There is limited clinical information comparing presentations and results of treatment of papillary and follicular thyroid carcinoma patients with distant metastases. We retrospectively analyzed data of 1,257 thyroid cancer patients who received their treatment and follow-up at Chang Gung Memorial Hospital. We found 992 patients with papillary carcinoma and 205 patients with follicular thyroid carcinoma. Of these, 68 patients with papillary thyroid carcinoma (6.9%) had distant metastases at the time of diagnosis or during the follow-up period. Of the follicular thyroid carcinoma patients, 69 (33.7%) had distant metastases. Of the 68 patients with papillary carcinoma, only 33 were categorized as stage IV at the time of diagnosis. Nine of the patients were categorized as clinical stage I carcinoma, 10 as stage II, and 16 as stage III. Sixteen patients (23.5%) died during the study period, all but 2 of thyroid cancer. Twelve of the 68 patients were disease-free after treatment. Of the 69 patients with follicular thyroid carcinoma, 58 were categorized as stage IV at the time of diagnosis. Six of the patients were categorized as clinical stage I carcinoma, 2 as stage II, and 3 as stage III at the time of diagnosis; all of these patients deteriorated to stage IV during the follow-up period. Of the 42 patients with follicular thyroid carcinoma involving bone, 24 presented with bone metastases during the initial diagnosis. After treatment, 25 of 69 patients with follicular carcinoma died of follicular carcinoma. Only 3 patients were disease-free after the treatment. In patients with follicular carcinoma, only tumor size was an important prognostic factor. In this study, 8 patients categorized as clinical stages I to III at the time of operation had thyroglobulin (Tg) levels less than 5 ng/mL and developed distant metastases during the follow-up period. In conclusion, at diagnosis a large group of Asian patients with metastatic well-differentiated thyroid cancer was more likely to have follicular than papillary histology, and that, as expected, metastases from follicular cancer were present earlier and more frequently, were more likely to involve bone, were more likely to be associated with mortality, and were linked to tumor size but not gender. Also unlike some other reports, treatment producing a low Tg did not always produce a good outcome. More aggressive surgical procedures may be able to improve outcomes.
Insulin therapy often becomes necessary when oral hypoglycemic agents are no longer effective. However, the rate of initiating insulin treatment is low among people with type 2 diabetes in Taiwan. A qualitative study was done at the diabetes centers of two hospitals and consisted of face-to-face interviews of patients who were reluctant to start insulin treatment. The results of interviews were subjected to Framework Analysis for emergent concepts and category system. There were 15 people (10 women, 5 men) who were interviewed, ages between 46 to 71 years old (mean age 59.7±7.3 years). We categorized the barriers of initiating insulin treatment as 1) Reluctance of physicians 2) Misconceptions about insulin 3) Low adaptation capacity 4) Needle phobia 5) Psychological insulin resistance. These barriers interfered with decisions to begin insulin treatment. To break these barriers, responsibility and decision-making should be placed upon caregivers for people with low adaptation capacity. Needle phobia should be looked at as a disease entity and addressed with greater patience. The possibility and benefits of insulin treatment should be included early in diabetes education. Physicians should adhere to the guidelines for initiation of insulin treatment and empower patients.
A 47-year-old woman had undergone cholecystectomy for gallstones in December 1994 at a local hospital. In December 1995 she presented at the surgical outpatient department with intermittent right upper quadrant pain. Laboratory studies revealed serum albumin 4.3 g/dl (normal 3.5–5.3 g/dl), total cholesterol 307 mg/dl (normal <200 mg/dl), total bilirubin 1.8 mg/dl (normal 0.0–1.3 mg/dl), alkaline phosphatase 602 U/litre (normal 28–94 U/litre), aspartate aminotransferase (AST) 129 U/litre (normal 0–34 U/litre), and alanine aminotransferase (ALT) 196 U/litre (normal 0–36 U/litre). Liver sonography revealed multiple stones in dilated intrahepatic and common hepatic ducts. However, the patient did not receive further studies of her hepatolithiasis at that time. The patient underwent percutaneous transhepatic cholangiostomy drainage for intrahepatic stones and jaundice in a medical centre in January 1998. In February 1998 she was transferred to the surgical department because of persistent jaundice. Physical examination revealed that the woman was markedly icteric, with an old scar on the right upper abdominal wall, and no xanthoma was found on the body. Laboratory results included that serum albumin was 4.1 g/dl, total cholesterol was 256 mg/dl, total bilirubin was 12 mg/dl, alkaline phosphatase was 512 U/litre, AST was 101 U/litre and ALT was 100 U/litre. Cholangiogram showed a dilated biliary tree with multiple stones in intrahepatic ducts, common hepatic ducts and the common bile duct. The patient underwent choledocholithotomy with choledochojejunostomy, Roux-en-Y jejunojejunostomy, and a T-tube drainage in the common bile duct in February 1998. The liver biopsy displayed cholestasis and no cirrhotic change. Following surgery the woman was regularly followed up in the outpatient department and intrahepatic stones were removed intermittently via a T-tube. Cholangitis was noted during follow-up, and the patient received five 7-day courses of amoxicillin 1000 mg/day in divided doses from September 1998 to February 1999. The jaundice was persistent during follow up, and painful xanthomas developed on both hands and elbows in February 1999, particularly on the palmar side (Figure 1). Laboratory tests revealed significantly raised serum total cholesterol, total bilirubin, and alkaline phosphatase levels (Figure 2). Lipoprotein electrophoresis displayed that total cholesterol was 1046 mg/dl, β-lipoprotein (low-density lipoprotein) was 72.6% (normal 36–61%), pre-β-lipoprotein (very low-density lipoprotein) was 15.7% (normal 2–30%), and α-lipoprotein (high-density lipoprotein) was 11.7% (normal 22–48%). Subsequently, the patient received no more amoxicillin, and the xanthomas gradually regressed. Total regression of hypercholesterolaemia and xanthomas was achieved in November 2000, at which point total serum cholesterol was 200 mg/dl, total bilirubin was 12 mg/dl, and alkaline phosphatase was 676 U/litre.
Objective: People with higher level of diabetes distress (DD) may have difficulty in managing their diabetes and possible higher A1c. In order to provide proper psychosocial care, we designed this study to understand the DD of participants in a diabetes clinic. Methods: The study was a cross-sectional design conducted in a diabetes clinic in Taiwan. Diabetes distress (DD) was assessed by Diabetes Distress Scale and accompanied by a semi-structured interview to collect qualitative information. DD includes 4 dimensions which are emotional burden (EB), interpersonal (IP), physician related (PR) and regimen-related (RR) distress. The correlation analysis was conducted to portray the relationships between DD and sociodemographic variables. Emotional state using Hospital Anxiety and Depression Scale, quality of life using WHO Quality of Life-BREF, and HbA1C levels were also gathered as the dependent variables in regression models to understand how DD related to the adaptive index in people with diabetes. Results: There were 71 (37 M and 34 F, 64 T2D and 7 T1D, 27 insulin treated) participants and mean age 51.6 ± 14.5 yrs. According to correlation analysis, age (r = -.30, p = .011) and taking insulin (r = .33, p = .005) were associated with the level of DD. Female participants had a higher level of EB (r = .26, p = .031) and IP distress (r = .29, p = .014). In the regression model with single independent variable, mean DD (β = .29, p = .016) and RR (β = .24, p = .040) was related to the level of HbA1C respectively, but they were not significant after entering control variables of taking insulin and new patients. Mean DD and EB distress were significant association with quality of life, the symptoms of depression and anxiety in the regression models. Conclusions: Younger people and using insulin were associated with higher level of DD. The mean score of DD and RR dimension were also associated with the levels of A1c, however, using insulin and new patients might have a stronger association with the levels of A1c. Disclosure K. Chen: None. H. Chen: None. C. Hung: None. J. Hwang: None. Y. Chuang: None. Z. Chen: None.
We establish a computerized diabetes educational system which may provide a personal educational advice come after a prior questionnaire. The questionnaire and educational advice were formed by a team of a physician, a dietitian, 3 nurses, and 3 information technology (IT) personnel. The questionnaire comprises the basic data of age, weight, height, and the level of blood pressure, lipid profile, and also the status of retinaopthy, nephropathy, and neuropathy. Our IT personnel design the programmatic link bewteen the result of questionnaire and educational advice on website, which using open source software, including Apache software, with Hypertext Preprocesssor (PHP) and MySQL database server. The precision and fluency of the advice was modified after repeated discussion on multiple clinical conditions. The final version was first applied on 14 patients (10 men, 4 women), the mean age is 51.6± 11.0 years (from 30 to 71 years). Furthermore, a satisfaction survey was performed and showed this system is helpful, feasible, and satisfied to them, also learning motivation was raised. Conclusion: We developed a web-base computerized diabetic educational system which may provide individualized education, and the system is helpful and feasible to people with diabetes. Disclosure K. Chen: None. Y. Chuang: None. C. Liu: None. Y. Chiu: None. H. Lin: None.
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