Taiwan Society Research Articles

Targeted treatment of primary aldosteronism - The consensus of Taiwan Society of Aldosteronism.

Even with the increasing recognition of primary aldosteronism (PA) as a cause of refractory hypertension and an issue of public health, the consensus of its optimal surgical or medical treatment in Taiwan has not been reached. Our objective was to develop a clinical practice guideline that is feasible for real-world management of PA patients in Taiwan. The Taiwan Society of Aldosteronism (TSA) Task Force recognized the above-mentioned issues and reached this Taiwan PA consensus at its inaugural meeting, in order to provide updated information of internationally acceptable standards, and also to incorporate our local disease characteristics and constraints into PA management. In patients with lateralized PA, including aldosterone producing adenoma (APA), laparoscopic adrenalectomy is the 'gold standard' of treatment. Mini-laparoscopic and laparoendoscopic single-site approaches are feasible only in highly experienced surgeons. Patients with bilateral adrenal hyperplasia or those not suitable for surgery should be treated by mineralocorticoid receptor antagonists. The outcome data of PA patient management from the literature, especially from PA patients in Taiwan, are reviewed. Mental health screening is helpful in early detection and management of psychopathology among PA patients. We hope this consensus will provide a guideline to help medical professionals to manage PA patients in Taiwan to achieve a better quality of care.

Interview with Dr. Yi-Wei Chen: education is the main method to popularize BNCT, a powerful special cancer treatment

The 3rd Annual Academic Conference of Taiwan Society of Neutron Capture Therapy (Jointly with the 10th Trilateral BNCT meeting between Taiwan and Japan) was held in Taipei Medical University Hospital in Taiwan on January 27th, 2018. Experts from Taiwan and Japan exchanged their opinions and discoveries related to Boron Neutron Capture Therapy (BNCT) on the forum.

Distribution of glomerular diseases in Taiwan: preliminary report of National Renal Biopsy Registry\u2013publication on behalf of Taiwan Society of Nephrology

BackgroundDespite the development of biomarkers and noninvasive imaging tools, biopsy remains the only method for correctly diagnosing patients with unexplained hematuria, proteinuria and renal failure. Renal biopsy has been performed for several decades in Taiwan; however, a national data registry is still lacking until 2013.MethodsThe Renal Biopsy Registry Committee was established within the Taiwan Society of Nephrology in January 2013. A biopsy registry format, including basic demographic data, baseline clinical features, laboratory data, and clinical and pathological diagnosis was developed. Approval from the local institutional review board was obtained in each participating medical center.ResultsFrom January 2014 to September 2016, 1445 renal biopsies were identified from 17 medical centers. 53.8% cases were reported in men. After excluding renal transplantation, renal biopsies were commonly performed in patients with primary glomerulonephritis (48.1%), secondary glomerulonephritis (36.2%), followed by tubulointerstitial diseases (12.3%) and vascular nephropathy (3.4%). Among primary glomerulonephritis, IgA nephropathy (26.0%), focal segmental glomerulosclerosis (21.6%), and membranous nephropathy (20.6%) were most frequently diagnosed. Diabetic nephropathy (22.4%) and lupus nephritis (21.8%) were the most common among secondary glomerulonephritis. Patients with minimal change disease and membranous nephropathy had heavier proteinuria than those with focal segmental glomerulosclerosis and IgA nephropathy (P < 0.001). Patients with minimal change disease had higher serum IgM and IgE levels. The most common cause of nephrotic syndrome in primary glomerular disease was membranous nephropathy (28.8%), followed by minimal change disease (28.2%). IgA nephropathy was the leading cause of chronic nephritic syndrome, acute nephritic syndrome, and persistent hematuria. The incidence of primary glomerulonephritis was approximately 2.19 in 100,000/year.ConclusionsThis is the first report of the National Renal Biopsy Registry in Taiwan. IgA nephropathy is the most common primary glomerulonephritis, while membranous nephropathy is the most common cause of nephrotic syndrome. Primary glomerulonephritis distribution in Taiwan is slightly different from that in other Asian countries.

Analysis of surgical manpower for the past 20 years in Taiwan

Background: The Taiwan Surgical Association (TSA) has been in operation for more than 50 years since its establishment. We checked the data of the members recently to have a full understandings and mastery of the human resources of TSA. Materials and Methods: All the data were collected from the basic data pool of the member maintained by the TSA. The annual membership, new memberships, deaths and withdrawals, age distribution, gender, surgical subspecialty, geographic distribution, and new major surgical specialist-issued licenses were checked. Results: The results were total membership increased lineally and doubled from 3020 to 6154; new members increased 124–197 per year, death and withdrawal were 4–53 annually; highest age range was 51–60, mean age 52.99 and median age 53; ratio of male and female increased from 0.8% to 4.4%; great majority of surgical specialist was gastroenterological surgery 29%, orthopedics 14%, urology 13%, thoracic and cardiovascular surgery 13%, and plastic surgery 11%; members were higher in metropolitan, Taipei 21.7%, New Taipei City 8.2%, Taichung 14%, and Kaohsiung 14.8%; and number of surgical-related subspecialty increased recently. Conclusions: There are still a lot of areas for the TSA members to explore. The data suggest that the government officials could provide more beneficial acts to the development of surgical society in Taiwan. For example, they might be able to guide a reasonable work shift hour limit, maximal care surgical patients' number, adequate nurse practitioners, setup legal surgical assistants in the operation room, well-training sufficient surgical residents program, and balance the number for the surgical subspecialty.

Strategies for Promoting Steelmaking Slag Resourcezation in Taiwan

Because of the world ever-growing pursuit of economic growth, natural resources have been overly exploited and squandered. Such actions have created a negative effect on the environment and led to resource depletion. These problems subsequently garnered the government attention for waste reuse, in which they began to promote sustainable circulation and reuse of resources to lower natural resource consumptions. Accordingly, the concept of the "3 R's," namely, reduce, recycle, and reuse was introduced. However, the said concept merely adopts a unidirectional, cradle-to-grave-based treatment and fails to consider the effects of waste on the economy and society. Taiwan produces approximately 20 million tonne s of waste annually, roughly 40% of which are slags. The illegal dumping and burying of slags have negatively influenced Taiwan's environment, economy, and society. Thus, the present study revolutionized the 3R concept by introducing the cradle to cradle concept. Producers are recommended to consider product features and slag usage options during the steelmaking process. Transparent productions, effective management, scientific treatments, and systematic inspections are employed to bring slags into industrial circulations, facilitating the recycling and reuse of resources.

Prof. Koji Ono: A pioneer of clinical applications of BNCT devoted to exploring its new possibilities

The 3rd Annual Academic Conference of Taiwan Society of Neutron Capture Therapy was held successfully at Taipei Medical University on 17 January, 2018.

Prof. Mitsunori Kirihata: concentrating on boron chemistry, promoting the development of boron neutron capture therapy

The 3 rd Annual Academic Conference of Taiwan Society of Neutron Capture Therapy [Jointly with the 10th Trilateral boron neutron capture therapy (BNCT) meeting between Taiwan and Japan] was successfully held on 27 January, 2018 at Taipei Medical University.

Prof. Junichi Hiratsuka: BNCT may be able to benefit cancer patients in the near future

On Jan 27, the 3rd Annual Academic Conference of Taiwan Society of Neutron Capture Therapy was successfully held at Taipei Medical University.

Prof. Jun Ma and Prof. Jin-Ching Lin: clinical trials: the vital key to NPC progress

The 2017 Taiwan Society for Therapeutic Radiology and Oncology Conference “Bring Insight into Impacts” and Both Sides across the Strait Forum was held at Taipei Medical University on 16th, 17th of December 2017. An army of world-renowned experts in the fields of radiology and oncology was invited to share and study a number of clinical cases via this highly-effective academic exchange platform.

Interview with Dr. Yi-Wei Chen: education is the main method to popularize BNCT, a powerful special cancer treatment

The 3rd Annual Academic Conference of Taiwan Society of Neutron Capture Therapy (Jointly with the 10th Trilateral BNCT meeting between Taiwan and Japan) was held in Taipei Medical University Hospital in Taiwan on January 27th, 2018. Experts from Taiwan and Japan exchanged their opinions and discoveries related to Boron Neutron Capture Therapy (BNCT) on the forum.

Endoscopic features and treatment response have better prediction rate than clinical symptoms/signs in distinguishing Crohn's disease and intestinal tuberculosis

SummaryBackgroundIntestinal tuberculosis (ITB) is less common than Crohn's disease (CD) in Taiwan. Despite the worldwide decline in TB incidence over last several years, the prevalence yet remains high. Therefore, there is a necessity to increase the clinical awareness of this serious health problem. The aim of this study was to investigate the value of clinical methods that may be helpful in distinguishing CD from ITB.MethodsEighty‐five patients, 67 and 18 patients diagnosed with CD and ITB, respectively, from January 2000 to April 2015 at Mackay Memorial Hospital, Taipei were included. The clinical, laboratory, endoscopic, and histological characteristics were reviewed retrospectively.ResultsCD patients (33 ± 13 years) were younger than ITB patients (57 ± 21 years) (p = 0.103). The incidences of hematochezia, abdominal pain, diarrhea, fever, and weight loss were not significantly different (p = 0.388, p = 0.699, p = 0.751, p = 0.468, and p = 0.611, respectively). The hemoglobin, platelet, and C‐reactive protein (CRP) levels were also not significantly different (p = 0.388, p = 0.440, and p = 0.330, respectively). The endoscopic features of aphthous ulcer and cobblestone appearance were seen more often in CD patients (p = 0.043 and p = 0.010, respectively). Rectal lesions (29.9 vs. 0%; p = 0.020) were seen only in CD patients. Patulous ileocecal valve was specifically seen in ITB patients (p = 0.006). The histological features of granuloma, cryptitis and crypt abscess, and fissure formation were not significantly different (p = 0.377, p = 0.293, and p = 0.212, respectively).ConclusionsThe endoscopic features of aphthous ulcerations, cobblestone appearance, and rectal involvement in CD and of patulous ileocecal valve in ITB, along with clinical treatment follow‐up, tend to be useful diagnostic characteristics differentiating CD and ITB.Copyright © 2017, The Gastroenterological Society of Taiwan, The Digestive Endoscopy Society of Taiwan and Taiwan Association for the Study of the Liver.

Performance of quantitative immunochemical test for fecal hemoglobin for surveillance of colorectal neoplasia after polypectomy in clinical practice

SummaryAimsWe examined the yield of immunochemical test for fecal hemoglobin (FIT) for the post‐polypectomy individuals in a colorectal cancer screening program.MethodsWe enrolled 50‐75 years average‐risk individuals who attended a biennial FIT‐based colorectal cancer screening program from March 2010 to December 2011 (index round) and from January 2012 to December 2013 (repeated round). Colonoscopy was recommended to the participants with an FIT ≧ 30 μg Hb/g feces.Participants identified with adenomas and removed by polypectomy in the index round were defined as surveillance group (Sur‐G). Participants with an FIT &lt; 30 μg Hb/g feces in the index round or identified as non‐neoplastic findings of the indexed colonoscopy were defined as repeated screening group (Rsc‐G). We compared key quality indicators for FIT and colonoscopy between Sur‐G and Rsc‐G according to the findings of the repeated round. A p &lt; 0.05 determined by chi‐square test was defined as significant.ResultsThere were 222 post‐polypectomy surveillance (Sur‐G) and 7311 repeated screening individuals (Rsc‐G) enrolled for analysis. The FIT positivity rate, colonoscopy compliance rate and colorectal neoplasia (CRN) detection rate were 504 of 7311 (6.9%) vs. 46 of 222 (20.7%) (p &lt; 0.001); 381 of 504 (75.6%) vs. 44 of 46 (95.7%) (p &lt; 0.001) and 207 of 504 (41.1%) vs. 32 of 46 (69.6%) (p &lt; 0.001) for Rsc‐G and Sur‐G respectively. The FIT positivity rate, colonoscopy compliance rate and CRN detection rate were significantly higher in the Sur‐G.ConclusionsOur results suggest individuals after polypectomy still had high risk of CRN. Biennial FIT may play a role for post‐polypectomy surveillance. Subsequent prospective study is necessary to evaluate the effectiveness of FIT for post‐polypectomy surveillance.Copyright © 2017, The Gastroenterological Society of Taiwan, The Digestive Endoscopy Society of Taiwan and Taiwan Association for the Study of the Liver.

CYP2C19 polymorphism has no influence on rabeprazole‐based sequential therapy

SummaryBackgroundThe aim of this prospective study was to evaluate the impact of cytochrome P450 2C (CYP2C19) and interleukin‐1β (IL‐1β) polymorphisms on the efficacy of Helicobacter pylori (H. pylori) eradication by using rabeprazole‐based sequential therapy.MethodsFrom March 2013 to May 2014, total 87 H. pylori‐infected patients were recruited to receive a 10‐day of sequential therapy. We had excluded 4 patients from analysis because of incomplete compliance. We performed either follow‐up endoscopy or 13C‐urea test to assess the treatment response. CYP2C19 and IL‐1β genotypes were analyzed to investigate the impact on H. pylori eradication.ResultsOn the whole, the eradication rate of H. pylori was 80.72% (67/83). The rates of H. pylori eradiation were 79.31% in extensive metabolizers (EM) and 81.48% in non‐EM according to the CYP2C19 genotypes. The rates of H. pylori eradiation were 80.00% in the normal acid secretion group and 81.03% in the low acid secretion group according to the IL‐1β genotypes. After multivariable logistic regression analysis, both genotypes of CYP2C19 and IL‐1β were not significantly independent factors of H. pylori eradication.ConclusionsBoth CYP2C19 and IL‐1β polymorphisms would not have influences on eradication rates of H. pylori by using sequential therapy.Copyright © 2017, The Gastroenterological Society of Taiwan, The Digestive Endoscopy Society of Taiwan and Taiwan Association for the Study of the Liver.

Muir‐Torre syndrome manifesting as sebaceous adenoma/adenocarcinoma and colonic adenocarcinoma – A case report

SummaryMuir‐Torre Syndrome (MTS) was first coined by Muir et al in 1967 and Torre in 1968. It is an autosomal‐dominant disorder characterized by combination of visceral disorder and sebaceous neoplasms. This syndrome is a subtype of hereditary nonpolyposis colorectal cancer. In most cases, it arises from germline mutation encoding mismatch repair (MMR) proteins. We encountered a case of MTS and relevant literatures were reviewed.Copyright © 2017, The Gastroenterological Society of Taiwan, The Digestive Endoscopy Society of Taiwan and Taiwan Association for the Study of the Liver.

Unusual subcutaneous and choroidal metastases from esophageal squamous cell carcinoma denote a poor prognosis: A case report and literature review

SummaryEsophageal squamous cell carcinoma (ESCC) is a devastating disease, generally diagnosed at an advanced stage. Skin metastasis is rare, and choroidal metastases are extremely rare. Herein, we report a case of a 47‐year‐old habitual smoker and drinker who presented with progressive dysphagia, weight loss, and multiple enlarged tumors over his trunk and limbs for 3 months. Upper endoscopy revealed an ulcerative esophageal mass, and pathology confirmed moderately differentiated SCC. Fluorodeoxyglucose‐positron emission tomography/computed tomography revealed high uptake in the esophageal mass, bone, and subcutaneous lesions. Incisional biopsy of the right thigh tumor indicated metastatic SCC. Accordingly, the patient received palliative chemotherapy and mediastinal radiotherapy. Two weeks later, he experienced partial right visual field loss. Imaging findings suggested choroidal metastasis. Although the skin lesions shrank after treatment, the patient's health quickly deteriorated and he died of severe pneumonia 3 months later. To our knowledge, this is the first report of ESCC with simultaneous subcutaneous and ocular metastasis. Cutaneous and ocular metastases secondary to ESCC are extremely rare; both suggest cancer dissemination and imply an ominous prognosis. Careful physical examination and high awareness are required during follow‐up.Copyright © 2017, The Gastroenterological Society of Taiwan, The Digestive Endoscopy Society of Taiwan and Taiwan Association for the Study of the Liver.

Management consensus guideline for hepatocellular carcinoma: 2016 updated by the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan.

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality in Taiwan. To help clinical physicians to manage patients with HCC, the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan produced the management consensus guideline for HCC. The recommendations focus on nine important issues on management of HCC, including surveillance, diagnosis, staging, surgery, local ablation, transarterial chemoembolization/transarterial radioembolization/hepatic arterial infusion chemotherapy, systemic therapy, radiotherapy, and prevention. The consensus statements were discussed, debated and got consensus in each expert team. And then the statements were sent to all of the experts for further discussion and refinement. Finally, all of the experts were invited to vote for the statements, including the level of evidence and recommendation. With the development of the management consensus guideline, HCC patients could benefit from the optimal therapeutic modality.

Gap between guidelines and clinical practice in heart failure with reduced ejection fraction: Results from TSOC-HFrEF registry

BackgroundHeart failure (HF) is a global health problem. Guidelines for the management of HF have been established in Western countries and in Taiwan. However, data from the Taiwan Society of Cardiology-Heart Failure with reduced Ejection Fraction (TSOC-HFrEF) registry showed suboptimal prescription of guideline-recommended medications. We aimed to analyze the reason of non-prescription and clinical outcomes as a result of under-prescription of medications. MethodsA total of 1509 patients hospitalized for acute HFrEF were recruited in 21 hospitals in Taiwan by the end of October 2014. Prescribed guideline-recommended medications and other relevant clinical parameters were collected and analyzed at discharge and 1 year after index hospitalization. ResultsAt discharge, 62% of patients were prescribed with either angiotensin-converting enzyme-inhibitors (ACEI) or angiotensin receptor blockers (ARB); 60% were prescribed with beta-blockers and 49% were prescribed with mineralocorticoid receptor antagonists (MRA). The proportions of patients at ≥50% of the target dose for ACEI/ARB, beta-blockers and MRA were 24.4%, 20.6%, 86.2%, respectively. At 1-year follow-up, dosages of ACEI/ARB and MRA were up-titrated in about one-fourth patients, and dosages of beta-blocker were up-titrated in about 40% patients. One-year mortality rate was lowest in patients who received at least 2 classes of guideline-recommended medications with ≥50% of the target dose, and highest in those who received 0 or 1 class of medications. ConclusionThe TSOC-HFrEF registry demonstrated the under-prescription of guideline-recommended medications and reluctance of physicians to up-titrate medications to target dose. Action plan needs be formulated in order to improve physician's adherence to HF guidelines.

Detection of rectal neuroendocrine tumor during screening colonoscopy and its difference from colonic adenocarcinoma

SummaryBackgroundsThe incidence of rectal neuroendocrine tumors (NETs) diagnosed during screening colonoscopy is rising. The features and outcomes of these patients and their difference from colonic adenocarcinoma are unknown.MethodsData on subjects who underwent screening colonoscopy as part of a health checkup during a five‐year period were retrospectively analyzed. The prevalence and outcomes of the patients with rectal NETs were evaluated. The features of the patients with histopathologically proven NET and colonic adenocarcinoma were compared.ResultsA total of 8,278 subjects were enrolled. Rectal NETs were detected and diagnosed by histopathologic analysis in 13 patients (0.16%). The mean tumor size was 0.4 ± 0.25 cm and 7.7% of the patients had chronic diarrhea. Colonic adenocarcinoma was diagnosed in 24 patients (0.29%). Patients with rectal NETs were significantly younger than those with colonic adenocarcinoma (mean age: 49.4 ± 14.2 years versus 59.5 ± 11.5 years, p = 0.033) and had fewer symptoms (92.3% versus 41.7%, p = 0.001). All of the rectal NETs were successfully resected endoscopically by snare polypectomy or ligation‐assisted endoscopic mucosal resection. Histopathological analysis revealed WHO 2010 grade I NETs in all patients. No recurrence was detected during a mean follow‐up of 33 ± 15.2 months.ConclusionsRectal NETs are not uncommon incidental findings of the colonic malignancies during screening colonoscopy. Those were younger and more asymptomatic as compared with colonic adenocarcinoma. Using endoscopic resection can successfully remove these small tumors without recurrence.Copyright © 2017, The Gastroenterological Society of Taiwan, The Digestive Endoscopy Society of Taiwan and Taiwan Association for the Study of the Liver.

A case of a large colonic lipoma resected by endoscopic submucosal dissection: A long‐term endoscopic observation

SummaryGastrointestinal (GI) lipomas are benign, slow‐growing subepithelial tumors, and are most commonly found in the colon. No intervention is needed for smaller or asymptomatic lipomas. Endoscopic removal or surgery is reserved for larger lesions. However, whether endoscopic submucosal dissection (ESD) is a suitable method for the treatment of a large submucosal lipoma of the colon has long been controversial. In addition, less is known regarding the long‐term prognosis of patients undergoing the ESD on large colonic lipomas. In this report, we present the case of a 67‐year‐old man who presented with abdominal pain and was diagnosed with a large colonic lipoma. Standard ESD was performed to remove the lipoma. During the follow‐up period of 7 years, no recurrence was observed. ESD is another option for the treatment of large colonic lipomas with an excellent long‐term prognosis.Copyright © 2017, The Gastroenterological Society of Taiwan, The Digestive Endoscopy Society of Taiwan and Taiwan Association for the Study of the Liver.

Comparison between tenofovir disoproxil fumarate and entecavir treatment in real‐world clinical practice

SummaryBackground and aimsEntecavir (ETV) and tenofovir disoproxil fumarate (TDF) are effective as two first‐line anti‐viral therapies for chronic hepatitis B (CHB); however, data are limited on directly comparing the safety and effectiveness of these two antivirals. Hence, we compared the efficacy and safety of TDF and ETV on treatment‐naïve patients with CHB.MethodsWe performed a hospital‐based, retrospective cohort study of 257 treatment‐naïve patients with CHB receiving TDF (n = 79) or ETV (n = 178). Virological and biochemical response as well as nephrotoxicity were assessed between TDF and ETV treatment groups.ResultsAt month 12, TDF group had faster on HBV DNA complete suppression than ETV group (p = 0.001). Multivariate analysis indicated that treatment with TDF was a significant predictor of HBV DNA suppression (HR = 1.33; 95% CI = 1.01 – 1.76; p = 0.045). In addition, HBeAg positivity (HR = 0.70; 95% CI = 0.52 – 0.96; p = 0.025) and higher baseline HBV DNA level (HR = 0.84; 95% CI = 0.76 – 0.92; p &lt; 0.001) were significant negative predictors for viral suppression. The ALT normalization rate between these two treatment groups were similar (p = 0.114). TDF group had more populations in ≧ 20% decrease of eGFR MDRD at month 24 than ETV group (31.5% vs. 17.2%, p = 0.044), but only the baseline eGFR was the independent factor by multivariate analysis (OR = 1.05; 95% CI = 1.03 – 1.07; p &lt; 0.001).ConclusionsTDF was significantly more effective in achieving complete viral suppression beyond month 12, and there was no significance in nephrotoxicity than ETV group.Copyright © 2017, The Gastroenterological Society of Taiwan, The Digestive Endoscopy Society of Taiwan and Taiwan Association for the Study of the Liver.