I-Nan Lien

Dysphagia in Patients with Nasopharyngeal Cancer After Radiation Therapy: A Videofluoroscopic Swallowing Study

This study evaluated swallowing status and the factors influencing swallowing in patients with nasopharyngeal carcinoma (NPC) after radiation therapy. During the period from July 1995 to June 1999, this cross-sectional study used videofluoroscopic swallowing study (VFSS) to evaluate 184 NPC patients who had completed radiation therapy [113 cases had completed radiation therapy ≤12 months prior to evaluation (acute group) and 71 cases had completed radiation therapy >12 months prior to evaluation (chronic group)]. The numbers of patients with tumors in each of the four stages were as follows: 24 in stage I, 45 in stage II, 41 in stage III, and 74 in stage IV. Swallowing abnormalities of the acute and chronic groups were correlated with multiple variables, including gender, age, the stage of the tumor, use of either neoadjuvant chemotherapy or radiosensitizer, and radiation modality. The analytical results indicated that the chronic group had a significantly higher proportion of swallowing abnormalities. Radiation modality, chemotherapy, and tumor staging were not significantly associated with swallowing dysfunction. Trend analysis revealed a progressive deterioration of most parameters of swallowing function in this group of patients. These findings indicate that swallowing function continues to deteriorate over time, even many years after radiation therapy in patients with NPC. Our results indicate that the time elapsed since radiation therapy correlates with the severity of dysphagia in NPC patients.

Hormone changes in men with spinal cord injuries.

The steady state profiles of 63 men with traumatic spinal cord injuries (24 quadriplegics and 39 paraplegics; average age of 31.2 ± 6.8 yr; 18-44 yr) were studied. The average length of post-traumatic period was 6.2 ± 5.0 yr, ranging from 8 months to 20 yr. It was found that all the subjects had normal serum thyroxine, thyrotropin, cortisol, growth hormone and plasma adrenocorticotropic hormone. Seven cases (11.1%) had low serum triiodothyronine and eight cases (12.7%) had low serum testosterone. On the other hand, 17 cases (27.0%) had hyperprolactinemia; 9 cases (14.3%) had elevated serum testosterone level; 6 cases (9.5%) had elevated serum follicle-stimulating hormone; and 4 cases (6.3%) had elevated serum luteinizing hormone. The level of spinal cord injury, injury period and patient age had no correlation with other serum hormone changes except that quadriplegic subjects had lower serum triiodothyronine than the paraplegic, with a mean of 1.42 ± 0.30 v 1.70 ± 0.36 nmol/liter (P < 0.005). Of the eight subjects who had low serum testosterone, none had elevated gonadotropin. There were also eight subjects with elevated follicle-stimulating hormone and/or luteinizing hormone, six of them had normal serum testosterone and two had elevated serum testosterone. This suggested their hypogonadism did not result primarily from classic primary gonadal failure. It could be speculated that other testicular paracrine factors and/or alteration of hypothalamus-pituitarytesticular axis are involved in the pathogenesis of hypogonadism. Further studies in this field will provide information regarding male reproductive physiology and may have impact on fertility enhancement options for men with spinal cord injuries.

Spinal cord injuries in Taipei, Taiwan, 1978-1981

This survey of spinal cord injuries in Taipei city from January 1978 to December 1981 was carried out by a review of the hospital records. During these four years 560 patients with acute spinal cord injury (SCI) were admitted to the hospitals in the city of Taipei. Of these, 123 were inhabitants of Taipei city, showing the annual incidence of SCI in Taipei to be 14.6 per million population. As a result of injury 118 patients were paraparetic, 180 were paraplegic, 117 tetraparetic and 145 were tetraplegic. The average age was 36 years and 2 months and one third were in the 20 to 29 year age group. The male/female ratio was 4.9. The causes of SCI were traffic accidents (44.5%), accidental falls (28.5%), struck by object (14.6%) and sports injury (3.4%). The mortality rate was 6.0%. Respiratory complication was the leading cause of death, accounting for 58% of the total deaths.

Anaerobic threshold and maximal oxygen consumption during arm cranking exercise in paraplegia

The major purpose of this investigation was to compare the anaerobic threshold (AT) and maximal cardiopulmonary responses to arm exercise between persons with paraplegia and the able-bodied. The locomotive stress on the heart in paraplegic subjects was also examined. Thirty-nine paraplegic subjects (T1-L4 lesions) and 32 able-bodied subjects completed a continuous, progressive, resisted arm cranking exercise test. The AT was determined from the ventilatory parameters. At the AT, the mean values of Vo2/body weight (BW) for class II (T1-T5, N = 9), III (T6-T10, N = 11), and IV (T11-L4, n = 19) paraplegic subjects were 10.9, 13.2, and 13.5mL/kg/min, respectively, and only class II had significantly lower value than the able-bodied (14.4mL/kg/min). During maximal exercise, the mean values of maximal oxygen consumption per body weight (Vo2max/BW) for class II and III paraplegics were 17.4 and 17.7mL/kg/min, respectively, which were significantly lower (p < 0.05) than that of class IV (21.3mL/kg/min) and the able-bodied (28.2mL/kg/min). The heart rate (HR) during wheelchair-propelling (119bpm, n = 37) was significantly less than that at the AT (134bpm), but the HR during crutch-walking (151bpm, n = 17) was significantly higher. The results indicate that both submaximal and maximal cardiopulmonary functions in high-lesion paraplegics were less than that of the able bodied. Furthermore, the intensity of wheelchair-propelling at comfortable speed is not enough for improving the cardiopulmonary functions.

Traumatic spinal cord injuries in the rural region of Taiwan: an epidemiological study in Hualien county, 1986-1990

In order to survey the epidemiological characteristics of traumatic spinal cord injuries (SCI) in Hualien county, a retrospective study was conducted from January 1986 to December 1990 in four local general hospitals. During this period, 135 traumatic SCI patients were identified and 99 of them were residents of Hualien county. The estimated annual incidence of traumatic SCI in Hualien county was 56.1 per million population. As a result of injury 36 patients were tetraparetic, 33 tetraplegic, 12 paraparetic and 18 paraplegic. The male/female ratio was 4:1. The mean age of onset for male patients was 44 years, and that for female patients was 46 years. The major causes of SCI were traffic accident (61.6%) followed by accidental falls (23.3%). The average duration of hospitalisation ranged from 62 days in paraparetics to 132 days in tetraplegics. Ten patients died of respiratory failure or sepsis, and the mortality rate was 10.1%. Our data revealed that traumatic SCI was prevalent in Hualien county in comparison with epidemiological studies elsewhere. The special population composition of Hualien county and the preponderance of the motorcycle as a transportation vehicle in this area might result in its unique epidemiological characteristics.

PREDICTORS OF LONG-TERM SURVIVAL AFTER STROKE IN TAIWAN

OBJECTIVE To determine the risk factors of long-term survival after stroke. DESIGN A prospective, hospital-based cohort study. SUBJECTS A total of 449 consecutive patients after acute stroke from 2 medical centres, within a 1-year period, were included. METHODS Dysphagia was confirmed with the water-swallow test within the first week after stroke. Data on co-morbidities and clinical risk factors were collected through chart review. Survival curves and independent risk factors were evaluated with Kaplan-Meier analysis and multivariate Cox proportion hazards analysis, respectively. RESULTS A total of 424 patients were followed for 10 years, and the survival was 54.2%. In univariate analysis, history of diabetes mellitus and recurrent stroke, dysphagia, urinary incontinence, cognitive impairment, tube feeding, dysarthria, and drooling were associated with higher mortality. In multivariate analysis, old age, history of recurrent stroke, and diabetes mellitus were independent predictors of long-term survival. The leading causes of death were cerebro-vascular diseases and malignancy during the 10-year post-stroke period. CONCLUSION Dysphagia was not an independent determinant of post-stroke survival. History of recurrent stroke and diabetes mellitus were independent predictors of long-term survival. These results suggest that differential treatment strategies should be used in the different stages of stroke.

The Hypothalamus-Pituitary-Ovary and Hypothalamus-Pituitary-Thyroid Axes in Spinal Cord-Injured Women

Sixteen women with spinal cord injury (SCI) underwent studies of the hypothalamus-pituitary-ovary (HPO) and hypothalamus-pituitary-thyroid (HPT) axes with luteinizing hormone (LH) releasing hormone (LHRH) and thyrotropin (TSH) releasing hormone (TRH) stimulation tests during the early follicular phase. The mean interval from injury to participation in this study was 7.5 years (range, 1.5 to 13.1). All subjects were menstruating regularly. Five (35.7%) SCI subjects who were menstruating before injury had postinjury amenorrhea for 1 to 12 months, and the other nine (64.3%) SCI subjects had no interruption of menstruation after injury. Two SCI subjects whose injury occurred in preadolescence proceeded to menarche without any delay. The amount of menstrual flow was noted to be reduced in nine (64.3%) SCI subjects. Two and three SCI subjects had elevated follicle-stimulating hormone (FSH) and prolactin (PRL) levels, respectively. LH responses to LHRH were significantly higher in the SCI group (P < .001). Ten (62.6%) SCI subjects had enhanced LH responses to LHRH. The mean TSH, PRL, and FSH responses to TRH and LHRH of the SCI group were not significantly different from those of age-matched controls. However, five (31.2%), four (25.0%), and five (31.2%) SCI subjects had enhanced TSH, PRL, and FSH responses to TRH and LHRH, respectively. Six (37.5%) SCI subjects had a delayed FSH response to LHRH. In total, 13 (81.2%) SCI subjects had at least one axis abnormality. These findings are consistent with the hypothesis that changes of central neurotransmitters may occur after SCI.

Suppression of the hypothalamus-pituitary somatotrope axis in men with spinal cord injuries

Thirty-two men with spinal cord injury (SCI) were studied for evaluation of the hypothalamus-pituitary somatotrope axis, using growth hormone-(GH)-releasing hormone (GHRH) and insulin-induced hypoglycemia. Twenty-six age-matched normal male volunteers served as controls. Six SCI subjects (18.7%) had elevated basal follicle-stimulating hormone (FSH) levels, eight (25.0%) had hyperprolactinemia, and 11 (34.4%) had reduced serum insulin-like growth factor-1 (IGF-1) levels. Twenty SCI subjects (62.5%) had reduced and/or delayed GH responses to GHRH, and eight (25.8%) had reduced GH response to insulin-induced hypoglycemia. Seven of eight hyperprolactinemic SCI subjects showed reduced GH response to GHRH and/or insulin-induced hypoglycemia. These findings are consistent with the notion that SCI subjects have a reduced central dopaminergic tone.

Scrotal temperature in spinal cord injury.

Twenty-five spinal cord-injured (SCI) males and 25 normal volunteers were studied for their scrotal and thigh temperatures by using contact liquid crystal thermography. The initial temperature was recorded after transfer and disrobing which took about 2 minutes. Later temperature was recorded 10 minutes after exposing the genitalia to room air (20-22°C). The initial scrotal and thigh temperatures of SCI subjects were significantly higher than those of normal volunteers (32.8 ± 0.8° C v 31.6 ± 0.4° C; 32.9 ± 0.8° C v 31.7 ± 0.4° C, respectively, P < 0.001), although their rectal temperatures were not different. The scrotal and thigh hyperthermia of SCI subjects disappeared after 10 minutes of exposure to room air. There was no significant difference between scrotal and thigh temperatures in either the SCI subjects or the normal volunteers in the later temperature reading. Sitting in a wheelchair for 2 hours results in an increase of average 0.8° C of scrotal and thigh temperature in five normal volunteers. Our study suggests that scrotal hyperthermia of SCI subjects is mainly the result of local factors such as a prolonged sitting position, adduction of the thighs, the cushions insulating effect and infrequent movement of the buttocks. Adequate ventilation of the scrotal area can overcome the impaired scrotal heat dissipation of SCI subjects. Liquid crystal thermography is a useful, noninvasive method for detecting hyperthermia in SCI subjects.

Rates and characteristics of lower limb amputations in Taiwan, 1997

This study aims to describe the national incidence rate and characteristics of lower limb amputations (LLA) in 1997 from an island-wide database of the national health insurance programme in Taiwan. Some 117,647 discharge records from a sampled database (1 in 20) of the National Health Insurance Research Database were analysed. This study included records (n=171) containing LLA procedures. The LLA procedure rates were obtained by multiplying the number of identified procedures by 20 as the numerator and mid-year total population of Taiwan in 1997 as the denominator. Each procedure was further analysed according to the demographic characteristics of the patients, cause and level of amputation. Summarised gender ratios of LLA procedure rates were obtained by Poisson regression analysis. The crude LLA procedure rate was 18.1 per 100,000 population per year and the crude major LLA procedure rate was 8.8 per 100,000 population per year in Taiwan in 1997. The major cause of LLA procedures was peripheral vascular disease (72%), and the toe was most frequently amputated (48%). The LLA procedure rates, which increased logarithmically with age of patients, were significantly higher in men with a summarised male to female rate ratio of 1.65. The age-standardised LLA procedure rate in Taiwan was lower than that reported in the United States, Finland, the Netherlands, the United Kingdom (Leeds, Middlesborough, and Newcastle), but higher than Spain, Italy, and Japan. The trend of an increasing proportion of PVD-related LLA procedures will prompt the health professionals to develop strategies for LLA prevention.