Status of endocrinology and metabolism specialists in Taiwan.

BACKGROUND: The literature emphasizes the importance of matching the demand and supply of endocrinology and metabolism (EM) specialists. This study analyzed the current status of EM specialists in Taiwan. The gender effects on the workplace of EM specialists were also evaluated. METHODS: The number of internal medicine (IM) specialists was obtained from the websites of the Ministry of Health and Welfare. Data about EM specialists were retrieved from the database of the Endocrine Society of the Republic of China (ESROC; Taiwan). Differences in age distribution and workplace levels or locations between female and male EM specialists were analyzed. RESULTS: Since 1988, 809 physicians were certified as EM specialists. The average age of 739 EM specialists (509 male, 230 female) who remained as active members of the ESROC was 49.9 ± 11.1 years. The age distribution (p < 0.001) and workplace location (p = 0.043) were significantly different between male and female EM specialists. Divided by decades, the ratio of female-to-male EM specialists revealed an increasing tendency (p < 0.001). The percentage of EM specialists among IM specialists, certified 2 years previously, declined from 14.0% in 2017 to 7.9% and 8.3% in 2018 and 2019, respectively. CONCLUSION: The female-to-male ratio of EM specialists increased gradually. Compared to males, female EM specialists were relatively younger, and more of them had clinical practice in northern Taiwan. The percentage of IM specialists becoming EM specialists declined in the last 2 years. The equilibrium between the supply and demand of EM specialists deserves further investigation.

Health literacy and depression in women with type 2 diabetes mellitus.

OBJECTIVES: The prevalence of diabetes mellitus has recently increased in Taiwan, and depression is common among these patients. Moreover, a lack of health literacy may lead to depression. In this study, we explored the correlation between health literacy and depression in diabetic women. METHODS: In this cross-sectional study, 152 women with type 2 diabetes mellitus were recruited from the outpatient clinic of a regional teaching hospital in Taiwan. The data were collected through medical records and a self-reported structured questionnaire, which included items on basic attributes, self-rated health status, the Center for Epidemiologic Studies Depression Scale (CES-D), and Chinese Health Literacy Scale for Diabetes (CHLSD). The results were analyzed using descriptive statistical analyses, bivariate correlation tests, and linear regression analyses. RESULTS: One hundred thirty-five valid questionnaires were obtained. Approximately 20% of the participants had a higher tendency toward depression as per their CES-D score, and the CHLSD results showed that 13.33% had poor health literacy. There was a negative correlation between health literacy and depressive tendencies after adjusting for self-rated health status, economic satisfaction status, employment status, and education level using multivariate linear regression analyses. For each 1-point rise in the CHLSD score, the CES-D score decreased by 0.17 points (z=-2.05, p=0.042). CONCLUSIONS: A negative correlation was identified between health literacy and depression. Self-rated health status, economic satisfaction, employment status, and higher education level are factors that also affect depressive tendency among diabetic women.

Health literacy and depression in women with type 2 diabetes mellitus

OBJECTIVES: The prevalence of diabetes mellitus has recently increased in Taiwan, and depression is common among these patients. Moreover, a lack of health literacy may lead to depression. In this study, we explored the correlation between health literacy and depression in diabetic women. METHODS: In this cross-sectional study, 152 women with type 2 diabetes mellitus were recruited from the outpatient clinic of a regional teaching hospital in Taiwan. The data were collected through medical records and a self-reported structured questionnaire, which included items on basic attributes, self-rated health status, the Center for Epidemiologic Studies Depression Scale (CES-D), and Chinese Health Literacy Scale for Diabetes (CHLSD). The results were analyzed using descriptive statistical analyses, bivariate correlation tests, and linear regression analyses. RESULTS: One hundred thirty-five valid questionnaires were obtained. Approximately 20% of the participants had a higher tendency toward depression as per their CES-D score, and the CHLSD results showed that 13.33% had poor health literacy. There was a negative correlation between health literacy and depressive tendencies after adjusting for self-rated health status, economic satisfaction status, employment status, and education level using multivariate linear regression analyses. For each 1-point rise in the CHLSD score, the CES-D score decreased by 0.17 points (z=−2.05, p=0.042). CONCLUSIONS: A negative correlation was identified between health literacy and depression. Self-rated health status, economic satisfaction, employment status, and higher education level are factors that also affect depressive tendency among diabetic women.

Prognostic factors on outcomes of follicular thyroid cancer.

PURPOSES: We investigated the influences of prognostic factors on long-term survival of patients with follicular thyroid cancer (FTC) based on all-cause mortality and two exclusive causes of death, FTC and non-FTC. METHODS: In this retrospective cohort study, we collected data of 204 patients with FTC diagnosed between 1985 and 2007 at National Taiwan University Hospital. For all-cause mortality, Cox proportional hazards models were used to estimate hazard ratios for prognostic factors. Cause-specific hazard and cumulative incidence function models were used to determine the influences of prognostic factors on FTC and non-FTC death, respectively. The dynamic processes of distant metastases and locoregional recurrences were included as time-varying factors in all models. RESULTS: The cumulative incidence of all-cause death was 24% and 45% at 10 and 20-years, respectively. Multivariate analyses identified that distant metastases, locoregional recurrences, and positive surgical margins were significant independent risk factors for overall survival, hazard, and cumulative incidence of FTC death. Age at diagnosis >60 years increased the risks of all-cause and non-FTC death as well as cumulative incidence of non-FTC death. Tumor size >4 cm had a harmful effect on overall survival. Female patients had higher risk and cumulative incidence of FTC death, but male patients had a higher cumulative incidence of non-FTC death. Lymph node metastases significantly increased the cumulative incidence of FTC death. CONCLUSION: Dynamic distant metastases and locoregional recurrences were the most dominant risk factors influencing FTC-specific hazard and cumulative incidence for FTC death by accounting for non-FTC death as a competing risk for FTC patients.

Three-Minute Step Test for Predicting Acute Mountain Sickness: A Post Hoc Analysis of Rhodiola Crenulata Extract for Prevention of Acute Mountain Sickness, a Randomized, Double-Blind, Placebo-Controlled, Crossover Trial.

BACKGROUND: Acute mountain sickness (AMS) often occurs in individuals who rapidly travel above 2,500 m. As the convenience of traveling and the development of mountain sports increase, AMS will become an increasingly important public health problem. However, no method to effectively predict AMS before it occurs is currently available. METHODS: This post hoc study investigated whether the 3-Minute Step Test (3MST), which evaluates physical fitness, is predictive of AMS development. The data collected in "Rhodiola crenulata extract for prevention of AMS: a randomized, double-blind, placebo-controlled, crossover trial" was used in the analysis. This study collected 204 observations of 102 participants who made two ascents of Hehuan Mountain (3,100 m) by bus within a 3-month period. Participants completed the 3MST at 250 m (before ascent) and 3,100 m (on Hehuan Mountain). The presence of AMS was accessed using the Lake Louise scoring system. RESULTS: AMS was identified in 124 observations (60.78%). In the univariate analysis, the pre-departure 3MST score (at 250 m) was not significantly associated with AMS (p = 0.498), but the 3MST score measured at 3,100 m, ascent number, pulse rate at 3,100 m, and saturation of peripheral oxygen (SpO2) measured at 3,100 m were significantly correlated with the occurrence of AMS (p = 0.002, 0.039, 0.005, < 0.001, respectively). In a further multivariate analysis, only SpO2 measured at 3,100 m had a significant association with AMS (p = 0.016 and 0.006, respectively). The trend analysis showed that for every 1-point increase in the 3MST score at 3,100 m, the AMS decreased by 4% (adjusted odds ratio [AOR] = 0.96, 95% confidence interval [CI] = 0.92-1.01). CONCLUSION: The 3MST score cannot be a predictor of AMS, but it may have a potential role in predicting ascent safety in high-altitude areas.

Serial association analyses of recurrent gap time data via Kendall's tau.

Recurrent event data are frequently encountered in long-term follow-up studies. In many applications, the gap times between two successive recurrent events are natural outcomes of interest. Investigation on patterns of associations among recurrent gap times within subjects is an important inferential issue. In this paper, we introduce flexible functions of previous gap times to create a class of summary measures of serial associations for a sequence of recurrent gap times through Kendall's tau. Such a general class of serial association measures provides a useful tool to quantify the predictive abilities of event history with different aspects. Non-parametric estimators of the proposed measures of serial associations are developed by generalizing the existing estimator of Kendall's tau for two serial gap times, in which inverse probability of censoring weights is used to overcome the induced dependent censoring. Various tests are further constructed for testing the constancy of serial associations over different events. Our method is applied to Denmark schizophrenia data and the results show that association structures are different for distinct ages of onset of schizophrenia.

The impact of locoregional recurrences and distant metastases on the survival of patients with papillary thyroid carcinoma.

OBJECTIVE: Some patients with papillary thyroid carcinoma (PTC) would suffer from locoregional recurrences or distant metastases. This study was aimed to elucidate the impacts of locoregional recurrences and distant metastases on these patients' survival. DESIGN: Retrospective hospital-based cohort study. POPULATION: Data were collected from 1636 subjects with PTC at National Taiwan University Hospital between 1985 and 2007. MEASUREMENTS: Overall and disease-specific survival curves were estimated by the Kaplan-Meier method. Time-independent and time-dependent prognostic factors were included simultaneously in multivariate analyses using Cox models. RESULTS: Overall survival (OS) rates at 10- and 20-years were 90% and 76%, respectively. The 10- and 20-year disease-specific survival (DSS) rates were 95% and 90%, respectively. Our multivariate analyses identified that older age, distant metastases (hazard ratio, HR: 6·69, 95% CI: 4·40-10·18), locoregional recurrences (HR: 1·88, 95% CI: 1·22-2·89), lymph node metastases, massive extrathyroid extension, male gender and larger tumour size (>4 cm) were significantly associated with poorer OS. Older age, distant metastases (HR: 15·03, 95% CI: 8·31-27·21), locoregional recurrences (HR: 3·63, 95% CI: 2·03-6·51), massive extrathyroid extension, male gender and larger tumour size (>4 cm) were independently related to worse DSS. The performance of high-dose (131) I ablation had a protective effect on OS and DSS. CONCLUSION: The locoregional recurrences had a moderately harmful impact on OS and DSS, but age and distant metastases were the major decisive factors for OS and DSS. High-dose (131) I ablation had a protective role. However, lymph node dissection did not alter the prognosis whenever lymph node metastases only influenced OS.

Rhodiola crenulata extract for prevention of acute mountain sickness: a randomized, double-blind, placebo-controlled, crossover trial.

BACKGROUND: Rhodiola crenulata (R. crenulata) is widely used to prevent acute mountain sickness in the Himalayan areas and in Tibet, but no scientific studies have previously examined its effectiveness. We conducted a randomized, double-blind, placebo-controlled crossover study to investigate its efficacy in acute mountain sickness prevention. METHODS: Healthy adult volunteers were randomized to 2 treatment sequences, receiving either 800 mg R. crenulata extract or placebo daily for 7 days before ascent and 2 days during mountaineering, before crossing over to the alternate treatment after a 3-month wash-out period. Participants ascended rapidly from 250 m to 3421 m on two separate occasions: December 2010 and April 2011. The primary outcome measure was the incidence of acute mountain sickness, as defined by a Lake Louise score ≥ 3, with headache and at least one of the symptoms of nausea or vomiting, fatigue, dizziness, or difficulty sleeping. RESULTS: One hundred and two participants completed the trial. There were no demographic differences between individuals taking Rhodiola-placebo and those taking placebo-Rhodiola. No significant differences in the incidence of acute mountain sickness were found between R. crenulata extract and placebo groups (all 60.8%; adjusted odds ratio (AOR) = 1.02, 95% confidence interval (CI) = 0.69-1.52). The incidence of severe acute mountain sickness in Rhodiola extract vs. placebo groups was 35.3% vs. 29.4% (AOR = 1.42, 95% CI = 0.90-2.25). CONCLUSIONS: R. crenulata extract was not effective in reducing the incidence or severity of acute mountain sickness as compared to placebo. TRIAL REGISTRATION: ClinicalTrials.gov NCT01536288.

Abnormal enlargement of pituitary gland during pregnancy remitted spontaneously after delivery.

Ovulation induction is seldom reported to cause pituitary abnormality and the physiological enlargement of the pituitary gland during pregnancy is asymptomatic. We report a woman who became pregnant after ovulation induction. She had symptomatic pituitary enlargement with a pituitary height of 2 cm on cranial magnetic resonance imaging (MRI) in the second trimester. Her symptoms (headache and blurred vision) improved greatly after delivery but she had absence of lactation. The height of the pituitary gland decreased to 1 cm on the second cranial MRI 40 days after delivery and her third cranial MRI only revealed a mild central bulge in the pituitary gland eight months after delivery. This article shows that the abnormal enlargement of the pituitary gland during pregnancy might remit spontaneously after delivery and these patients might have higher risk of postpartum hypopituitarism. Neurological symptoms and signs should be closely monitored during pregnancy and neurosurgery may not be necessary. Endocrine surveys should be performed regularly after delivery to detect hypopituitarism as early as possible.

Hypopituitarism: a sequela of severe hypoxic encephalopathy.

BACKGROUND/PURPOSE: Central diabetes insipidus (DI) is an established phenomenon after hypoxic encephalopathy or brain death, but hypopituitarism is seldom described. This study investigated the characteristics of 11 patients with DI and hypopituitarism which developed after severe hypoxic encephalopathy. METHODS: The medical records of patients with DI and hypopituitarism after severe hypoxic encephalopathy from 1997 to 2002 were retrospectively reviewed. Eleven patients with DI and hypopituitarism after severe hypoxic episodes were included. Demographic data, primary diagnosis, the time of onset of DI, the time of diagnosis of hypopituitarism, the presence of symptoms of hypopituitarism, and outcome of these patients were analyzed. RESULTS: Eleven patients comprising nine females and two males aged 47.4 +/- 19.3 years (range, 24-74 years) were included. The mean interval from the precipitating event to the onset of DI was 60 +/- 46 hours (range, 11-131 hours). The mean interval from the precipitating event to the diagnosis of hypopituitarism was 423 +/- 182 hours (range, 132-672 hours). The average duration of hospitalization was 63 +/- 35 days (range, 9-113 days). The overall mortality rate during hospitalization was 45%. Four patients died of sepsis and one died of heart failure due to acute myocardial infarction. CONCLUSION: The development of DI after severe hypoxic encephalopathy is a sign of severe brain damage. It usually ensues immediately or days after loss of brain stem reflexes. Hypopituitarism developed several weeks later than DI in these patients. Recognition and treatment of these deficiencies may prevent organ dysfunction.

Long-term primary medical therapy with somatostatin analogs in acromegaly.

To cure acromegalic patients, transsphenoidal surgery is considered first, especially for microadenoma. However, less than 50% of patients with macroadenoma achieve satisfactory biochemical control. Moreover, surgery may cause hypopituitarism. Medical therapy may offer the prospect of near normalization of growth hormone (GH)/insulin-like growth factor-1 levels with substantial tumor shrinkage in a significant number of patients. Here, we report two cases of acromegaly under treatment with somatostatin analogs alone for more than 10 years. Case 1 was a 54-year-old man with a pituitary macroadenoma. He received 4 years of octreotide treatment followed by 6 years of prolonged-release (PR) lanreotide resulting in normal GH level. Case 2 was a 60-year-old woman with a 1.3 cm pituitary tumor. She received 8 years of octreotide treatment followed by 6 years of PR lanreotide resulting in subnormal GH level and gallbladder sludge. She had received bilateral total hip replacement for hip osteoarthritis at the age of 59 years. These cases illustrate that long-term treatment with somatostatin analogs offers an alternative choice in selected acromegalic patients, such as those with pituitary tumor who cannot be cured by surgery, those who have unacceptable anesthetic risk and those who refuse surgery.

Secondary infection and ischemic necrosis after fine needle aspiration for a painful papillary thyroid carcinoma: a case report.

BACKGROUND: Papillary thyroid carcinoma (PTC) is often asymptomatic and rarely presents as a painful goiter. Further, the thyroid gland is not easily infected. Therefore, acute suppurative thyroiditis (AST) is unusual. PTC is also seldom combined with AST. We report a case of painful PTC with secondary infection after fine needle aspiration (FNA). CASE: A 19-year-old girl complained of a painful goiter without skin change after an episode of upper airway infection. PTC was diagnosed according to the FNA cytology (FNAC) at another hospital. The goiter became more painful after FNA. The patient's second FNAC at our hospital revealed only many polymorphonuclear leukocytes (PMNs). Antibiotic treatment ameliorated the pain, but the goiter persisted. The third FNAC revealed some PMNs and papillary carcinomatous cells. After total thyroidectomy, pathology revealed ischemic necrosis with a focal PMN aggregation around the needle track and papillary carcinomatous cells nearby. According to the time sequence, secondary infection after FNA was suspected. CONCLUSION: A painful goiter is an unusual presentation of PTC. Although FNAC is feasible for studying a thyroid lesion, malignant cells might be missed when secoandary injection and ischemic necrosis occur after FNA. Therefore, aseptic procedures are necessary to prevent bacteria from seeding into the thyroid.

Septic cavernous sinus thrombosis: an unusual and fatal disease.

BACKGROUND: Septic cavernous sinus thrombosis (CST) is a rare and fatal disease. Clinical presentations in the early stage are nonspecific, and the sensitivity of cranial axial computed tomography (CT) with thick section is low. This study analyzed the clinical manifestation and neuroimaging findings in patients with septic CST in a medical center in Taiwan. METHODS: This retrospective case series included nine patients with septic CST who had typical symptoms and clinical course, evidence of infection, and imaging studies which demonstrated cavernous sinus lesion, and who were treated between 1995 and 2003 at National Taiwan University Hospital. RESULTS: Seven (77.8 %) patients were more than 50 years old. Five (55.6%) had diabetes, and three (33.3%) had hematologic diseases. All cases were associated with paranasal sinusitis. The most frequent initial symptom was headache (66.7%), followed by ophthalmic complaints (diplopia or ophthalmoplegia, 55.6%; blurred vision or blindness, 55.6%), and ptosis (44.4%). Initial cranial images failed to identify CTS in all patients. Subsequent magnetic resonance imaging (MRI) or coronal contrast-enhanced CT (CECT) with thin section confirmed the diagnosis. Fungi were the most common pathogens (55.6%). The inhospital case-fatality rate was high (44.4%). CONCLUSION: Due to the high case-fatality rate and low yield rate of blood cultures, fungal CST should be suspected in an immunocompromised patient with ophthalmic complaints that progress from one eye to the other. Coronal thin-section CECT may be a useful alternative to MRI as a diagnostic modality for this condition.

Secondary hyperparathyroidism as a palpable intrathyroid parathyroid gland in a patient with hypophosphatemic osteomalacia.

Secondary hyperparathyroidism is sometimes seen in patients with hypophosphatemic osteomalacia after long-term oral phosphate therapy. Parathyroidectomy is sometimes needed for the correction of hypercalcemia in these patients, and is rarely performed in patients without hypercalcemia. A 46-year-old female patient had hypophosphatemic osteomalacia with unknown cause and secondary hyperparathyroidism. A palpable neck mass developed after long-term oral phosphate therapy. An intrathyroid parathyroid gland was confirmed through partial thyroidectomy and parathyroidectomy. Renal phosphate wasting decreased strongly, and serum parathyroid hormone was in the normal range after the operation. A correction of secondary hyperparathyroidism may partially overcome hyperphosphaturia in some patients with hypophosphatemic rickets.

Unusual presentation of thyrotoxicosis as bradycardia, acute renal failure and hyperuricemia in an elderly patient.

Bradycardia with renal system involvement in patients with thyrotoxicosis has rarely been reported. We report a 72-year-old woman with unusual presentations of sinus bradycardia and normothermia accompanied by acute renal failure and hyperuricemia in thyrotoxicosis. The electrocardiogram changes in this patient included sinus bradycardia (50 beats per minute), followed by atrial fibrillation (84 beats per minute), and finally sinus rhythm with T wave inversion (80 beats per minute). Her renal function and hyperuricemia completely recovered after appropriate antithyroid therapy. A high index of suspicion is needed for early diagnosis and antithyroid treatment in patients with unusual manifestations of thyrotoxicosis in general clinical practice.

Post-traumatic anterior and posterior pituitary dysfunction.

BACKGROUND AND PURPOSE: The recognition of hypopituitarism after head trauma is important because related neurobehavioral problems can be alleviated by hormone replacement. This study investigated the clinical presentations and imaging findings of patients with hypopituitarism developing after head trauma. METHODS: We retrospectively reviewed the medical records of patients with hypopituitarism from 1982 through 2002. Data on disease history and hormone deficiencies of patients with hypopituitarism which developed after head trauma were analyzed. RESULTS: Eighteen patients with hypopituitarism or diabetes insipidus (DI) due to head trauma, including 11 men and 7 women, were identified. Head trauma thus accounted for the etiology in 2.8% of all 635 patients with a diagnosis of hypopituitarism during the study period. The major cause of head trauma was road accident (n = 11, 61%). Ten of the patients (56%) had lost consciousness after the head injury. The duration from head trauma to the onset of symptoms of hypopituitarism ranged from < 1 month to 15 years. Sex hormone (61%) and growth hormone (56%) were the most common hormone deficiencies, followed by corticotropin deficiency (39%) and thyrotropin deficiency (22.2%). DI developed in 9 patients (50%) and 5 of these patients had only DI without anterior hypopituitarism. Routine skull radiograph did not show abnormal signs. Among the 10 patients with magnetic resonance imaging of the pituitary gland, a small or atrophic anterior lobe was seen in patients with anterior hypopituitarism. Loss of bright signal intensity from the pituitary posterior lobe on T1-weighted magnetic resonance imaging was seen in all 3 patients with DI. An ectopic posterior lobe could be seen in 2 patients with hypopituitarism without DI. CONCLUSIONS: Identification of head trauma as the etiology of hypopituitarism may be overlooked if there is a long delay in onset after trauma. DI is a common early complication. Since anterior hypopituitarism can develop decades after the episode of head trauma, monitoring for endocrine dysfunction during follow-up of these patients is important.

Follicular variant of papillary thyroid carcinoma: diagnostic limitations of fine needle aspiration cytology.

OBJECTIVE: To study the diagnostic sensitivity and specificity of fine needle aspiration cytology (FNAC) offollicular variant of papillary thyroid carcinoma (FVPTC). STUDY DESIGN: The study group consisted of 390 papillary thyroid carcinoma (PTC) cases diagnosed histologically with thyroidectomy specimens. The FNAC and histopathologic classification were compared in terms of the appearance of FVPTC and non-FVPTC statistically with the chi squared test. Also, several features of the cytologic smears of FVPTC were reviewed. RESULTS: Twelve of the 390 PTC cases were classified as FVPTC histologically. Five of the 12 cases were also reported as FVPTC in the diagnosis by FNAC and the other 7 as the usual type of PTC (UTPTC). There was 1 case classified as UVPTC histologically but FVPTC cytologically. If we use histologic diagnosis as the gold standard, the sensitivity and specificity of FNAC diagnosis of FVPTC were 42% and 83%, respectively. CONCLUSION: FNAC may be a good tool for diagnosing PTC, but it is unreliable to differentiate between FVPTC and UTPTC.

Rare presentation of endocrine pancreatic tumor: a case of diffuse glucagonoma without metastasis and necrolytic migratory erythema.

Glucagonoma is a very rare endocrine pancreatic tumor. At diagnosis, most glucagonomas are malignant and often metastatic. Suspicion of glucagonoma is based on characteristic presentations known as "glucagonoma syndrome". Glucagonoma is often found in the pancreatic body and/or tail and is usually large enough to be localized by computed tomography. We report a case of diffuse glucagonoma necrolytic migratory erythema (NME) in a 45-year-old man with mild diabetes mellitus, mild anemia, and weight loss over 1.5 years. Diffused enlarged pancreas was noted on abdominal ultrasonography incidentally during a routine health check-up. The levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were within normal limits. No enlarged lymph node or extrapancreatic tumor mass was found by several imaging studies. Total pancreatectomy was performed, and the pathology revealed glucagon-producing islet cells and intrapancreatic vascular emboli of tumor cells. He died due to internal bleeding and sepsis after surgery. Presentation of diffuse malignant glucagonoma with tumor emboli but no metastasis or NME is unusual.