Journal of the Chinese Medical Association : JCMA最新文献

Background: Monteggia fracture is defined as a combination of a proximal ulnar fracture with radial head dislocation. Radial head dislocation may be misdiagnosed under an elbow radiograph, leading to further complications. This study aimed to compare the ulnar fracture pattern characteristics between Monteggia fracture and an isolated proximal ulnar fracture in terms of how close the fracture site is to the coronoid and what type of fracture pattern is more likely to result in radial head dislocation.

Methods: This single-center retrospective study, conducted from January 2014 to June 2022, included adult patients with proximal to midshaft ulnar fractures, excluding nonacute trauma, revision surgeries, and intra-articular fractures. All patients underwent anteroposterior (AP) and lateral elbow radiographs and forearm radiograph. Fracture patterns and injury mechanisms were recorded for analysis.

Results: We included 51 patients in this study. The mean age was 38.5 ± 16.1 years, and 70.1% were men (n = 36). Monteggia fractures were classified according to the Bado classification into type I (n = 5), type II (n = 7), type III (n = 8), and type IV (n = 0). Traffic accidents comprised 63% of the injuries (n = 32), and 45% were oblique type ulnar fractures (n = 23). Monteggia fracture and proximal ulnar fracture presented with mean distance from coronoid tip to fracture of 6.12 ± 2.32 cm and 9.00 ± 3.00 cm ( p < 0.01). As per the receiver operating characteristic curve (ROC), the distance from coronoid tip to fracture of 7.33 cm had the highest area under the curve (AUC) value (0.807). Angulations of Monteggia fracture and isolated ulnar fracture were 24.02° ± 12.10° and 10.77° ± 8.10° ( p < 0.01). However, there were no differences in the length of the fracture line between two groups.

Conclusion: The distance from coronoid tip to fracture within 7.3 cm is more likely to cause a Monteggia fracture than an isolated proximal ulnar fracture. Otherwise, a Monteggia fracture is prone to more severe angulation.

Background: Pancreatic cancer can be challenging to diagnose, particularly when it presents with features resembling pancreatitis. Misdiagnosis can delay treatment and adversely affect patient outcomes. This case series highlights the diagnostic difficulties and clinical outcomes in patients initially diagnosed with pancreatitis, who were later found to have pancreatic malignancies such as pancreatic ductal adenocarcinoma (PDAC).

Methods: We reviewed the medical records of patients who underwent pancreatic-related procedures from 2011 to 2024 at a tertiary care hospital in Taiwan.

Results: The review identified 70 patients with resectable pancreatic malignancies, of whom 18 (26%) had a diagnosis of pancreatitis before their cancer was diagnosed. Four cases were selected for detailed presentation, highlighting the potential for missed or delayed pancreatic cancer diagnoses in patients with recurrent pancreatitis. Upon further investigation, we found that subtle signs of malignancy are often masked on initial imaging studies, leading to delays in definitive diagnosis and treatment.

Conclusion: This case series demonstrates the complexities in diagnosing pancreatic cancer, particularly when the presentation is that of pancreatitis. Our findings emphasize the need for careful review of imaging results and a high clinical suspicion of malignancy in patients with recurrent pancreatitis. Further research into more effective diagnostic tools and treatment strategies is warranted to enhance the early detection and management of pancreatic cancer in similar clinical scenarios.

Background: Academic publications are important for developing medical specialties. Respiratory system diseases are among the most common human diseases and have a significant impact on morbidity and mortality. This is particularly true regarding the impact of the new coronavirus, severe acute respiratory syndrome coronavirus 2. This study aimed to perform a bibliographic analysis of Taiwanese academic publications in the Web of Science (WoS) subject category of respiratory systems.

Methods: Publications in the WoS Respiratory System Category, including papers in Science Citation Index Expanded and Social Sciences Citation Index journals from 1972 to 2023, were retrieved and analyzed.

Results: Among 392 030 papers published worldwide in the WoS Respiratory System Category from 1972 to 2023, 3672 (0.94%) were published in Taiwan, ranking 21st in the world, with a total of 82 956 citations. Over these five decades, the annual number of Taiwanese publications and citations has increased over time. However, the mean impact factor of publications has shown a tendency to decrease since 1997. International collaboration with coauthors outside Taiwan was found in 780 papers (21.24% of the total publications), mainly from the United States, the People's Republic of China, the United Kingdom, France, and South Korea. Collaborative papers had a significantly higher mean impact factor (8.2 ± 0.3 vs 5.6 ± 0.1, p < 0.001) and citation counts per paper (44.2 ± 3.3 vs 25.2 ± 0.8, p < 0.001) than those of non-collaborative papers.

Conclusion: Taiwanese publications in the WoS Respiratory System Category have a trend of increasing number and citations since 1972. However, the mean impact factor of the published papers has decreased since 1997. This disproportionate trend is an observational finding that deserves further investigation.

Background: Airway stenting in patients with esophageal cancer involving the airway possibly improves survival by relieving the symptoms of obstructive pneumonitis and facilitating cancer treatment. However, its advantages over conservative management remain unclear. Therefore, we compared the survival outcomes of airway stenting and conservative treatment in patients with advanced esophageal cancer.

Methods: We retrospectively reviewed patients with advanced esophageal cancer involving the airway who were treated at Taipei Veterans General Hospital between July 2005 and January 2023. Airway involvement included airway obstruction with obstructive symptoms or esophago-respiratory fistulas. Patients were categorized into the stent and conservative treatment groups. We compared patients' clinical characteristics, post-airway involvement survival (PAIS), and overall survival (OS) and assessed the prognostic factors for survival.

Results: A total of 52 patients, including 31 with airway stenting and 21 with conservative treatment, were included. No differences were observed between the two treatment groups in terms of age, sex, body mass index, clinical performance (Eastern Cooperative Oncology Group [ECOG]), tumor location, clinical N stage, or site of airway involvement. However, the conservative treatment group had more patients with clinical T4 stage ( p < 0.001) and M1 stage ( p = 0.04) than did the stent group. PAIS (117 vs 43 days; p = 0.02) and OS (351 vs 106 days; p < 0.001) were significantly longer in the stent group than in the conservative treatment group. In addition, airway stenting significantly reduced pneumonia-related mortality (9.7% vs 52.4%; p = 0.001). Multivariable analysis revealed anticancer treatment after airway involvement (hazard ratio [HR], 0.13; confidence interval [CI], 0.06-0.27; p < 0.001) and airway stenting (HR, 0.37; CI, 0.20-0.68; p = 0.001) as significant prognostic factors for PAIS. For OS, ECOG ≥1 (HR, 2.20; CI, 1.09-4.42; p = 0.03) and airway stenting (HR, 0.37; CI, 0.17-0.78; p = 0.01) were significant prognostic factors.

Conclusion: Airway stenting reduced pneumonia-related mortality in patients with advanced esophageal cancer with airway involvement. Moreover, patients who underwent airway stenting had better survival than did those who received conservative treatment alone; thus, airway stenting should be recommended after careful patient selection.

Background: The traditional Chinese medicine ReDuNing (RDN) is primarily composed of Artemisia annua , Gardenia jasminoides , Lonicera japonica , and clinically utilized for treating influenza. Therefore, we explored the mechanism of RDN in sepsis-induced lung injury.

Methods: Network pharmacology was used to identify the active components of RDN. A drug component network was constructed using Cytoscape 3.10.1 to identify key compounds, and a protein‒protein interaction (PPI) network was established using the STRING database. Common targets of RDN and sepsis were uploaded to the DAVID Bioinformatics Resources 6.8 for Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses to predict potential signaling pathways. In vitro, reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and western blot assays were used to detect the expression levels of JAK1/STAT3 and inflammatory factors. Subsequently, in vivo experiments were performed to validate these hypotheses.

Results: JAK1 was the most significantly enriched common target, and RDN may exert its effects via the JAK1/STAT3 signaling pathway. The expression of proinflammatory cytokines decreased in RDN-treated MH-S cells, which increased after inhibiting the JAK1/STAT3 pathway. The in vivo experimental results confirmed the in vitro findings.

Conclusion: RDN regulates the secretion of inflammatory cytokines by alveolar macrophages by activating the JAK1/STAT3 pathway, thereby alleviating sepsis-induced acute lung injury.

Background: Flexible bronchoscopy is frequently employed for therapeutic interventions in tracheal lesions, but airway management during these procedures is challenging due to the need to share the airway for both ventilation and instrumentation. Endotracheal intubation, while providing a secure airway, often requires repeated insertion and removal of the tube to allow for bronchoscopic access. Additionally, the narrower internal diameter of the endotracheal tube can limit the maneuverability of the bronchoscope, making procedures more technically demanding. In contrast, the supraglottic airway (SGA)-originally developed by an anesthesiologist known as laryngeal mask-is a less invasive device that sits above the larynx and forms a seal around the glottic opening to allow for effective ventilation. SGAs typically have a wider lumen and do not require repeated placement during procedures, offering a more convenient and potentially safer conduit for flexible bronchoscopy. Despite these advantages, direct comparative evidence on the safety and efficacy of SGA vs endotracheal intubation in this context remains lacking.

Methods: We reviewed charts and perioperative data regarding patients who underwent tracheal therapeutic procedures using flexible bronchoscopy under general anesthesia at Taipei Veterans General Hospital between 2019 and 2024. The primary outcome was the total number of repeated airway manipulations required. Secondary outcomes included oxygenation, ventilation, length of hospital stay, and procedure-related complications.

Results: A total of 65 procedures were analyzed. There was a significantly higher proportion of female patients in the SGA group (67.7%) compared with the endotracheal intubation group (22.9%, p < 0.001). Mann-Whitney U tests revealed a significant reduction in the requirement for repeated airway manipulations with the SGA compared with endotracheal intubation ( p < 0.001). The median lowest oxygen saturation was higher with SGA (97% vs 94%, p = 0.001), while end-tidal carbon dioxide (EtCO 2 ) levels were comparable (45 vs 44 mmHg, p = 0.94). In addition, patients in the SGA group were weaned from mechanical ventilation earlier and had significantly shorter hospital stays (5.5 vs 30 days, p < 0.001).

Conclusion: Compared with endotracheal intubation, the SGA is an effective alternative for airway management during therapeutic tracheal procedures using flexible bronchoscopy. It reduces the need for repeated airway manipulation, provides better oxygenation with comparable ventilation, maintains continuous airway control, and serves as a reliable conduit for bronchoscope insertion.

Background: The use of generative AI, particularly large language models such as GPT-4, is expanding in medical education. This study evaluated GPT-4's ability to interpret emergency medicine board exam questions, both text- and image-based, to assess its cognitive and decision-making performance in emergency settings.

Methods: An observational study was conducted using Taiwan Emergency Medicine Board Exam questions (2018-2022). GPT-4's performance was assessed in terms of accuracy and reasoning across question types. Statistical analyses examined factors influencing performance, including knowledge dimension, cognitive level, clinical vignette presence, and question polarity.

Results: GPT-4 achieved an overall accuracy of 60.1%, with similar results on text-based (60.2%) and image-based questions (59.3%). It showed perfect accuracy in identifying image types (100%) and high proficiency in interpreting findings (86.4%). However, accuracy declined in diagnostic reasoning (83.1%) and further dropped in final decision-making (59.3%). This stepwise decrease highlights GPT-4's difficulty integrating image analysis into clinical conclusions. No significant associations were found between question characteristics and AI performance.

Conclusion: GPT-4 demonstrates strong image recognition and moderate diagnostic reasoning but limited decision-making capabilities, especially when synthesizing visual and clinical data. Although promising as a training tool, its reliance on pattern recognition over clinical understanding restricts real-world applicability. Further refinement is needed before AI can reliably support emergency medical decisions.

This article reviews the advancements made in the diagnosis and treatment of metabolic dysfunction-associated steatotic liver disease (MASLD) and its progression to metabolic dysfunction-associated steatohepatitis (MASH). For inhibition of the MASLD progression, newly approved thyroid hormone receptor β agonists and potential agents, including farnesoid X receptor (FXR) agonists, peroxisome proliferator-activated receptor (PPAR) agonists, glucagon-like peptide-1 (GLP-1) receptor agonists, GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor co-agonists, and or GIP/GLP-1/glucagon receptor co-agonists, offering new prospects for the pharmacological management of MASLD. Lifestyle interventions, particularly personalized dietary and exercise regimens, as well as multidisciplinary collaboration, are recognized as vital components of treatment strategies. Although surgical options can yield significant benefits in certain cases, their risks and the criteria for patient selection necessitate more stringent research and guidance. Given the complexity of MASLD-related hepatocellular carcinoma (HCC), various insulin resistance, oxidative stress, gut-liver axis dysregulation, genetics, and epigenetics-based anti-tumor treatments have been ongoing explored to improve outcomes. Considering the global prevalence of MASLD and the relatively young age of disease onset, healthcare providers should be more vigilant in the timely diagnosing of MASLD progression to MASH, cirrhosis, and HCC. Likewise, regular medical check-ups are essential for early disease diagnosis and prevention before the development of complications, thereby improving their overall quality of life. Significant progress has been made in the research surrounding MASLD, MASH, and HCC, instilling new hope for future clinical practices.

Background: Gastric cancer is a common malignancy worldwide, especially in East Asia. However, increasing age is an independent risk factor associated with high operative complications and surgical mortality in radical gastrectomy. To improve the prognosis of surgery, we proposed strategic postoperative sedation for geriatric patients with gastric cancer undergoing radical gastrectomy.

Methods: A total of 324 gastric cancer patients, more than 75 years of age who underwent open radical gastrectomy at Taipei Veterans General Hospital between 2006 and 2020 were enrolled. The patients were classified into the sedation group (preemptive light sedation with prolonged mechanical ventilation assistance for the first five days postoperatively in the intensive care unit, n = 53) and the control group (early extubation, received morphine for pain control but no postoperative sedatives in the ordinary ward, n = 271). We compared the two groups' baseline clinical characteristics and the associated surgical outcome. We also conducted an in vitro cell experiment with RAW 264.7 macrophage cell line and evaluated the cell performance in various concentrations of sedation drug propofol and dexmedetomidine.

Results: Patients in the sedation group has significantly lower postoperative complication rates (13.7% vs 29.9%; p = 0.031). Among overall postoperative complications, the incidence rate of pulmonary events was significantly lower in the sedation group. Moreover, the incidence of other complications, including cardiac events, intra-abdominal abscesses, anastomotic leakage, adynamic ileus, and wound infection, was slightly higher in the matched control group without a statistically significant difference. Regarding surgical mortality rate and postoperative hospital length of stay (LOS), there were no significant differences between the two groups. For in vitro cell experiments with RAW 264.7 macrophage cell line, propofol, or dexmedetomidine significantly decreased tumor necrosis factor (TNF)-α production.

Conclusion: For elderly patients with gastric cancer who undergo open radical gastrectomy, strategic postoperative sedation is safe and may reduce the incidence of pulmonary complications without prolonging hospital LOS.