成立二十周年時，本院首度承辦內分泌 及糖尿病學會秋季學術研討會。當年彰基才剛晉昇為醫學中心。僅有中華及二 林兩家分院，教研大樓也尚在興建中。如今，彰基醫療體系已擴展為包括中華、 二林、鹿基、鹿東及雲基等五家分院，並有員生、南基、佑民、大陸宗人卿醫 院及台東基督教醫院等五家合作醫院。兩年前更成為台灣第一家通過 JCI 國際 醫院評鑑的醫學中心。今年是貴學會成立三十週年，再度選擇彰基舉辦年度盛 會，突顯彰基十年來努力的成果已獲得各位專家的肯定，本人備感欣慰。 114 年前，也就是甲午戰爭後一年，蘭大衛醫師因上帝的愛，來到中台灣 鄉下創立彰化基督教醫院。早期本院因地處偏遠，既沒有公立醫院的政府資源 補助，也無企業財團當靠山。因此不容易吸引一流的人才到此發展。但與眾不 同的是，我們擁有「同心服事」的精神文化，這種核心價值讓一群「平凡」的 員工展現出「非凡」的力量。在彰基的企業文化裡，擔任領導人就是要以身作 則，以當大家的僕人自居。我常勉勵彰基的主管們，人人學習謙卑，做他人的 僕人，這就是「共好」精神。在這種團隊合作的氛圍下造就了今日彰基在各專 業領域傑出的表現。 內分泌及糖尿病學會成立於中美斷交後一年，當時的內分泌及糖尿病學專 家多集中在三總、榮總及台大等三大醫學重鎮。中南部民眾若有相關之疑難雜 症都需北上求診。貴學會成立後定期舉辦學術及病例研討會，培育許多優秀的 專科醫師回到地方，造福無數的中南部鄉親。這正是實踐聖經所言：「各人不 要單顧自己的事，也要顧別人的事」 。期許各位會員在兩位理事長領導下能群 策群力，精益求精。讓台灣的內分泌及糖尿病學術研究在國際上繼續發光發熱。 最後祝大會圓滿成功，各位會員身體健康，彰化之旅愉快順心！

彰 化 基 督 教 醫 院 院長

郭守仁

謹上

民國九十九年九月四日 3

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

理事長致詞 各位會員女士先生、各位來賓： 歡迎大家來彰化基督教醫院參加中華民國內分泌學會暨糖尿病學會舉辦 的 99 年度秋季學術研討會。秋季會為本兩會規模僅次於年會之年度例行學術 研討會。然而，自 96 年於成大醫院舉行後，其中 97 年與「第 5 屆華夏內分泌 大會」 、98 年與「第 11 屆亞洲分子糖尿病學研討會」合併辦理。本 99 年度終 於又獨立辦理，很高興能獲得彰化基督教醫院協辦，會議地點安排在彰基本院 蘭大衛國際會議廳。彰基為糖尿病衛教重鎮之一並擁有全台最大糖尿病照護 網，在本次秋季會中也會有專門時段介紹彰基的糖尿病衛教系統。 學術演講方面，除了傳統由會員發表研究成果外，我們特別邀請張天鈞教 授演講甲狀腺的兩性議題；陳榮福主任演講糖皮質素引起的骨質疏鬆症。另外 安排一演講系列名為﹝經典案例討論﹞，其主要目的是為了讓本兩會會員以及 前來參與本會議之其他科別醫師能夠在最短時間內對幾個內分泌及新陳代謝 領域內重要典型疾病有提綱挈領的了解。 本兩會並延請各大教學醫院之醫師專家學者蒞臨演講及主持，討論範圍不 僅包含內分泌新陳代謝、並廣涉內科、家醫及兩性議題。學術盛宴，各方菁英 薈萃，勢必精彩可期！ 本次秋季會會後依往例安排會員及眷屬彰化鹿港旅遊聯誼活動。 最後，感謝彰化基督教醫院各單位與謝明家主任、彰基鹿港分院杜思德院 長盡心盡力協辦，各醫藥、生物科技及儀器產品公司贊助經費。並祝福各位會 員身體健康，本次秋季會圓滿成功。

中華民國內分泌學會 理事長

謹上

民國九十九年九月四日 4

理事長致詞

理事長致詞 各位會員、小姐、先生大家好： 歡迎參加本兩學會主辦之秋季學術研討會，前二年因為舉辦華夏國際會議 及第 11 屆亞洲分子糖尿病學術研討會因而暫停，今年恢復並選在彰化基督教 醫院舉行，感謝彰基有著全台最大糖尿病照護網，對於國內糖尿病照護品質的 提昇及推廣貢獻良多，並熱烈支持本兩學會的學術活動。 今年的秋季研討會節目內容非常精彩，除了邀請各專家學者蒞臨演講外， 也規畫六個經典案例討論；在特別演講有張天鈞教授及陳榮福主任的熱門題 目，個案報告由黃天祥教授、劉瑞川副教授、曾芬郁副教授、徐維信醫師、楊 宜瑱醫師、李國陽醫師為大家講授及討論。節目內容包含內分泌新陳代謝、內 科、家醫、兩性議題，演講內容豐富，相信大家必定能滿載而歸。會後還有由 謝明家主任帶領大家參觀彰基的糖尿病衛教體系，讓您有臨場的感受。 另外，「彰化鹿港」是有名的百年古都，自建城以來迭經歷史的洗禮，卻 仍保存許多見證歷史的史跡和建築物，相信您會讓愛上這座風華萬種的古都。 希望這二天的活動，能讓所有會員滿載而歸。最後祝福大家身體健康，並預祝 秋季會圓滿成功。

中華民國糖尿病學會 理事長

謹上

民國九十九年九月四日

5

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

中華民國內分泌暨糖尿病學會 99 年度秋季學術研討會 日期：民國 99 年 9 月 4 日（星期六）下午 1 時至 6 時 30 分 地點：彰化基督教醫院教學研究大樓 12 樓蘭大衛國際會議廳

程 序 表 時

間

節

目

內

容

1:00 ~ 1:20 pm

報到

1:20 ~ 1:30 pm

會長致歡迎詞

1:25 ~ 1:30 pm

內分泌學會理事長致開幕詞

1:30 ~ 2:10 pm

【特別演講】/【Special Lecture】

2:10 ~ 2:30 pm

Poster & Exhibits & Tea Break

2:30 ~ 4:15 pm

【經典案例討論】/【Classical Case】

4:15 ~ 4:35 pm

Poster & Exhibits & Tea Break

4:35 ~ 5:35 pm

【會員研究成果發表論文投稿】/【Oral Presentation】

5:35 ~ 5:55 pm

彰化基督教醫院-糖尿病遠距照護系統介紹

5:55 ~ 6:05 pm

糖尿病學會事長致閉幕詞

6:05 ~ 6:30 pm

【彰化基督教醫院糖尿病衛教場地及設施導覽】

6

節目表

Special Lecture 主持人：王佩文 1:30~1:50pm SL-01 The Clinical Influence of Gender on Thyroid Diseases 張天鈞 臺大醫院內科部

主持人：蔡克嵩 1:50~2:10pm SL-02 Glucocorticoid-Induced Osteoporosis 陳榮福 高雄長庚醫院新陳代謝科

Classical Case 主持人：林宏達 2:30~2:45pm CC-01 A 55-year-old man, with underlying hypertension, complained about sudden onset of chest pain since one hour ago. 曾芬郁 臺大醫院內科部

主持人：吳達仁 2:45~3:00pm CC-02 A 64-year-old man, with underlying diabetes mellitus and hyperlipidemia, was found to have deterioration of renal function.

1 徐維信，2 黃士銘，1 楊麗瓊，3 吳達仁 1 臺灣基督長老教會新樓醫院內科部，2 國立成功大學附設醫 院斗六分院外科部內分泌外科，與 3 國立成功大學附設醫院內 科部內分泌新陳代謝科 7

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

主持人：林仁德 3:00~3:15pm CC-03 A 21-year-old woman complained that she never had menstruation throughout her life.

1 尤則雅，2 林桓生，3 陳沛隆，1 黃天祥 1 臺大醫院內分泌新陳代謝科，2 臺北縣立醫院內分泌新陳代 謝科，3 臺大醫院基因醫學部

主持人：黃建寧 3:15~3:30pm CC-04 A 55-year-old woman with schizophrenia presented with fluctuated blood pressure for 6 years.

1

楊宜瑱，1 黃建寧，2 蔡青峰，3 王紹全 中山醫學大學附設醫院，1 內分泌科，2 心臟科，3 泌尿科

主持人：張淳堆 3:30~3:45pm CC-05 A 20-year-old woman, without underlying systemic diseases, complained about facial pimples and round face for 2 months.

1 李國陽，2 張天鈞 1 中國醫藥大學附設醫院台北分院內科部，2 臺灣大學醫學院 附設醫院內科部

主持人：辛錫璋 3:45~4:00pm CC-06 A 56-year-old woman, with underlying diabetes mellitus, hypertension and obesity, was admitted due to poor glycemic control. 劉瑞川，黃怡欽 高雄長庚醫院新陳代謝科

主持人：黃天祥 4:00~4:15pm

Panel Discussion

8

節目表

Oral Presentation 主持人：何橈通 4:35~4:45pm OP-01 IFNG 和 DRB1 基因在 GRAVES 氏病之交互作用 1,2,9 李燕晉，1 黃琪鈺，1 丁瑋信，3,4 羅福松，5 林昭旭， 1 吳怡磊，6 李欣蓉，7 洪禎鎂，8 詹佳蓉 馬偕紀念醫院，1 小兒科部，2 醫學研究部 長庚紀念醫院， 3 兒童內分泌科 長庚大學，4 醫學院 馬偕紀念醫院新竹分院， 5 小兒科 財團法人天主教聖馬爾定醫院，6 小兒科 國泰綜合 醫院新竹分院，7 小兒科 沙鹿童綜合醫院，8 兒童醫學部 台 北醫學大學，9 小兒科

主持人：詹錕鋙 4:45~4:55pm OP-02 葛瑞夫茲氏症與人類白血球抗原之相關:性別有差異嗎？ 1,2 陳沛隆，3,4 范盛娟，5 朱正中，3 張倩青，3 張書瑋， 3 謝馨儀，1,6,7 楊偉勛，1,7 張天鈞 1 台大醫內科部內分泌暨新陳代謝科，2 台大醫院基因醫學部， 3 中央研究院生物醫學所，4 陽明大學公共衛生學院，5 馬偕醫 院輸血醫學研究所，6 台大醫學院臨床醫學研究所，7 台大醫 學院內科

主持人：鄧錦泉 4:55~5:05pm OP-03 以原子碘治療甲狀腺機能亢進症之成效-某區域教學醫院之 經驗 蔡政麟，1 陳明宗，2 廖安琪 童綜合醫療社團法人童綜合醫院 內分泌暨新陳代謝科， 1 核醫科，2 財團法人嘉義基督教醫院 核醫科

9

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

主持人：王治元 5:05~5:15pm OP-04 病例報告：乳突性腎臟腎細胞癌合併腫瘤胚胎抗原指數上升 陳芃如，張淳堆，張慶忠，陳清助，陳榮興，王子源，黃偉倫， 謝旻晃，黃國欽 中國醫藥大學附設醫院內科部新陳代謝科

主持人：許惠恒 5:15~5:25pm OP-05 台灣地區糖尿病使用中醫療法之狀況 侯俊成，1 胡念祖，陳瑩陵，羅綸謙，張順昌，陳嘉允 彰化基督教醫院中醫部，1 國立虎尾科技大學資訊管理學系

主持人：宋育民 5:25~5:35pm OP-06 高血糖治療惰性與高血糖復發的情形 張毓泓，張道明，林昆正，徐慧君，李佩儒，方淑音，李洮俊 李洮俊診所

Diabetes Education 主持人：杜思德、林瑞祥 5:35~5:55pm DE-01 彰化基督教醫院糖尿病遠距照護系統介紹 廖培湧 彰化基督教醫院

主持人：謝明家 6:05~6:30pm DE-02 【彰化基督教醫院糖尿病衛教場地及設施導覽】 （可自由選擇是否參加） 王川銘，吳靜雯，黃倍紋，劉兆坤 彰化基督教醫院 10

節目表

1:00~6:30pm

Poster Presentation PP-01 居家執行運動光碟計畫對第二型糖尿病患者代謝控制的成效 戴研光，1 黃秋玲，2 王瑞霞，1 蕭若妤，簡誌銘 阮綜合醫療社團法人阮綜合醫院內科部新陳代謝科， 1 護理 部，2 高雄醫學大學護理學院 PP-02 南台灣某榮民醫院糖尿病共同照護計畫門診病人代謝指標 改善之研究 1 郝立智，2 田凱仁，3 趙海倫，1 洪靜如，4 周福星，5 吳達仁， 6 趙建剛，7 奚明德，8 柴國樑，9 葛光中，10 馬瀰嘉 1 永康榮民醫院內科部新陳代謝科，2 台南奇美醫院內科部新 陳代謝科，3 中華醫事科技大學醫管系，4 國立成功大學資訊 管理學系，5 成功大學附設醫院內科部新陳代謝科，6 玉里榮 民醫院精神部，7 永康榮民醫院病理檢驗科，8 永康榮民醫院 內科部，9 屏東龍泉榮民醫院院本部，10 國立成功大學統計 學系 PP-03 一位年輕女性的腎上腺庫欣氏症候群以早產及嚴重駝背為表 現-病例報告 戴研光，簡誌銘 阮綜合醫療社團法人阮綜合醫院內科部新陳代謝科 PP-04 伴隨原發性副甲狀腺功能亢進，甲狀腺乳突癌和轉移性類 癌：一病例報告 1 陳育正，1 廖培湧，1 謝明家 1 彰化基督教醫院內分泌新陳代謝科 PP-05 使用連續血糖監測系統，以協助診斷胰島素瘤：病例報告 1 陳育正，2 高美燈，1 蔡東華，1 林世鐸 1 彰化基督教醫院內分泌新陳代謝科，2 彰化基督教醫院雲林 分院內分泌新陳代謝科

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PP-06 由鼻竇炎誘發的糖尿病酮酸中毒:案例報告 徐佩君，洪晧彰，歐弘毅，吳達仁 國立成功大學醫學院附設醫院 內科部內分泌新陳代謝科 PP-07 合併使用 REPAGLINIDE 與 GEMFIBROZIL 導致低血糖延 長:案例報告 徐佩君，歐弘毅，洪晧彰，吳達仁 國立成功大學醫學院附設醫院內科部內分泌新陳代謝科 PP-08 第 2A 型多發性內分泌腫瘤個案報告 郭志豪，葉淑婷，施婷婷，王治元 亞東紀念醫院新陳代謝科 PP-09 以低鉀性麻痺及急性呼衰竭為表現的 三碘甲狀腺毒血症 洪逸芷，王子源，張淳堆，陳清助，陳榮興，謝旻晃 中國醫藥大學附設醫院新陳代謝科 PP-10 非典型糖尿病 李仰民，蘇矢立，謝明家 彰化基督教醫院內科部內分泌暨新陳代謝科 PP-11 使用標靶治療末期甲狀腺乳突癌病患合併多發轉移的經驗 1 姜和均，1 蕭璧容，1,2 林昆德，1 李美月，1,3 辛錫璋 1 高雄醫學大學附設醫院內分泌新陳代謝內科，2 高雄醫學大 學醫學研究所，3 高雄醫學大學醫學系醫學遺傳學科 PP-12 以連續性血糖監測觀測第 2 型糖尿病人合併庫欣氏病的血糖 型態-病例報告 陳品汎 佛教大林慈濟綜合醫院內科部內分泌暨新陳代謝科 PP-13 以連續性血糖監測觀測懷孕之第 2 型糖尿病人的血糖型態-病 例報告 陳品汎 佛教大林慈濟綜合醫院內科部內分泌暨新陳代謝科 12

摘 要

SL-01 The Clinical Influence of Gender on Thyroid Diseases 性別對甲狀腺疾病之影響 張天鈞 臺大醫院內科部 甲狀腺疾病發生率的男女性比率 許多甲狀腺疾病的發生率與性別有明顯關係，以女性居多。1941 年在新竹的研 究顯示，地方性甲狀腺腫尖峰分佈男在 11-15 歲，女在 26-30 歲，過了尖峰期，發生 率明顯降低，男性 28.5％降至 3％，女性由 44.9％降至 25％。而從河石九二夫的台 灣地方性甲狀腺腫流行病學研究的圖片中，亦可看到甲狀腺腫主要以女人為主。 雖然自 1967 年，台灣食鹽已全面加碘，在 1993-1994，我們對 1020 位成年健檢 受檢者的調查亦顯示，甲狀腺腫發生率，女比男高（33.6％比 19.4％）。在甲狀腺囊 腫，我們 1988 年的研究，65 位病人中，男性 13 位，女性 52 位，為 1：4。 至於在自體免疫性甲狀腺疾病方面，女性和男性的發生率更有明顯的差別。我 們從 1980 至 1987 年，確診為自體免疫性甲狀腺炎的 106 位病例顯示，男性只有 4 位，女性有 102 位，也就是 1 比 25.5。而在葛瑞夫茲氏病方面，我們最近收集 1024 位病人，包括男性 176 位，女性 848 位（男女比為 1 比 4.8），與我們過去連續收集 55 位甲狀腺機能亢進之葛瑞夫茲氏病人，男性 11 位，女性 44 位（1 比 4）近似。 至於在甲狀腺癌，我們 1987-1992 收集的 47 位做過超音波，手術證實為乳突癌 的病人，其中男性 11 位，女性 36 位，男比女為 1 比 3.3。在甲狀腺濾泡癌，根據 Orlo H. Clark 他們 132 例的統計，男性 40 位，女性 92 位，男比女為 1 比 2.3。在甲 狀腺髓質癌，我們 1977-2000 收集的 54 位病人，男性 24 位，女性 30 位，差別就比 較不大（1 比 1.25） 。至於未分化癌，我們 1980-1988 收集的 24 位病例，男性 10 位， 女性 14 位，為 1：1.4，差別亦不是很明顯。 非自體免疫性甲狀腺疾病女性發生率多於男性的原因 為何很多甲狀腺疾病，女性皆比男性發生率多很多呢？有一個可能是甲狀腺細 胞有動情素受器，因此會受到動情素的刺激，這可由我們做的小學甲狀腺腫的盛行 率調查，在 5、6 年級，也就是 11 歲，12 歲，開始動情素分泌時，女性甲狀腺腫發 13

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

生率明顯增加，且高於男性學童得到證實(表 1)。 此外，為解釋甲狀腺癌發生率為何女性多於男性，以及停經後甲狀腺癌發生率 減少，大阪醫學院的 Noguchi 等，利用 real-time PCR 在正常甲狀腺和甲狀腺濾泡腺 瘤及各種甲狀腺癌測定動情素受器(ER)α 和 β 之 mRNA 表現量。結果顯示 ER-αmRNA 在正常甲狀腺與甲狀腺濾泡腺瘤、甲狀腺乳突癌，和甲狀腺髓質癌無差 別，但高於甲狀腺濾泡癌和甲狀腺未分化癌。至於 ER-βmRNA 在正常甲狀腺與其 他組織間無差別。而 ER-β 與 ER-α 之比值，則正常甲狀腺高於甲狀腺濾泡腺瘤。 在甲狀腺濾泡癌和甲狀腺未分化癌 ER-α 之 down regulation，表示動情素在它們產 生癌化及進展不扮演重要角色。此可以解釋為何甲狀腺未分化癌男女比沒多大差 別。而在甲狀腺濾泡腺瘤，ER-β 與 ER-α 之比值減少，表示動情素與甲狀腺濾泡 腺瘤致病機轉有關，就如同在 estrogen-dependent breast cancers 一樣。 自體免疫性甲狀腺疾病女性發生率多於男性的原因 至於自體免疫性甲狀腺疾病，由於女性比較容易發生自體免疫性疾病(表 2)，因 此女、男之比也就明顯拉開，特別是自體免疫性甲狀腺炎。 那麼為何女性較容易發生自體免疫性疾病呢？根據最近的文獻，主要與動情素 和染色體 X 有關(表 3)。 由於女性在胚胎發育早期，從母親和父親各得到一個 X 染色體，其中一個會隨 機去活化，讓女性和男性的基因劑量相當。這會去活化 X 染色體(X chromosome inactivation)70%以上的基因。現在認為因此 X 染色體上的自體抗原，自體反應性 T 細胞可能無法耐受。自體反應性 T 細胞在週邊刺激 B 細胞，而導致全身性自體免疫 反應。 在自體免疫性甲狀腺疾病方面，根據丹麥 Hegedus L 等的研究，他們檢查 32 對 有自體免疫性甲狀腺疾病的女性雙胞胎的 X 染色體去活化，並與 96 對健康女性雙胞 胎比較。當 X 染色體去活化超過 80%時，叫做 X 染色體去活化偏離(skewed X chromosome inactivation)。結果顯示，偏離之 X 染色體去活化之頻率在自體免疫性甲 狀腺疾病、葛瑞夫茲氏病、橋本氏甲狀腺炎各為 34, 37, 31%，比對照組之 11%(P =0.003)，14%(P=0.046)，8%(P=0.057)高。顯示偏離之 X 染色體去活化發生自體免 疫性甲狀腺疾病之風險增加，odds ratio 為 9.0(95% confidence interval：1.64-49.4, P=0.022) 。因此 X 染色體去活化可能在誘發自體免疫性甲狀腺疾病扮演部份的角 色，也解釋為何自體免疫性甲狀腺疾病，女性發生率為何較高。 14

摘 要

此外，特納氏症(45XO)病人的自體免疫性甲狀腺炎較高，也可用上述的原理來 解釋。

結語 總之，性別對甲狀腺疾病的發生率有明顯的影響，大部分以女性居多，在身體 檢查時要特別注意。 台灣食鹽全面加碘，可以減少因缺碘造成的甲狀腺腫。但有自體免疫性甲狀腺 疾病時不宜吃含碘的食物，以免使疾病惡化。

表 1.小學學童年級與性別和甲狀腺腫發生率(%)之關係 年級

1st

2nd

3rd

4th

5th

6th

女性甲狀腺腫

0.90

2.38

1.37

3.88

6.05

6.36

男性甲狀腺腫 0.56 0.53 0.79 2.43 2.93 2.22 ________________________________________________________ Chang TC et al: J Formos Med Assoc 90:941, 1991. 表 2.女性好發自體免疫性疾病 疾病

女男比 10:1

自體免疫性甲狀腺疾病 原發性膽管硬化症

9:1

修格蘭氏症

9:1

全身性紅斑性狼倉

8:1*

類風濕性關節炎

3:1

硬皮症

3:1

重症肌無力

2:1

多發性硬化症 2:1 ________________________________________________________ *在懷孕年齡 Hernández-Molina G et al: Autoimmunity Reviews 6:218, 2007.

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表 3.性別影響自體免疫性疾病發生率之機轉 疾病

影響因素

全身性紅斑性狼倉

動情素

機轉 使自體反應性 B 細胞存活並 偏離其成熟至邊緣帶表現型

乳促素

使自體反應性 B 細胞存活並 偏離其成熟至濾泡表現型； 導致 γ 干擾素製造

睪固酮

抑制 anti-dsDNA 抗體的製造

X 染色體

PAR1 區 triplication TRL7 duplication

重症肌無力

動情素

促進 AchR 特異性 Th1 細胞擴張

類風濕性關節炎

動情素

活化滑囊膜細胞增生，包括巨喫細胞及纖維母 細胞

全身性硬化症

X 染色體

增加週邊 T 和 B 淋巴球 X 染色體 monosomy 之頻率

動情素 誘導纖維母細胞功能失常 ________________________________________________________ Zandman-Goddard G et al: Autoimmunity Reviews 6:366, 2007.

◎ 推薦讀物 1. Brix TH et al: High frequency of skewed X-chromosome inactivation in females with autoimmune thyroid disease: a possible explanation for the female predisposition to thyroid autoimmunity. J Clin Endocrinol Metab 90:5949, 2005.

2. Chang TC et al: Clinical significance of cytomorphology and thyroid antibodies in autoimmune thyroiditis. J Formos Med Assoc 87:538, 1988.

3. Chang TC et al: Correlation of orbital computed tomography and antibodies in patients of hyperthyroid Graves’ disease. Clin Endocrinol 32:551, 1990.

4. Chang TC et al: Higher prevalence of goiter in endemic area of blackfoot disease of Taiwan. J Formos Med Assoc 90:941, 1991.

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摘 要

5. Chang TC et al: Ultrasonographic findings in relation to ease of aspiration and fluid characteristics in thyroid cyst. J Formos Med Assoc 89:350, 1990.

6. Egawa C et al: Quantitative analysis of estrogen receptor-α and –βmessenger RNA expression in normal and malignant thyroid tissues by real-time polymerase chain reaction. Oncology 61:293, 2001.

7. Hashimoto Y et al: On the distribution of endemic goiter in the district of Chongkan river area , Chunan County, Hsinchu. J Formosan Med Assoc 1942;41:602.

8. Hsiao YL et al: Prevalence of goiter in Taiwanese adults: a preliminary study. J Formos Med Assoc 94:197, 1995.

9. Kawaishi K et al: Distribution of endemic goiter of aborigine in Taiwan. J Formos Med Assoc 43:374, 1944 10. Kawaishi K et al et al: Distribution of endemic goiter of Chinese in Taiwan. J Formos Med Assoc 1944;43:481, 1944.

11. Hernández-Molina G et al: The role of the X chromosome in immunity and autoimmunity. Autoimmunity Reviews 6:218, 2007.

12. Zandman-Goddard G et al: Gender and autoimmunity. Autoimmunity Reviews 6:366, 2007.

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中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

SL-02 Glucocorticoid-Induced Osteoporosis 陳榮福 高雄長庚醫院新陳代謝科 GCs(Glucocorticoids) have very outstanding therapeutic effects and are some of the most important drugs in clinical use for autoimmune disease today. Unfortunately, GC therapy is sometimes accompanied by severe and/or irreversible side effects like osteoporosis and resulting fractures. The different molecular mechanisms of GC actions are better understood and support a certain number of starting points for the development of optimized and/or new GCs and GC receptor ligands such as selective GC receptor agonists that could improve clinical medicine by demonstrating a better benefit–risk ratio compared with conventional GCs .Some abnormalities in bone quality associated with GCs can occur even before deleterious effects on BMD are observed. Therefore, GIOP guidelines differ in the use of BMD criteria to recommend treatment for GC users ( the intervention threshold of the Royal College of Physicians is a T score of −1.5 and those of the American College of Rheumatology is a T score of –1) including some recent important clinically prevention trials.Nevertheless, whenever patients receiving GC therapy should have a bone assessment in order to receive calcium, vitamin D, bisphosphonates, or anabolic agents if necessary.

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摘 要

CC-01 A 55-year-old man, with underlying hypertension, complained about sudden onset of chest pain since one hour ago. 曾芬郁 臺大醫院內科部 This 55-year-old male has hypertension for 15 years. His blood pressure is controlled around 120/80 mmHg by losartan (50mg) 0.5# po qd and amlodipine (5mg) 1# po qd. He has suffered from chronic headache, insomnia, easily diaphoresis, anxiety, tremor, and palpitation for many years. He takes traditional Chinese medicine for those symptoms in the recent 2 years.

The patient suffered from sudden onset of chest pain after shower on Jan 9, 2010. He visited our ER for the pain was associated with cold sweating and persisted for one hour.

His blood pressure was 205/121 mmHg. Other physical examination, laboratory data, CxR, and EKG were un-remarkable. Trandate, losartan and amlodipine were prescribed to control his blood pressure. Abdominal CT was arranged under the impression of hypertensive crisis, possible aortic dissection or pheochromocytoma. He was admitted for further evaluation.

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中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

CC-02 A 64-year-old man, with underlying diabetes mellitus and hyperlipidemia, was found to have deterioration of renal function.

1

徐維信、2 黃士銘、1 楊麗瓊、3 吳達仁 1 臺灣基督長老教會新樓醫院內科部、2 國立成功大學附設醫院斗六分院外科部內分 泌外科、與 3 國立成功大學附設醫院內科部內分泌新陳代謝科 A 64-year-old male was admitted to Tainan SinLau hospital for the problems of poor control DM and hyperlipidemia in April 2007. He was treated with insulin injection and gemfibrozil 600mg 1# bid after dismissal. As glycemic control was rather good, only Metformin 250mg bid was used and follow-up fasting glucose showed 113 mg/dL. Despite the patient subjectively felt well, increased serum creatinine levels of 2-2.2 mg/dL were noted during November - December 2008. Nateglinide 120mg tid/AC replaced metformin therapy for glycemic control. HbA1c was 7.1%. In addition, we found his serum calcium was 11.5 mg/dL. The further Lab study revealed that intact PTH: 145 pg/mL (N:15-68.3)，Alkaline phosphatase:105 U/L (N:32-92)，Chloride:107 mmol/L (N:104-112)，Phosphate:1.8 mg/dL (N:2.5-4.6)，Cholesterol:234 mg/dL(N: -200)，Triglyceride: 976 mg/dL(N: -200).

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摘 要

CC-03 A 21-year-old woman complained that she never had menstruation throughout her life.

1

尤則雅、2 林桓生、3 陳沛隆、1 黃天祥 1 臺大醫院內分泌新陳代謝科、2 臺北縣立醫院內分泌新陳代謝科、3 臺大醫院基因醫 學部 A 21-year-old lady, a salesman of a convenience store, had been otherwise healthy.

She denied any perinatal insult and previous toxin or radiation exposure. Her academic performance during elementary, junior, and senior high school ranked in the middle of her class. The development of her breast was first noted in the third year of junior high school and there had been no galactorrhea. She hardly recalled the exact time when pubic hair growth grew initially. She had not experienced cold or heat intolerance and her olfactory function was normal. She had a brother with normal pubertal development and ranked top in his class. As far as is known, her parents had normal pubertal development.

She even went to St. Joseph's hospital where a pelvic ultrasound demonstrated small uterus and ovaries. Then, she visited Yun-Lin branch of NTUH in Oct. 2009. Clinical examination revealed a short neck and acanthosis nigricans over posterior area of neck.

The laboratory examinations showed prolactin 3.62 ng/mL, free T4 1.1 ng/dl, hsTSH 3.33 μIU/ml, LH 8.88 mIU/ml, FSH 21.28 mIU/ml, E2 16 pg/ml, progesterone 0.2 ng/ml, testosterone 0.58 ng/ml, growth hormone 0.439 ng/ml, ACTH 20 pg/ml, cortisol (PM) 7.75 μg/dl, and IGF-1 88 ng/ml. She was admitted for further evaluation.

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CC-04 A 55-year-old woman with schizophrenia presented with fluctuated blood pressure for 6 years.

1

楊宜瑱、1 黃建寧、2 蔡青峰、3 王紹全 中山醫學大學附設醫院、1 內分泌科、2 心臟科、3 泌尿科 This 55-year-old woman has schizophrenia for nine years, with initial presentation of

delusion, self-talking, aggressive behavior, receiving mirtazapine and bupropion. Poor sleep quality and persecutory delusion persisted, estazolam was added.

About six years ago, hypertension was diagnosed, systolic blood pressure in average 140-160 mmHg, and diastolic blood pressure 90-110 mmHg. Initially, amlodipine 5 mg/day was prescribed initially, which was subsequently increased to 7.5 mg/day 6 months later. Her blood pressure is controlled in average around 120/80 mmHg, but still with fluctuation, which was attributed to the poor sleep and emotional stress. Episodes of headache, fatigue, leg weakness has been described for the past few years. Hypokalemia was noted once three years ago, when she was hospitalized to the psychiatry department.

On July 6, 2010, she was found loss of responsiveness by her son, brought to our emergency department, found to have benzodiazepin overdose. Her blood pressure was 186/161mmHg, pulse rate 84 beats/min. She was hospitalized for further evaluation.

22

摘 要

CC-05 A 20-year-old woman, without underlying systemic diseases, complained about facial pimples and round face for 2 months.

1

李國陽、2 張天鈞 1 中國醫藥大學附設醫院台北分院內科部、2 臺灣大學醫學院附設醫院內科部 The 20-year-old woman was previously healthy. She developed facial pimples, round face for 2 months. According to the patient, her skin was intact until 2months earlier, when pimples started to appear on her face. She used anti-acne medication but in vain. In the following weeks, weight loss from 58 to 51 kilograms, loss of appetite, insomnia, labile and irritable mood, proximal muscle weakness, easy bruising, skin thinning developed and her menses also ceased.

On physical examination, the temperature was 36.5oC, the pulse was 95 beats per minute, the blood pressure was 150/86 mmHg, and the respiratory rate was 19 breaths per minute. Her consciousness was clear. The conjunctiva was pink. The sclera was not icteric.

Round face with disseminated facial pimples with plethora was noted. The neck was supple without jugular vein engorgement and lymphadenopathy. Buffalo hump were noted.

The breath sounds were clear on chest auscultation. The heart sound was regular without audible murmur. The abdomen was ovoid and soft without striae. Bowel sounds were normoactive. No tenderness and rebounding tenderness were found by palpation. Her four extremities showed mild muscle atrophy and proximal muscle weakness of bilateral lower limbs. There was no purpura, telangiectasia or rash over skin. However, thin and fragile skin with ecchymoses was noted.

She was referred from local clinic to medical center for possible endocrine disorder.

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CC-06 A 56-year-old woman, with underlying diabetes mellitus, hypertension and obesity, was admitted due to poor glycemic control. 劉瑞川、黃怡欽 高雄長庚醫院新陳代謝科 A 56-year-old woman was diagnosed with type 2 diabetes mellitus at our hospital in 2006 with a glycohemoglobin (HbA1c) level at 9.4%. After two outpatient clinic visits, she was lost to follow-up. She visited our diabetes outpatient clinic again in August 2008.

At that time HbA1c was 12.7% without any antidiabetic treatment. Oral antidiabetic medications including metformin and sulfonylureas were started with progressive increase in dosage. Follow-up HbA1c was 13.1% in November 2008 and 13.8% in April 2009 when she received glibenclamide 10 mg twice daily, metformin 1000 mg twice daily, and sitagliptin 50 mg per day. She denied poor drug or diet compliance. She was admitted for glycemic control. She was 150 cm in height and 76 kg in weight with a BMI of 33.8 kg/m2.

Blood pressure without treatment was 110-170/80-100 mmHg. Family history revealed history of diabetes mellitus in both her father and sister. Her past history included laminectomy for lumbar spinal stenosis in 2006 and total knee replacement for left knee osteoarthritis in 2007.

24

摘 要

OP-01 Interaction Between the IFNG and DRB1 Genes in Graves Disease 1,2,9

YJ LEE, 1CY HUANG, 1WH TING, 3,4FS LO, 5CH LIN, 1YL WU, 6HJ LI, 7CM HUNG, 8CJ CHAN

1

Pediatrics and 2Medical Research, Mackay Memorial Hospital

3

Division of Pediatric Endocrinology, Chang Gung Memorial Hospital

4

College of Medicine, Chang Gung University

5

Pediatrics, Mackay Memorial Hospital HsinChu Branch

6

Pediatrics, St. Martin De Porres Hospital

7

Pediatrics, Cathay General Hospital, Hsinchu Branch

8

Pediatrics, Tungs' Taichung MetroHarbor Hospital

9

Pediatrics, Taipei Medical University

Graves disease (GD) is among the most prevalent autoimmune endocrinologic diseases in children and adolescents. The risk to a female sib (λs) of a proband with GD is increased and the concordance rate is higher in monozygotic twins than in dizygotic ones.

These observations suggest that genetic factors play a role in the pathogenesis of GD, but the pattern of inheritance is unclear. Multiple genes are thought to be involved. The genes in the HLA complex have been found to contribute major part of susceptibility to GD. Interferon-gamma (IFN-γ), produced mainly by activated lymphocytes and natural killer cells, is one of the dominant cytokines that polarize helper T cells toward the Th 1 phenotype and inhibit the development of Th 2 cells. Th1 cells play a role in the pathogenesis of GD. Therefore the IFNG gene is a candidate gene for studying GD susceptibility. A microsatellite (dbSNP rs3138557) in intron 1 of the gene consists of CA repeats and is associated with the efficiency of expression. It has been reported to be associated with GD in Japanese. We studied the IFNG and DRB1 genes in children with GD. Materials and Methods: The patients were 211 consecutively recruited unrelated children with GD. The age at the diagnosis of GD was 10.5 ± 3.5 years. GD was diagnosed on the basis of clinical and laboratory evidence (clinical symptoms and signs of thyrotoxicosis, elevated free T4/total T4 and suppressed TSH levels, diffuse goiter, with or without ophthalmopathy, and presence of autoantibodies to TSH receptor and thyroglobulin, microsomes or both).

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The controls were 376 subjects selected from among hospital personnel or individuals undergoing routine health examinations or minor surgery.

Genotyping of the DRB1 gene was performed with PCR-SSP and direct sequencing.

Genotyping of the IFNG (CA)n repeat was analyzed by PCR amplification followed by capillary electrophoresis. The primer pairs were 5´-FAM-GCT GTC ATA ATA ATA TTC AGA C-3´ (forward) and 5´-CGA GCT TTA AAA GAT AGT TCC-3´ (reverse). The alleles were designated according to the number of repeats.

Statistical analysis: The Hardy-Weinberg equilibrium was assessed for each gene in both the control and study groups by PyPop 0.7.0. Odds ratios and 95% confidence intervals were calculated. The Bonferroni correction was used for multiple comparisons.

Two-tailed Pc values of less than 0.05 were considered to be statistically significant.

Results: The genotype distribution was in Hardy-Weinberg equilibrium in both DRB1 and IFNG genes. The DRB1*0901 allele was significantly higher in frequency in patients than in controls, 125 (33.1%) vs. 107 (16.2%), and conferred a risk to GD with OR 2.56 (1.90-3.45), Pc = 3.6E-09. The DRB1*1202 allele was significantly lower in frequency, 14 (3.7%) vs. 64 (9.7%), and rendered protection against GD with OR 0.36 (0.20-0.65), Pc = 5.3E-03.

There were 8 different alleles of the IFNG (CA)n microsatellite. The major alleles were alleles 13 and 15. There was not significant difference in the frequency of each allele between patients and controls. When stratified by DRB1 types, the frequency of allele 16 was significantly higher in patients than in controls with DRB1*0901, but not significant after correction, 9 (4.6%) vs. 2 (1.0%), OR 4.76 (1.02-22.34), P = 0.03, Pc = 0.16.

Conclusion: HLA DRB1*0901 conferred a risk to GD but *1202 rendered protection.

No association was detected between the IFNG gene and GD. but marginally significant association was present after stratification by DRB1 allele. Thus there was possible interaction between the two genes in GD.

26

摘 要

OP-02 Graves’ Disease Associated with HLA Alleles: Is There Gender Difference?

1, 2

P-L CHEN, 3, 4CS-J FANN, 5C-C CHU, 3C-C CHANG, 3S-W CHANG, 3H-Y HSIEH, 1, 6, 7W-S YANG,

1, 7

T-C CHANG

1

Division of Endocrinology & Metabolism, Department of Internal Medicine, National Taiwan University

Hospital; 2Department of Medical Genetics, National Taiwan University Hospital; 3Institute of Biomedical Sciences, Academia Sinica; 4Institute of Public Health, National Yang-Ming University; 5Transfusion Medicine Laboratory, Medical Research Department, Mackay Memorial Hospital; 6Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University; 7Department of Medicine, College of Medicine, National Taiwan University

Graves’ disease (GD) [MIM 27500] is the leading cause of hyperthyroidisim and thyroid eye disease inherited as a complex trait. Its prevalence in general population is around 1.0-1.6%, more common in females. The human leukocyte antigen (HLA) loci play an important role in GD pathogenesis; however, the risk alleles identified in Caucasians (such as the HLA-DRB1*03 and the DRB1*03-DQB1*02-DQA1*0501 haplotype) showed no disease association in Asians. Furthermore, it is not clear whether there is gender difference of the association HLA alleles. We conducted a case-control association study (499 GD cases and 504 controls), and a replication in an independent family sample (419 GD individuals and their 282 relatives in 165 families). To minimize genetic and phenotypic heterogeneity, we included only ethnic Han Chinese in Taiwan and excluded subjects with family history of hypothyroidism. Six classical HLA loci (HLA-A, -B, -C, -DPB1, -DQB1 and -DRB1) were comprehensively genotyped. We found that, under a dominant model of inheritance, B*4601 (odds ratio [OR] = 1.33, combined P [Pc] = 3.4x10-4), DPB1*0501 (OR = 2.34, Pc = 7.6x10-12), DRB1*1501 (OR = 1.68, Pc = 3.6x10-4) and DRB1*1602 (OR = 2.63, Pc = 4.3x10-7) were associated with increased risk of GD, while DQB1*0302 (OR = 0.62, Pc = 5.8x10-4) and DRB1*1202 (OR = 0.51, Pc = 3.4x10-3) were associated with reduced risk. These alleles accounts for sizeable population-attributable risk percentage (PAR%), with DPB1*0501 (PAR% = 48.4%) being the most important allele. In a logistic regression model based on these 6 alleles and gender, the area under curve of the receiver operating characteristic (ROC) curve is 0.75.

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Gender dose not seems to make major difference of allele risk. We found no evidence of GD risk association with the HLA alleles previously reported in Caucasians. Our results, with considerable support from previous studies in Asians, show that in Asian populations GD is associated with a distinct spectrum of HLA alleles different from the known associated alleles in Caucasians. Identification of population-specific associated alleles is the critical first step for individualized medicine. Furthermore, comparison between different alleles provides an opportunity for better understanding of GD pathogenesis.

28

摘 要

OP-03 The Therapeutic Outcome of Radioactive Iodine for Hyperthyroidism- Experience From a Regional Teaching Hospital C-L TSAI, 1M-J CHEN, 2A-C LIAO Division of Endocrinology and Metabolism, Department of Internal Medicine, 1

Division of Nuclear Medicine, Tungs’Taichung MetroHarbor Hospital,

2

Division of Nuclear Medicine, Chia-Yi Christian Hospital

Purpose: Radioactive iodine (RAI) is a potent treatment for hyperthyroidism. But there is variability among individuals in terms of the response to thyroid tissue to RAI. RAI of fixed dose method seems to be more convenient than other methods. We would like to investigate the therapeutic outcome including function status and volume reduction after RAI. Material and Methods: From Jun 2005 to Dec 2009, total 87 patients with hyperthyroidism received 107 doses of RAI which ordered by one Endocrine specialist.

Patients were educated that permanent hypothyroidism was almost inevitable but thyroid hormone replacement was relative safe. Many but not all patients received sonography before and 6 to 8 months after RAI. Also their thyroid function was monitored and determined 6 months after RAI. These data were analyzed.

Results: Twenty four men and sixty three women were studied. Eighteen patients received more than one dose (two in 16 patients and three in 2 patients). The mean age of these patients on 1st dose of RAI was 37±12 years, while 54(62%) in the range of 20-40 years. Forty patients (46.0%) received 12mCi and 39 patients (44.8%) received 10mCi. Six months after first dose 54.0% were cured (44.8% hypothyroid and 9.2% euthyroid), while 32.2% patients did not recovery and 13.8% unknown. The mean TSH receptor antibody (TRAb) of 80 patients was 55±27%. Forty-seven patients received sonography before and after RAI. The reduction of thickness in right lobe and left lobe was 7.2± 3.5mm, 7.0±3.8mm, respectively; while the reduction ratio of thickness was 35±15%, 36±19%, respectively.

Conclusion: Previous study concluded that the optimal 131I dose for curing hyperthyroidism was approximated by starting with 7-10 mCi and increasing it for 29

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

unusually large glands. Studies also revealed higher dose might cause higher successful rate but with higher incidence of hypothyroidism. Our study supports that RAI of fixed dose method is safe and effective in curing hyperthyroidism and reduce thyroid volume.

For patient with large goiter, larger dose should be considered.

30

摘 要

OP-04 Elevated Carcinoembryonic Antigen Level in a Case of Papillary Renal Cell Carcinoma P-J CHEN, C-T CHANG, C-C CHANG, C-C CHEN, R-H CHEN, T-Y WANG, W-L HUANG, M-H HSIEH, K-C HUANG Division of Endocrinology and Metabolism, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan

Carcinoembryonic antigen (CEA) level may elevated in benign as well as malignant disease and smokers. There may be a higher elevation (greater than 20 ng/mL) in malignant disease. It is not a organ-specific antigen and may elevated in various tumor types such as entodermal origin (colon, stomach, pancreas and lung) and nonendodermal origin (head, neck, ovary, thyroid and breast). However, it is an unsual presentation of renal tumor. Here, we report a healthy

middle-aged man presented to our hospital due to

a right kidney lesion and high CEA level. The abnormal tumor marker value led us to diagnose the second mailgnancy.

A 38-year-old man was referred to our genitourinary(GU) outpatient department (OPD) due to elevated carcinoembryonic antigen (CEA, 176.6 ng/mL) level with hypodense lesion over middle pole of right kidney in Oct 2009. Positron emission tomography - computed tomography (PET-CT) during GU OPD revealed two hypermetabolic lesions at right kidney and left thyroid region in Dec 2009. He was referred to our endocrinologic OPD where 2 hypoechoic lesion were detected by thyroid ultrasound. Extremely high clacitonin level (> 2000 pg/mL) was also discovered.

Radical total thyroidectomy and left lymph node dissection was performed 4 months after first OPD visit. Microscopically, encapsulated medullary thyroid carcinoma in left with level IV ipislateral lymph node metastasis and non-capsulated papillary microcarcinoma in right thyroid were reported. Following tumor marker after thyroid operation showed calcitonin 27.4 pg/mL. Abdomianl image disclosed no significant change of right kidney lesion as before. He underwent partial nephrectomy 1 month after thyroid surgery and pathologic showed papillary renal cell carcinoma.

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中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

OP-05 The Usage of Traditional Chinese Medicine for Diabetes in Taiwan - A Ten Years Retrospective Study C-C HOU, 1N-Z HU, Y-L CHEN, L-C LO, S-C CHANG, C-Y CHEN Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Department of Chinese Medicine, Changhua Christian Hospital, Taiwan, R.O.C.; 1Department of Information Management, National Formosa University, Taiwan, R.O.C.

Introduction: The increasing prevalence of diabetes leads to a significant health problem globally. There has a development in interest in Traditional Chinese Medicine (TCM) for diabetic control. National Health Insurance (NHI) program had started to provide public health care including conventional medicine and TCM for all citizens in Taiwan. However, when diabetic patients received conventional medicine and TCM at the same time, there could be some unexpected effects taking place such as hypoglycemia.

The purpose of this study was to investigate the demographic characteristics and frequency on the jointed usage of conventional medicine and TCM among patients with diabetes by analyzing the population-based dataset from 1998 to 2007 in Taiwan.

Material & Method: The National Health Insurance Research Database (NHIRD) includes all medical claims data from the NHI program which covered in approximately 98% of the nationwide population in Taiwan. Longitudinal Health Insurance Database 2005 (LHID2005) was randomly sampled from the year 2005 Registry for 1,000,000 Beneficiaries of the NHIRD. There were approximately 25.68 million individuals in the registry at the year of 2005. All the diabetes patients on CAM were screened from the LHID2005 and obtained ten years record from NHIRD. Their demographic characteristics were analyzed and the usages of different CAM modalities were also explored.

Result: 151,005 visits of diabetic patients were screened from LHID2005. 2,455 visits had received at least one combined treatment of conventional medicine and TCM 163 female and 132 male patients received combined treatment. Their average age was 59.17±.12.56 in 2005. 16 visits (0.65%) had received acupuncture alone while 2 visits (0.08%) had received tuina alone. The number of visits with Chinese herbal treatment was 2331(94.95%). The visits with both herbal remedies and acupuncture were 10(0.41%). The visits to receive the other therapies were 96(3.91%).

32

摘 要

OP-06 The Prevalence of Clinical Inertia and Glycemic Relapse of a Diabetic Practice Clinic Y-H CHANG, D-M CHANG, K-C LIN, H-C HSU, P-J LEE, S-Y FANG, Y-J LEE Lee's Endocrinology Clinic

Background: Although glycemic treatment goal has been set, the rate of ideal glycemic control is still low. The aim of this study is to disclose the prevalence and related factor of clinical inertial and glycemic relapse in a diabetic practice clinic.

Methods: Diabetic patients fulfilled the following inclusion criteria were enrolled into this study: 1) initially had HbA1C >8% 2) followed up in the comprehensive diabetic care program every 3 months and as least lasted for 1 year. The clinical inertial was defined as less than 1% of improvement of HbA1C after intervention. The definition of glycemic relapse was defined as subsequent HbA1C>8% and an absolute increase at least 1% above the post-interventional nadir HbA1C. Results: A total of 312 diabetic patients were enrolled and retrospective reviewed their medical records. The mean baseline HbA1C was 10.20±1.56% and mean follow up duration was 26.98±13.89 months. There were 14.7% and 62.6% of diabetic patients diagnosed of clinical inertial and glycemic relapse, respectively. There were 42.6% of diabetic patients ever reached HbA1C<7% during follow up; however, 58.2% relapsed in 8.04±5.29 months. The clinical inertia and glycemic relapse were not related to age, gender, body mass index, lipid profile. The statuses of education, marriage, smoking, alcohol, betel nut, diabetic duration were also not associated with clinical inertia and glycemic relapse. Interestingly, there was a lower baseline HbA1C level (9.40±1.27%) in patients who had clinical inertia as compared to whom response to treatment (10.36± 1.57%).

Conclusions: Our result demonstrated that diabetic hyperglycemia would response to the diabetic management, and prevention of relapse is important in chronic diabetic disease management. Further investigation is necessary to identify the reason of clinical inertia in diabetic patients.

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中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

PP-01 Effects of a Home-Based Exercise Video Program on Metabolic Control in Adults with Type 2 Diabetes Y-K TAI, 1C-L HUANG, 2R-H WANG, 1J-Y HSIAO, C-M CHIEN Division of Endocrinology and Metabolism, Department of Internal Medicine, Yuan's General Hospital,Taiwan;1 Department of Nursing, Yuan's General Hospital,Taiwan;2 College of Nursing, Kaohsiung Medical University,Taiwan

Objective: Five-Element gymnastics (五行健康操) is a traditional Chinese exercise integrating martial arts, Qigong and artistic gymnastics. This exercise program has been promoted through DVD among communities and diabetes support groups in recent years.

The aim of this study was to assess the effects of the home-based Five-Element gymnastics on glucose and lipid control in adults with type 2 diabetes.

Methods: A total of 76 type 2 diabetic patients were recruited from a diabetes clinic in a regional hospital for this quasi-experimental study. Patients visiting Monday clinic were assigned to an experimental group (n＝38). Patients visiting Wednesday clinic were assigned to a control group (n＝38). Participants of the experimental group were asked to practice the video-assisted Five-Element gymnastics at home twice daily, 20 minutes per session, for 16 weeks. Participants of the control group were asked to maintain their usual physical activity. FPG, A1C, TC, TG, LDL-C, and HDL-C were measured at baseline, 8 weeks, and 16 weeks after intervention in both groups. We used a mixed model to analyze the changes of blood glucose and lipids between baseline and 8 weeks and 16 weeks after intervention in the two groups.

Results: There were no significant differences in baseline characteristics between the two groups. Compared with the control group, the experimental group demonstrated a significantly greater decrease in FPG (p=.01), A1C (p<.01), TG (p=.04), and LDL-C (p<.01) after 8 weeks of intervention. However, comparing the 16-week to the 8-week results, the experimental group showed a significantly greater decrease only in A1C (p=.02) relative to the control group. In contrast, there was no significant difference in the change of HDL-C between the two groups.

Conclusion: The home-based video-assisted Five-Element gymnastics program was effective to improve glucose and lipid profile after 8 weeks of intervention.

Glycemic control (A1C) continued to manifest significant improvement at the 16-week interval. Five-Element gymnastics could be an alternative aerobic exercise for adults with type 2 diabetes.

34

摘 要

PP-02 Metabolic Outcome for Diabetes Shared Care Program Outpatients in a Veterans Hospital of Southern Taiwan 1

L-J HAO, 2K-J TIEN, 3H-L CHAO, 1C-J HONG, 4F-S CHOU, 5T-J WU, 6J-K CHAO, 7M-D SHI, 8K-L CHAI, 9K-C KO, 10M-C MA 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Yongkang Veterans Hospital, Yongkang, Taiwan. (Dr Hao and Miss Hong, CDE) 2 Division of Endocrinology and Metabolism, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan. (Dr Tien) 3 Department of Health Care Administration, Chung Hwa University of Medical Technology, Tainan, Taiwan.

(PhD Chao) 4 Institute of Information Management, National Cheng Kung University, Tainan, Taiwan. (PhD Chou) 5 Division of Endocrinology and Metabolism, Department of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan. (Dr Wu) 6 Department of Psychiatry, Yuli Veterans Hospital, Hualien, Taiwan. (Dr Chao) 7 Department of Pathology and Laboratory Medicine, Yongkang Veterans Hospital, Yongkang, Taiwan. (PhD Shi) 8 Division of Gastroenterology, Department of Internal Medicine, Yongkang Veterans Hospital, Yongkang, Taiwan. (Dr Chai) 9 Department of Administration, Longcyuan Veterans Hospital, Pingtung, Taiwan. (Dr Ko) 10 Department of Statistics, National Cheng Kung University, Tainan, Taiwan. (PhD Ma)

Background: To evaluate the metabolic outcomes of Diabetes Shared Care Program (DSCP) for type 2 diabetes after completion of 1 and 3-year of intervention.

Methods: Total 162 type 2 diabetes (average age 67.14 years old with 62.35% male and 37.65% female) in 2004 were referred to the diabetes educator for the program.

Parameters related to diabetes among these patients were inquired, and biochemical data were compared before and after the DSCP. Results: DSCP did increase patient number in achieving the glycated hemoglobin (A1C), BP and LDL-C target levels. These patients have 3.1% emergency utilization rates and 1.9% hospitalization utilization rates and significant improvement in diastolic blood pressure (DBP), BW, fasting plasma glucose (FPG), A1C levels after one year, and significant improvement in systolic blood pressure (SBP), DBP, BW, total cholesterol, HDL-C, LDL-C levels after three years. But only 4.84% and 8.87% met all the ABC target values after the 1 and 3-year intervention, respectively.

Conclusion: DSCP should be offered as close to the time of diagnosis, and directed towards patients with high baseline A1C, SBP, DBP, LDL-C, low baseline HDL-C levels.

Further public health efforts are needed to control risk factors for vascular disease among diabetes.

Keywords: diabetes mellitus; diabetes mellitus educator; diabetes shared care program 35

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

PP-03 Premature Delivery and Severe Kyphosis in a Young Woman with Adrenal Cushing's Syndrome - A Case Report Y-K TAI, C-M CHIEN Division of Endocrinology and Metabolism, Department of Internal Medicine, Yuan's General Hospital, Taiwan

Introduction: Pregnancy in women with Cushing’s syndrome is rare. Pregnancyrelated physical and biochemical changes make early diagnosis of Cushing's syndrome a difficult task. Osteoporosis is a common manifestation of Cushing’s syndrome. However, severe kyphosis due to vertebral compression fractures is unusual in a young woman. Here we presented a delayed diagnosed case with Cushing’s syndrome. The risk of permanent spinal deformity cannot be overemphasized to all healthcare professionals.

Case presentation: This 28-year-old female first visited our hospital for progressive kyphosis about one and a half years after her first childbirth. Her body height before the pregnancy was 155cm. The pregnancy course seemed uneventful till gestational age of 32 weeks, when preeclampsia occurred. She received C/S and delivered a premature baby weighing 1500g. Postpartum, she became aware of progressive thoracic kyphosis. She consulted an orthopedist and vertebral compression fractures was diagnosed. In addition, she visited a gynecologic clinic for persistent amenorrhea and only hormone therapy was prescribed. Finally, she was introduced to the orthopedist in our hospital. Because of Cushingoid appearance, she was admitted for further study. On admission, her body height was 135cm, a height loss of 20cm compared to previous measurement. Lumbar spine T-score (by DXA) was -7.02. MRI of the spines revealed extensive T-spine compression fractures (involving T5,6,7,8,11&12). Endocrine and image studies confirmed the diagnosis of adrenal Cushing’s syndrome. Through laparoscopic approach, an adrenal adenoma was removed smoothly. Unfortunately, subsequent vertebroplasty for her back pain led to a sequela of paraplegia.

Conclusion: The presence of Cushing’s syndrome during pregnancy may be masked.

A high index of clinical suspicion is required for early diagnosis. When encountering a young woman with severe osteoporosis, the clinician should include hypercortisolism in the differential diagnosis. Early treatment could reverse the process of bone loss; delayed diagnosis may result in permanent spinal deformity.

36

摘 要

PP-04 Concomitant Primary Hyperparathyroidism, Papillary Thyroid Cancer and Metastatic Carcinoid - A Case Report 1

Y-C CHEN, 1P-Y LIAO, 1M-C HSIEH

1

Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital,

Changha, Taiwan

Concomitant primary hyperparathyroidism, papillary thyroid cancer and metastatic carcinoid is a rare condition. We present a case of 36-year-old man with a history of bilateral ureteropelvic junction stone and hypertension (diagnosed at May 2005).

Blood tests revealed calcium of 11.4 mg/dl and intact PTH of 86 pg/mL. Parathyroid scan was done and revealed hyperfunctioning parathyroid tissues at bilateral thryoid bed and mediastinum. Survey for MEN IIa was performed and mildly elevated urine norepinephrine and dopamine was found. Abdominal CT was arranged and showed small nodualr tumor(1.2cm in size ) over right adrenal gland. Thyroid echo and was arranged and showed right nodular goither with calcification, bilateral cervical lymphadenopathy.

Fine needle aspiration was performed and no malignant cell was noted. The patient was underwent right laparoscopic adrenalectomy and subsequent pathologic section showed carcinoid tumor. CXR, panendoscopy and colonoscopy were applied for location of primary carcinoid tumor but no lesions were found. First time chemotherapy with regimen of cisplatin and Etoposide was administered. Then the patient was underwent total parathyroidectomy with autoimplatation over left m and bilateral radical total thyroidectomy. Subsequent pathologic report showed parathyroid hyperplasia and right thyroid papillary carcinoma. Three years later, extensive metastasis of carcinoid in both lungs, mediastinal lymph nodes, liver, left adrenal gland and bones were detected.

Overview of the case, concomitant primary hyperparathyroidism, papillary thyroid cancer and metastatic carcinoid was diagnosed but the possibility of MEN I maybe considered.

37

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

PP-05 Using Continuous Glucose Monitoring System to Assist Diagnosis of Insulinoma- A Case Report 1

Y-C CHEN, 2M-T KAO, 1D-H TSAI, 1S-D LIN

1

Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital,

Changha, Taiwan 2

Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital

Yulin branch, Yulin, Taiwan

Insulinomas are rare neuroendocrine tumors of the pancreas. Clinically, it usually represented as recurrent symptomatic hypoglycemia. Delayed diagnosis of insulinoma is common. We reported a case of repeated hypoglycemia since three years ago. Continuous glucose monitoring system was applied and demonstrated frequent midnight and early morning hypoglycemic episodes. The 72-hour fast test was performed and the results fulfilled the criteria for insulinoma. Abdominal magnetic resonance imaging found a 1.0-cm nodular lesion over pancreatic body. A laparoscopic partial pancreaectomy over body was taken. The patient's plasma glucose became within normal range postoperatively and no hypoglycemic episode occurred after six months follow-up. The usage of CGMS for hypoglycemic patients may provide more and better dynamic data to pathophysiology of hypoglycemia and help to diagnose insulinoma earlierly.

38

摘 要

PP-06 Diabetic Ketoacidosis Precipitated by Sinusitis - A Case Report PEI-CHUN HSU, HAO-CHANG HUNG, HORNG-YIH OU, TA-JEN WU Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C.

Introduction: Infection is one of the most common precipitating factors of diabetic ketoacidosis (DKA). Successful treatment accounts on effective infection control. We report a case of DKA precipitated by sinusitis with mucomycosis colonization. Exogenous insulin was successful taken off after effective debridement and antibiotics.

Case Report: A 47-year-old male without diabetes history suffered from general weakness, polyuria, thirsty and polyuria for 1 month. He came to a district hospital for help 2 days ago. Under the impression of newly diagnosed diabetes with DKA, he was treated in the intensive care unit. He was referred for reluctant DKA. Initial survey showed leukocytosis with left shifting (WBC: 16700/μl, Seg.76 %, Band: 12%), plasma glucose of 236 mg/dl, high anion-gap metabolic acidosis (PH 7.183, PCO2 12.6mmHg, PO2 161 mmHg, HCO3 4.7mmol/L, BEecf -24 mmol/L, Anion gap 24), serum ketone ++++, CRP 239.4 mg/L. Elevated serum amylase of 314 U/L and lipase of 5025 U/L without symptoms of pancreatitis were noted. Chest X-ray, urinalysis, abdominal computerized tomography all didn’t show infection focus. As the patient’s complaints of nasal obstruction, headache, maxillary tenderness, and epistaxis, x-ray film of Water’s view showed bilateral sinusitis. Sinoscopy showed crusts in bilateral nasal cavity. After debridement and antibiotics treatment, insulin was tapered off and his sugar was well control under metformin 2000mg per day. The final pathology revealed sinusitis with mucomycosis colonization.

Conclusion: Sinusitis may precipitate DKA, and well debridement and infection control are the key of successful treatment.

39

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

PP-07 Concomitant Use of Repaglinide-Gemfibrozil Related Prolonged Hypoglycemia - A Case Report PEI-CHUN HSU, HORNG-YIH OU, HAO-CHANG HUNG, TA-JEN WU Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, R.O.C.

Introduction: Repaglinide, a short-acting insulin secretagogue, was reported to have an interaction with gemfibrozil. Here we report a case of prolonged hypoglycemia by concomitant use of repaglinide and gemfibrozil.

Case Report: An 86 year-old male with underline hypertension, diabetes mellitus, dyslipidemia, gout and dementia was presented to ER with the chief problem of conscious disturbance. He irrationally banged his head on wall at home. Initial tests revealed finger blood sugar 35 mg/dl and plasma sugar 29 mg/dl by central Lab. His conscious returned to baseline after hypoglycemia corrected. Despite of supplying profuse dextrose water and discontinuing anti-diabetic medication, repeated hypoglycemia episodes attacked him during a period of 10.5 hours. He has regularly taken repaglinide 1mg twice daily for glucose control for years and had never experience hypoglycemia before. Gemfibrozil was the new drug added for one month. HbA1c checked was 5.7% and creatinine was 1.37 mg/dl in the admission. Medication review found interaction between repaglinide and gemfibrozil. He discharge 3 days later with normoglycemia without diabetes medication.

Sitagliptin 100 mg once daily was added at OPD and well control without hypoglycemia thereafter.

Conclusion: The concomitant use of repaglinide and gemfibrozil may result in enhanced and prolonged hypoglycemia.

40

摘 要

PP-08 Case Report of Multiple Endocrine Neoplasms Type 2A C-H KUO, S-T YEH, T-T SEE, C-Y WANG Division of Endocrinology and Metabolism, Department of Internal Medicine, Far-East Memorial Hospital, Taiwan, R.O.C

This 22 years old young man is a patient with bilateral medullary thyroid carcinoma s/p twice total thyroidectomy in 2010-01 and 2010-03.

He got dizziness, palpitation suddenly in 2010-04. Tachycardia with hypertension was found at ER of LMD. Further image survey with abdomen and brain CT revealed bilateral adrenal hyperplasia and then he was transferred to our OPD for further study.

However, general malaise with impalpable peripheral pulse was noted at OPD and tachycardia with fluctuated blood pressure was noted at our ER. Because of multiple endocrine neoplasms type 2A was highly suspected, he was admitted for symptoms control and complete study.

After admission, pheochromocytoma work up, MTC staging and parathyroid function evaluation were done. The results showed image study with MRI & PET was compatible with pheochromocytoma. Later, urine catecholamines & VMA revealed strongly positive, and genetic study indicated RET proto-oncogene 634 point mutation.

Fortunately, no evidence was found of MTC distal metastasis via bone scan & CT, and parathyroid function was within normal limited.

We provide symptoms control to pheochromacytoma with Doxaben and Inderal, and the clinical condition of patient improved rapidly. Then he was discharged with refusal of surgical intervention. Meanwhile, genetic study for familial members, especially his brother, was suggested, but patient's family refused. This young man was ordered but irregularly followed up in our OPD. We still keep close touch with him and his mother, and try to persuade him receiving operation and familial genetic survey.

41

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

PP-09 Triiodothyronine Toxicosis Presenting as Hypokalemic Paralysis and Acute Respiratory Failure Y-C HUNG, T-Y WANG, C-T CHANG, C-C CHEN, R-H CHEN, M-H HSIEH Division of Endocrinology and Metabolism,Department of Internal Medicine,China Medical University Hospital,Taichung,Taiwan, R.O.C.

Thyrotoxic periodic paralysis (TPP) is a not uncommon manifestation of hyperthyroidism in young Asian population. TPP occurs in about 13% of the Chinese male and 0.17% of female thyrotoxic patients. We report a very rare case of TPP occurring in a middle-age woman who presented with sudden onset of muscle paralysis in all extremities and acute respiratory failure.

A 44-year-old woman with history of hypertension and gout was sent to the emergency room because of flaccid paralysis of four limbs. She denied weight loss, palpitation, nerviousness and heat intolerance. She took atenolol 100 mg daily for controlling of blood pressure. The blood biochemistry examination revealed severe hypokalemia 1.4 mmol/L. Although she was treated with intravenous potassium chloride.

Five hours later, she developed chest tightness and progressive dyspnea, following by loss of consciousness. Emergent endotracheal intubation were perfomed. After sixteen hours, her muscle strength was fully recovered, with serum potassium concentration of 3.8 mmol/L. She was extubated on the third day of hospitalization. Thyroid function tests showed FT4 0.96 ng/dL (0.54 –1.40 ng/dL), free T3 4.28 pg/mL (2.0 –4.0 ng/dL) and TSH 0.033μIU/mL (0.34–5.6 ng/dL), confirming the diagnosis of triiodothyronine (T3 ). toxicosis Methimazole 5 mg twice daily and propranolol 20 mg trice daily were prescribed for her hyperthyroidism. The TSH and free T3 level returned to normal after one month’s medications and she didn't have muscle weakness or paralysis again.

To our knowledge, this is the first reported case of T3 toxicosis-induced TPP in a middle-age woman. The clinical features of T3 toxicosis in patients with TPP may be very subtle or virtually nonexistent. Thyroid function tests should be routinely checked in patient presenting as hypokalemic paralysis.

42

摘 要

PP-10 Atypical Ketosis-Prone Diabetes YANG-MING LEE, SHIH-LI SU, MING CHIA HSIEH Division of Endocrinology and Metabolism, Department of Internal Medicine,Canghua Christian Hospital

Introduction: An atypical ketosis-prone diabetes is revealed by ketosis (ketosis-prone type 2 diabetes mellitus) in the absence of β -cell autoimmunity, frequently occurring in individuals who are black and of African origin, and characterized by an acute onset requiring transient insulin therapy. It is increasingly frequent in nonwhite populations. Here we report a case of ketone prone diabetes.

Case Report: A 25 years old man with a 6-year history of type 2 diabetes mellitus with oral antidiabetic drug (Current medications: metformin 0.5# tid) and hypertension presented in June 2010 with general weakness, polyuria and thirst for 5 days. He also had dysuria, frequent urination and mild fever. At first, he went to local clinic and empirical antibiotic cephradine was prescribed. However, progressive shortness of breath developed.

He denied cough, chest pain, abdominal pain and diarrhea.Then he was admitted on 4th June 2010. Laboratory tests showed leukocytosis (17.1x 103/μL). The arterial PH was revealed acidemic, anion gap 12.5, serum bicarbonate 10.5mmol/L and blood glucose 293mg/dL. Urine analysis showed 4+ ketone, microscopic hematuria, no pyuria. After receiving standard treatment for DKA with iv fluid and insulin. He recovered uneventfully and was discharged on the 6th hospital day.

At this presentation, Anti-GAD antibody: <1.0 U/mL . C-Peptide: 0.26 ng/mL (0.9-7.1).

Conclusion: This young, obese Taiwanese patient with early-onset type 2 diabetes and well glycemic control with oral antidiabetic drug in the past 6 year presented with DKA. Laboratory tests revealed no evidence of acute infection, cardiac ischemia, or cerebrovascular disease, renal or liver dysfunction, or recent alcohol use except possible post partial treatment urinary tract infection. Furthermore, he has no evidence of β-cell autoimmunity. He had partially preserved β -cell functional reserve. It fits the characteristics of ketone prone diabetes as marked insulin deficiency associated with ketosis in the abscence of precipitating event and markers of β-cell autoimmunity.

Despite current HM regimen, we may come off insulin therapy and change to oral antidiabetic agents later. Additionally, C-peptide level should be followed up to see if β -cell function evolution after this ketosis epidsode.

43

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

PP-11 Case Experience of Target Therapy for Patient with Thyroid Papillary Carcinoma with Advanced Metastasis 1

H-J JIANG, 1P-J HSIAO, 1,2K-D LIN, 1M-Y LEE, 1,3S-J SHIN

1

Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical

University Hospital. 2Graduate Institute of Medicine, Kaohsiung Medical University. 3Department of Medical Genetics, School of Medicine, Kaohsiung Medical University, Taiwan, R.O.C.

The standard treatment of papillary thyroid cancer includes total thyroidectomy, radioiodine and thyroid hormone suppression therapy. However, there is still lack of effective therapy to manage the distant metastasis, especially for patients who have achieved the maximal cumulative dosage of radioiodine. Targeted therapy with tyrosine kinase inhibitor (sunitinib) and anti-angiogenesis (thalidomide) has been developed and applied in treatment of advanced thyroid carcinoma. Here, we presented our limited experience in a case of progressive metastasis of thyroid papillary carcinoma.

A 70-year-old female has ever received surgical excision for benign recurrent neck nodules three times about 40 yrs ago. However, a rapidly growing neck mass occurred and papillary thyroid carcinoma was diagnosed in our hospital in 2005. Total thyroidectomy was done and I131 whole body scan showed distant metastasis to lung and bone with elevated thyroglobulin 1623 ng/mL. Five times of radioiodine therapy were done to reach the accumulated dose as 930 mCi with adjuvant therapy with thalidomide 100 mg daily within this 5 year period. The thyroglobulin level declined to 7.11 ng/mL gradually. But hematuria, multiple hard subcutenous nodules over back and left neck and pleural effusion were detected by the routine follow-up in 2010. The cancer work up study proved the advanced metastasis of papillary carcinoma with malignant effusion, left obstructive uropathy and skin metastasis.

Target therapy with Sunitinib was tried with initial dosage of 50mg once daily for 2 weeks, then the neck lymph node metastasis dramatically disappeared by sonographic evaluation. The lung metasistatic lesion improved and the obstructive hydronephrosis showed resolution. Dosage of Sunitinib was tapered to 25 mg daily for another 2 weeks because of severe thrombocytopenia and leukopenia. After 2 week-period of drug 44

摘 要

withdrawal, the lung metastasis worsed rapidly with hilar enlargement and atelectasis. So she is still under the treatment of Sunitinib until now.

This case experience demonstrated the fact thyroglobulin level is not a good tumor marker when the differentiated thyroid carcinoma progressed with advanced courses. And target therapy with tyrosine kinase inhibitor combined with agents to block angiogenesis (thalidomide) may be considered as an option to treat such patients with terminal stage of papillary carcinoma.

45

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

PP-12 Glucose Pattern of Type 2 Diabetes with Cushing’s Disease by Using Continuous Glucose Monitoring System - a Case Report P-F CHEN Division of Endocrinology and Metabolism, Department of Internal Medicine, Buddhist Da Lin Tzu Chi General Hospital

Objective: Continuous glucose monitoring system (CGMS) provides a way to look glucose pattern for 24 hours, which is very distinct from self-monitoring blood glucose, mostly eight points of glucose a day. When CGMS is used, the HbA1C level can decrease further about 1%. Now we use CGMS for the diabetic patients with poorly glycemic control, even they had being using insulin. We evaluate the glucose pattern from CGMS and make some decisions to improve glycemic control of these patients.

Case report: we report a case of type 2 diabetes mellitus who had poorly glycemic control. Finally, Cushing’s syndrome was suspected from the pattern of CGMS. The glucose pattern of CGMS after operation was compared. A 60-year-old female who came to our hospital because of poorly glycemic control in Dec, 2008. She had type 2 diabetes mellitus for 4 years. The initial A1C was 9.8%. She started basal insulin of levemir in May, 2009 and titrate up to 18U within 3 months. However, she experienced there is no effect of insulin because fasting glucose levels stills above 200 mg/dl. Then we performed CGMS for this patient in May, 2010. The glucose pattern revealed the strange surge of post-prandial glucose levels of three meals per day under well diet control. C-peptide level was 26.5 μIU/ml that exclude the possibility of type 1 diabetes. As this patient had hypokalemia, hypertension, moon face, and neck skin tags, functional dexamethasone suppression tests and MRI of sella are both compatible with Cushing’s disease. She received endoscopic transnasal pituitary surgery in Jul, 2010. The pathologic report confirmed an ACTH-secreting microadenoma. She experienced symptoms of adrenal insufficiency. However, morning serum cortisol level is 8.0 μg/dl 2 weeks after operation.

After operation, the glucose pattern showed the disappearance of post-prandial glucose surge.

Conclusion: In patients with type 2 diabetes mellitus with poorly glycemic control, there is need to perform CGMS to see the glucose pattern. Under the guidance of glucose pattern, we can make some decisions, like this reported case, to improve the glycemic control for these patients.

46

摘 要

PP-13 Glucose Pattern of Type 2 Diabetes and Pregnancy by Using Continuous Glucose Monitoring System - A Case Report P-F CHEN Division of Endocrinology and Metabolism, Department of Internal Medicine, Buddhist Da Lin Tzu Chi General Hospital

Objective: Continuous glucose monitoring system (CGMS) provides a way to monitor glucose pattern for 24 hours, which is very distinct from self-monitoring blood glucose, mostly eight points of glucose a day. Perinatal mortality has 2-fold increase in preexisting diabetes in pregnancy. Although HbA1C level is a treatment goal for diabetes, it can’t be used in pregnancy condition. So we use the glucose pattern from CGMS to make quickly improvement of glycemic control without further hypoglycemia risk.

Case report: we report a case of type 2 diabetes mellitus, diagnosed in Mar, 2006 with initial HbA1C level of 8.3%. Finally, the HbA1C level touched 6.0% in Oct, 2008.

She didn’t take oral anti-diabetic drugs since Feb, 2009 as she wished to get pregnancy.

However, this conception did not success. Then she lost follow-up till Jan, 2010 when she was told to have pregnancy. The body weight was 90.7 kg and the BMI was 35.9 kg/m2.

The A1C level was 7.7%. For the purpose of quick control of diabetes, we used CGMS immediately and titrated up the insulin doses day-by-day aggressively. The dose of Aspart ( Novorapid® ) was then decreased because post-prandial hypoglycemia was found several times. The HbA1C level was 6.8% in the next month and was falsely low to 5.2% in mid-pregnancy in Jun, 2010. We arranged real-time CGMS to adjust insulin dose. The post-prandial glucose excursion is below 140 mg/dl in each meal. However, we found mid-night hypoglycemia that was related with decreased fetal activity. So bedtime NPH insulin injection was decreased to 9U. Now, the fetus is health and it’s weight is within normal limits.

Conclusion: In patients with type 2 diabetes mellitus and pregnancy, there is need to perform CGMS to see the glucose pattern. Under the guidance of glucose pattern, we can make some decisions for tighter glycemic control and to avoid hypoglycemia risk for these patients.

47

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

中文作者索引 姓 名

頁數

姓 名

頁數

丁瑋信

25

施婷婷

41

尤則雅

21

洪逸芷

42

方淑音

33

洪禎鎂

25

王子源

31, 42

洪靜如

35

王治元

41

洪晧彰

39, 40

王紹全

22

胡念祖

32

王瑞霞

34

范盛娟

27

田凱仁

35

奚明德

35

朱正中

27

徐佩君

39, 40

吳怡磊

25

徐維信

20

吳達仁

35, 39, 40

徐慧君

33

吳達仁

20

柴國樑

35

李仰民

43

郝立智

35

李佩儒

33

馬瀰嘉

35

李欣蓉

25

高美燈

38

李洮俊

33

張天鈞

13, 23, 27

李美月

44

張倩青

27

李國陽

23

張書瑋

27

李燕晉

25

張淳堆

31, 42

辛錫璋

44

張順昌

32

周福星

35

張毓泓

33

林世鐸

38

張道明

33

林昆正

33

張慶忠

31

林昆德

44

郭志豪

41

林昭旭

25

陳沛隆

21, 27

林桓生

21

陳育正

37, 38

侯俊成

32

陳芃如

31

姜和均

44

陳明宗

29

48

作者索引

姓 名

頁數

姓 名

頁數

陳品汎

46, 47

廖安琪

29

陳清助

31, 42

廖培湧

37

陳嘉允

32

趙建剛

35

陳榮福

18

趙海倫

35

陳榮興

31, 42

劉瑞川

24

陳瑩陵

32

歐弘毅

39, 40

曾芬郁

19

蔡東華

38

黃士銘

20

蔡青峰

22

黃天祥

21

蔡政麟

29

黃怡欽

24

蕭若妤

34

黃建寧

22

蕭璧容

44

黃秋玲

34

戴研光

34, 36

黃偉倫

31

謝明家

37, 43

黃國欽

31

謝旻晃

31, 42

黃琪鈺

25

謝馨儀

27

楊宜瑱

22

簡誌銘

34, 36

楊偉勛

27

羅福松

25

楊麗瓊

20

羅綸謙

32

葉淑婷

41

蘇矢立

43

葛光中

35

※頁數下劃底線，表示第一作者。

詹佳蓉

25

49

中 華 民 國內 分泌 暨 糖 尿病 學 會 99 年 度 秋 季 學 術 研 討 會

Author Index (English) Name

Page

Name

Page

CHAI K-L

35

HONG C-J

35

CHAN C-J

25

HOU C-C

32

CHANG C-C

27

HSIAO J-Y

34

CHANG C-C

31

HSIAO P-J

44

CHANG C-T

31, 42

HSIEH H-Y

27

CHANG D-M

33

HSIEH M-C

37, 43

CHANG S-C

32

HSIEH M-H

31, 42

CHANG S-W

27

HSU H-C

33

CHANG T-C

13, 23, 27

HSU P-C

39, 40

CHANG Y-H

33

HSU W-H

20

CHAO H-L

35

HU N-Z

32

CHAO J-K

35

HUANG C-L

34

CHEN C-C

31, 42

HUANG C-N

22

CHEN C-Y

32

HUANG C-Y

25

CHEN J-F

18

HUANG I-CH

24

CHEN M-J

29

HUANG K-C

31

CHEN P-F

46, 47

HUANG S-M

20

CHEN P-J

31

HUANG T-S

21

CHEN P-L

21, 27

HUANG W-L

31

CHEN R-H

31, 42

HUNG C-M

25

CHEN Y-C

37, 38

HUNG H-C

39, 40

CHEN Y-L

32

HUNG Y-C

42

CHIEN C-M

34, 36

JIANG H-J

44

CHOU F-S

35

KAO M-T

38

CHU C-C

27

KO K-C

35

FANG S-Y

33

KUO C-H

41

FANN C-J

27

LEE K-Y

23

HAO L-J

35

LEE M-Y

44

50

作者索引

Name

Page

Name

Page

LEE P-J

33

TAI Y-K

34, 36

LEE Y-J

33

TIEN K-J

35

LEE Y-J

25

TING W-H

25

LEE Y-M

43

TSAI C-F

22

LI H-J

25

TSAI C-L

29

LIAO A-C

29

TSAI D-H

38

LIAO P-Y

37

TSENG F-Y

19

LIN C-H

25

WANG C-Y

41

LIN H-S

21

WANG R-H

34

LIN K-C

33

WANG S-C

22

LIN K-D

44

WANG T-Y

31, 42

LIN S-D

38

WU T-J

35, 39, 40

LIU R-TS

24

WU T-J

20

LO F-S

25

WU Y-L

25

LO L-C

32

YANG W-S

27

MA M-C

35

YANG Y-S

22

OU H-Y

39, 40

YEH S-T

41

SEE T-T

41

YU L-K

20

SHI M-D

35

YU T-Y

21

SHIN S-J

44

※Underline Indicate First author

SU S-L

43

51

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