陳前總統神經醫學診療共識與我的解說
陳順勝醫師 神經醫學教授
前台灣神經學學會理事長、前世界神經學會法規會委員
北榮與北監已經把陳前總統的病情在新聞報導公佈，但其中神經學共識部份邏輯思維有所差異、避重就輕、或避而不談。
當時我有聲明，若與我的原意有所出入，或損及陳前總統的權益時，我保有對第三者告知義務與權利。
因而我需要作此說明，對當時的共識結論與並列的意見，加以解說，以平衡報導。
前一陣子，北榮以外的幾位國內的獨立專家教授，不約而同地有共識，認為阿扁至少有四項隨時有會危及生命的疾病等待處裡，包括重度憂鬱症、重度睡眠呼吸中止症、妄想症與防衛行為、與微小血管病變引起的腦中風或心血管疾病。
本內容曾在10月4日立法院司法與法制委員會發表，並經醫療小組核可。
1.結巴性語言障礙合併命名障礙，病因待查
(STUTTER SPEECH DISORDER WITH DYSNOMIA, CAUSE TO BE DETERMINED)
鑑別診斷包括：精神性疾患或是腦部病變結巴性語言障礙。
解說：
我認為神經學症狀應該是言語重復症(palilalia)、或部分表達性失語症(expressive aphasia)與命名失語症(nominal aphasia)。依據神經學檢查、床邊神經行為與語言檢查、腦部核磁共振檢查結果作此判定。如此可以確定這是腦神經疾病所致。因陳前總統，失語的部分可以覆述(echolalia)，因而判定是皮質下語言徑路病變所致，此點與腦部核磁共振檢查結果不謀而合。
榮總神經內科不用失語症，堅持要用語言障礙來表示，因為語言障礙包括失語症與精神疾患強調所引起的。
雙方僵持不下，因而以鑑別診斷包括精神性疾患或是腦部病變結巴性語言障礙兩者並列。
2.多發非特異性皮質下白質高訊號點，病因待查
(MULTIPLE NONSPECIFIC SUBCORTICAL WHITE MATTER HYPERINTENSITIES, CAUSE TO BE DETERMINED)
鑑別診斷包括：高血壓併微小血管病變、重度憂鬱症、睡眠呼吸中止症、老化、退化性腦病變。
解說：
北榮起先提議腦核磁共振掃描檢查只發現非特異性皮質下白質高訊號點，我堅持一定要加多發兩字，而且有一定好發部位，有其意義。病因待查，因而依序加入高血壓併微小血管病變、重度憂鬱症、睡眠呼吸中止症、老化、退化性腦病變。其中本來只列高血壓，我堅持在高血壓後面加上腦的微小血管病變。
陳前總統腦非特異性皮質下白質高訊號點雖不像腦中風，大部分專家也不敢完全排除其可能性。還需繼續追蹤，白質高訊號點是否會有所增減再加判定。
3.重度阻塞性睡眠呼吸中止症
(SEVERE OBSTRUCTIVE SLEEP APNEA)
解說：
本來北榮陳昌明醫師反對加入重度阻塞性睡眠呼吸中止症，認為不是神經疾病。我說美國神經學會有睡眠呼吸中止症的診療準則，另外台灣神經學會也有睡眠障礙學組，故在我堅持下加入此一診斷。
再說重度阻塞性睡眠呼吸中止症會因起腦損傷、腦微小血管病變或腦中風，互有其因果關係。
4.妄想症尚未處理。
解說：
本項是我加註在共識備忘錄內的。陳前總統有厲害的妄想症，被迫害妄想對象為台灣與中國的領導人，並有防衛的言行，除非大家認為這種迫害的想法是真的，否則應考慮為可以保外就醫的妄想症。
而且我認為陳前總統妄想症應為腦病變引起的器質性妄想障礙(Organic delusional disorder)。
但北榮神經科與精神科對陳前總統妄想症不予處理。
5.其他重要解說：
a.我認為陳前總統有額葉症候群(Frontal lobe syndrome)，且額葉有中等度萎縮、顳葉有萎縮，左腦語言區也有較清楚的萎縮，皮質下白質高訊號點也集中在額葉與顳葉，此點可以解釋失語與妄想症，然而北榮未接受。
b.未寫在共識內，但大家有共識，一定建議陳前總統目前病情的確需轉院繼續治療。
c.為了治療憂鬱、認知功能障礙、與妄想症，陳前總統需離開引起憂鬱與旺鄉的環境。為了改善認知功能與語言障礙，因提供他熟悉的環境。
d.目前總統為「受刑人」身份，同時有重度鬱症與妄想症，在醫學倫理上屬雙重易受傷害族群，根據法制化的倫理，理應受特別之保護，保外就醫是唯一的選擇。
我們強烈建議陳總統須繼續在無政治干擾的醫學中心接受神經內科與精神科的團隊治療。
The Discrepancy in the Diagnoses Between the “Consensus” and My Original Statements on the Neurological Conditions of Former President Chen Shui-bian
Shun-Sheng Chen, MD & PhD, Emeritus Professor of Neurology, Chang-Gung University, Former Member of By-law and Constitutional Committee, World Federation of Neurology
The Taipei Veterans General Hospital (TVGH) and Taipei Prison announced the diagnostic report of Former President Chen Shui-bian in October, but they tried to marginalize or discount the severity of his conditions, ignore the differences among the neurological diagnoses from different sides during the joint meeting, and neglect the critical thinking of cause and effect to determine the true cause of the symptoms.
I have declared that if there is any misleading of my original statement to harm the rights of former President Chen, I shall speak out.
So far, a panel of nine experts, inside and outside of TVGH, have reached a consensus that Former President Chen Shui-bian has four life-threatening conditions, including severe depression with strong suicidal thoughts, severe sleep apnea, delusional disorder with defensive behaviors (such as refusal of food intake for avoiding poisoning), and potential risks of stroke and/or cardiovascular diseases due to microangiopathies and labile hypertension. However, this “consensus” excludes some serious neurological conditions because either their causes have not yet been clarified or the panel failed to reach a consensus. I would like to elaborate them as follows:
1. NOMINAL APHASIA AND STUTTER SPEECH DISORDER, CAUSES TO BE DETERMINED
One possible cause, as suggested by the doctors of TVGH, is psychiatric illness or cerebral insult, which has induced stuttering. However, in my original statement, I consider the causes of this neurological symptom as palilalia, partial expressive aphasia and nominal aphasia. My conclusion was based on neurological examinations, neurobehavioral cognitive tests, speech tests, and findings from Brain magnetic resonance imaging (MRI). The MRI images confirmed that there are subcortical lesions blocking the language pathways. Neurologists of TVGH insisted on using the term of speech disorder instead of aphasia, because by doing so, it leads to the diagnosis of depression only, rather than brain lesion. We failed to reach a consensus for this diagnosis but the consequence of incorrect diagnosis could be life threatening and more tests must be conducted to confirm its causes.
2. MULTIPLE NONSPECIFIC SUBCORTICAL WHITE MATTER HYPERINTENSITIES, CAUSES TO BE DETERMINED
The possible causes of multiple non-specific subcortical white matter hyperintensities included: hypertensive disease complicated with microangiopathies, severe depression, sleep apnea syndrome, aging, degenerative neurological diseases. The TVGH doctors suggested using the term: “nonspecific white matter hyperintensities from his brain MRI”, but I insisted to add the word "multiple". Consequently, I made appropriate diagnostic findings as, in the order of the most probable cause to the least: hypertension complicated with microangiopathy, severe depression, sleep apnea syndrome, neurodegenerative disorders, and lastly aging.
3. SEVERE OBSTRUCTIVE SLEEP APNEA
According to the report of TVGH, they did not consider severe obstructive sleep apnea as important in the neurological field. However, I insisted to add "severe obstructive sleep apnea" in the statement in order to observe the guidelines of obstructive sleep apnea from American Academy of Neurology and Taiwan Neurology Society. Moreover, severe obstructive sleep apnea may cause brain damage, microangiopathies, and stroke, and vice versa.
4. DELUSIONAL DISORDERS
I proposed to add delusional disorders into the diagnosis consensus because I think that President Chen's delusional disorders were caused by organic lesions due to microangiopathies in his brain. However, the Neurologists of TVGH did not consider this issue serious enough to be mentioned.
I strongly recommend that former President Chen continue his current treatment in a combined Neurology and Psychiatry care unit, preferably at an independent and competent Medical Center, which is free from political interferences.
美國華府人權行動中心新聞稿 2012.11.16
HUMAN RIGHTS ACTION CENTER PRESS RELEASE ON CHEN SHUI-BIAN
The Human Rights Action Center sponsored a visit by two scholars well-versed in human rights standards and prison standards to investigate the conditions of detention of former President of Taiwan, Chen Shui-bian, after four years of incarceration. Hans Wahl and Harreld Dinkins concluded that the lack of access to independent medical care for the former president was jeopardizing his health by needlessly exacerbating conditions and by contributing to the emergence of new medical problems. Mr. Chen was and is in dire need of good and independent medical care to try to mitigate or reverse these conditions, some of which may now be permanent and others of which carry the potential to be fatal if Mr. Chen is returned to his previous state of neglect.
Chen Shui-bian should not be allowed to be killed in custody due to medical neglect. If the intent of the government of Taiwan to send Mr. Chen back to jail in very near future is true, it would be repeating a mistake. The care he needs is not possible in jail in particular if it would be provided by the same government that abused him in the first four years of his sentence in jail. Our belief is that Mr. Chen should be sent home to recover or to die in peace. If Mr. Chen is returned to prison, HRAC feels that such a procedure would be the same as a death sentence. Even in his current hospital setting in Taipei Veteran General Hospital, he is still subjected to surveillance and daily threat from the prison warden to return to the jail. Please leave him in peace to recover.
We call on the KMT government to meet the international protocols for human rights and prisoner treatment. We further call on the KMT government to reconsider sending Mr. Chen back to prison under any circumstances in order to avoid a repeat and increase of these conditions to begin with.
A death in prison of this prisoner would undermine the unity of Taiwan. Our answer is not to take that risk. Send him home. Unify the nation around someone who served the nation as its President for eight years. Repeat what President Ford did for the wrongs of President Nixon. Grant an amnesty, a release to go home and be as well as possible for the good of the nation.
Please contact us with any further questions about our statements and findings. We're happy to respond to all media and political inquiries. An increasing number of members of the US Congress are expressing concern about this treatment of Mr. Chen.
Jack Healey
Director and Founder, Human Rights Action Center, Washington DC, US
https://www.facebook.com/HumanRightsActionCenter, jackghealey@gmail.com
Hans Wahl, hhwahl@hhw-solutions.net
Hans Dinkins, hdinkins@gmail.com
Nov. 15, 2012
source: 陳總統辦公室
引用:台灣大地文教基金會
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NOWnews – 2012年11月16日 下午6:11
