Journal of the Chinese Medical Association : JCMA最新文献

Sarcopenia, characterized by the progressive loss of skeletal muscle mass and function, significantly impacts health outcomes in older adults. This review explores the evolving landscape of sarcopenia research, with a particular focus on its unique characteristics in Asian populations and emerging pharmaceutical interventions. Recent studies have revealed distinct patterns of muscle mass decline in Asian adults, particularly in women, challenging the universal application of global sarcopenia diagnostic criteria. The Asian Working Group for Sarcopenia has proposed region-specific diagnostic criteria, acknowledging these ethnic variations. Prevalence estimates of sarcopenia vary widely, ranging from 10% to 40% in community-dwelling older adults. For specific chronic conditions, the prevalence of sarcopenia is notably higher, reaching 35% for cardiovascular diseases and 24.5% for chronic kidney disease. Sarcopenia is strongly associated with various chronic conditions, increasing the risk of falls by 1.5 to 3 times and significantly increasing mortality risk by 29% to 51%. Current management strategies primarily involve resistance exercise and nutritional interventions, with a recommended daily protein intake of at least 1.2 g/kg to maintain muscle health. Pharmaceutical development has gained significant momentum, with over 20 compounds in various stages of clinical trials. These include myostatin inhibitors, selective androgen receptor modulators, ghrelin receptor agonists, mesenchymal stem cell therapy, and follistatin gene therapy. However, the unique dietary patterns, cultural contexts, and potentially distinct drug responses in Asian populations necessitate tailored interventions and Asia-specific clinical trials. Future directions include refining Asian-specific diagnostic criteria, conducting large-scale epidemiological studies across multiple Asian countries, developing culturally appropriate interventions, integrating sarcopenia management into chronic disease care, and advancing pharmaceutical research with a focus on Asian populations. In conclusion, sarcopenia emerges as a critical nexus in the aging process, intricately linked with multiple organ systems and chronic conditions, underscoring the imperative for its recognition as a cornerstone in person-centered care and the holistic management of age-related health challenges.

Background: This study aims to delineate the resistance profiles of integrase strand transfer inhibitors (INSTIs) among patients in southern Taiwan who had experienced antiretroviral therapy (ART) failure. We focused on individuals previously treated with highly active ART (HAART) regimens, providing insights into the implications of INSTI resistance in a broader treatment-experienced population.

Methods: Data were collected from patients failing an INSTI-containing regimen in a medical center in southern Taiwan between 2009 and 2022. Virological failure was defined as a plasma viral load >1000 copies/mL. Reverse transcriptase, protease, and integrase coding regions were sequenced at failure. Resistance-associated mutations included in the 2022 International Antiviral Society (IAS)-USA list were used. Drug resistance was analyzed using the HIV Stanford HIVDB 9.4 edition algorithm. Logistic regression analysis was used to analyze the risk factors associated with INSTI failure.

Results: A total of 184 patients were enrolled for genotypic drug resistance testing due to virological failure, of whom 104 failed on nonnucleoside reverse transcriptase inhibitors, 58 on protease inhibitors (PIs), and 21 on INSTIs. Among 21 patients who failed INSTI therapy, 6 failed raltegravir-based treatment, 3 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (EVG/COBI/FTC/TAF), 2 bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF), and 10 abacavir/dolutegravir/lamivudine (ABC/DTG/3TC). Only 10 patients had INSTI drug resistance testing results available, and 40% (4/10) showed INSTI resistance at failure. Among the seven patients who failed on second-generation INSTIs with drug resistance reports available, one harbored E157Q and another with R263K mutations, respectively. Multivariable logistic regression analysis showed that patients with INSTI failure were less likely to have pol resistance (p = 0.007, adjusted odds ratio [OR], 0.176, 95% CI, 0.050-0.618), less previous exposure to NNRTI (p = 0.003, aOR, 0.063, 95% CI, 0.010-0.401), PIs (p = 0.002, aOR, 0.030, 95% CI, 0.003-0.272), and with long duration of HAART (p = 0.018, aOR, 1.02, 95% CI, 1.003-1.037).

Conclusion: INSTI resistance was uncommon when used as the first-line single tablet regimen in Taiwan. The results confirmed the robustness of ABC/DTG/3TC and BIC/FTC/TAF regarding integrase resistance in cases of virological failure in routine clinical care.

Background: The present study aimed to investigate whether proper sizing can improve the procedural and clinical outcomes of transcatheter aortic valve replacement (TAVR) with new-generation self-expanding valves (SEVs) and balloon-expandable valves (BEVs) for treating bicuspid aortic stenosis (BAS).

Methods: We retrospectively evaluated consecutive patients who underwent TAVR with Sapien 3 valves (Edwards Lifesciences, Irvine, CA) or Evolut R/PRO valves (Medtronic, Minneapolis, MN) for severe BAS from 2017 to 2022. The primary endpoints were device success rate and major adverse cardiac and cerebral events (MACCEs), including mortality, nonfatal myocardial infarction or disabling stroke, transcatheter heart valve failure, or clinically relevant valve thrombosis during follow-up. Our team used a complementary approach of supraannular sizing in addition to the conventional annular sizing method (Wei's method) to guide the TAVR procedures.

Results: We recruited a total of 75 consecutive patients, of whom 43 (57%) were treated with BEVs from October 2017 to June 2021, and 32 (43%) were treated with SEVs from July 2021 to December 2022. Device success was similar between the BEV and SEV groups (93% vs 94%; p > 0.99), and no cases of annular rupture occurred in either group. Similar rates of moderate-to-severe paravalvular leak were observed in the BEV and SEV groups (5% vs 6%, p > 0.99). At a median follow-up of 464 days, the MACCE rates were comparable between the two groups. In multivariate analysis, the presence of previous percutaneous coronary interventions (hazard ratio: 5.43; p = 0.039) and New York Heart Association functional class III/IV heart failure at 30 days of follow-up after TAVR (hazard ratio: 9.90; p = 0.037) were independently associated with long-term MACCEs.

Conclusion: Our results demonstrated comparable efficacy and safety for BAS patients undergoing TAVR using either BEVs or SEVs when using Wei's sizing method.

Background: This study sought to assess the risk factors of herpes zoster (HZ) in rheumatoid arthritis (RA) patients treated with tofacitinib (TOFA).

Methods: This retrospective study reviewed RA patients receiving TOFA. We compared clinical characteristics, laboratory profiles, concomitant medication use, and HZ incidence in patients with and without recent biologic synthetic disease-modifying antirheumatic drugs (bDMARDs) treatment, which is defined as their administration ≤180 days before the initiation of TOFA treatment. We used univariate Cox proportional hazards models and Kaplan-Meier analysis to assess risk factors.

Results: Among 304 RA patients, 97 had recent bDMARDs use and 207 did not. Patients with recent bDMARDs use typically had lower weekly doses of methotrexate, less hydroxychloroquine use, and shorter follow-up. In the recent bDMARDs group, 64 (66.0%) used tumor necrosis factor inhibitors (TNFi), 19 (19.6%) used tocilizumab, and 14 (14.4%) used abatacept. The overall incidence rate (IR) of HZ was 5.62 per 100 person-years. Patients with recent bDMARDs use exhibited a higher HZ risk compared to those without recent bDMARDs use (IR ratio: 2.34, 95% CI, 1.04-5.19, p = 0.028). Recent bDMARDs use (hazard ratio: 2.4, 95% CI, 1.12-4.95, p = 0.024) was an independent risk factor for HZ among multivariable analysis. Kaplan-Meier analysis confirmed increased HZ risk in RA patients on TOFA with recent bDMARDs use (log-rank p = 0.015).

Conclusion: HZ is common in RA patients treated with TOFA, and recent bDMARDs (TNFi, tocilizumab, and abatacept) use is a risk factor for HZ. HZ vaccination, therefore, should be recommended for this group.

Background: Metastatic melanoma of the ampulla of Vater is rare. The purpose of this study was to summarize the characteristics and outcomes of metastatic melanoma in the ampulla of Vater and highlight the impact of surgery on the prognosis of patients with metastatic melanoma.

Methods: Pooled data from a case encountered at our institution and from all sporadic cases published on PubMed and MEDLINE between 1996 and 2023 were analyzed.

Results: Fourteen patients with metastatic melanoma in the ampulla of Vater were enrolled. Seventy-three percent of primary melanomas were cutaneous and 27% were mucosal. Jaundice was the most common symptom (86%). The size of metastatic melanoma to the ampulla ranged from 1.5 cm to 8 cm, with a median of 2.75 cm. Concomitant metastasis to other organs occurred in 82% of the patients at the time of diagnosis, most commonly in the brain, lungs, and liver (36% each). Among the reported cases, pancreaticoduodenectomy was performed in five patients. The overall 1-year survival rate was 27.3%, with a median survival of four months. Wide excision of the primary lesion and chemotherapy significantly improved survival rates (p= 0.048). There is a trend toward improved survival in patients undergoing pancreaticoduodenectomy followed by chemotherapy.

Conclusion: Given the availability of effective systemic therapies, metastatic melanoma of the ampulla of Vater does not necessarily preclude major surgeries.

Background: Accurate age estimation is vital in forensic medicine and clinical dentistry. The Demirjian method is commonly used for this purpose, but its applicability to Asian individuals is understudied. The present study evaluated the accuracy of dental age (DA) estimation for Taiwanese children by using the Demirjian, Williems, and modified Demirjian methods, comparing these estimates to those of chronological age (CA) based on panoramic X-ray images.

Methods: A total of 232 Taiwanese children aged between 5 and 12 years underwent panoramic X-ray scans. Their permanent teeth were assessed using the Demirjian, Williems, and modified Demirjian methods to estimate DA. Regression analysis was employed to determine the correlation between CA and DA, with linear regression equations established using SPSS to identify differences.

Results: The Willems method had the lowest mean absolute error and the smallest mean difference between DA and CA among the 3 age estimation methods analyzed (p < .001). The R2 value for the difference between DA and CA was 0.831 for the Williems method, 0.813 for the Demirjian method, and 0.782 for the modified Demirjian method (p < .001). The Williems method had the highest correlation with CA, with the linear equation for Taiwanese children being CA = 0.822 × DA + 1.093. For comparison, for the Demirjian method, the equation was CA = 0.894 × DA + 0.165.

Conclusion: The effectiveness of predictive methods varies across ethnicities, and therefore, region-specific formulas are required. For Taiwanese children, the Williems method predicts CA most accurately. This study contributes to the fields of legal medicine and clinical dentistry by demonstrating the accuracy of DA in predicting CA.

Background: Pruritus is a distressing symptom of systemic opioid analgesia that responds poorly to conventional antipruritus treatments. This study aimed to determine the incidence and risk factors for postoperative pruritus using intravenous patient-controlled analgesia (IV-PCA).

Methods: Opioid-naïve patients who underwent morphine-based IV-PCA for postoperative pain at a tertiary center between January 1, 2020, and June 30, 2023, were included retrospectively. The primary outcome was pruritus within 72 h after surgery. Cumulative morphine consumption and pain numerical rating scores were measured to evaluate the potential impact of pruritus on postoperative pain control.

Results: A total of 1,696 patients were enrolled, of whom 119 (7.0%) developed pruritus during the study period. Five independent factors for pruritus were identified, including intraoperative uses of hydroxyethyl starch solutions [adjusted odds ratio (aOR): 0.13, 95% confidence interval (CI): 0.04-0.43], lockout interval of IV-PCA (aOR: 0.50, 95% CI: 0.27-0.94, on base-2 logarithmic scale), droperidol addition to morphine solutions (aOR: 0.53, 95% CI: 0.35-0.81), cumulative morphine dose (aOR: 1.76, 95% CI: 1.47-2.12, on base-2 logarithmic scale), and postoperative uses of antihistamines (aOR: 2.90, 95% CI: 1.83-4.60) (c-statistic = 0.745). Patients with pruritus had higher postoperative morphine consumption (median: 67.5 mg, interquartile range: 38.3-94.0 vs. 38.0 mg, 21.0-65.4, p<0.0001) but similar pain intensity compared to those without pruritus.

Conclusion: Increasing the lockout interval and the droperidol regimen may protect patients from morphine-induced pruritus after IV-PCA. Further studies are warranted to clarify the mechanisms underlying the anti-pruritus effects of hydroxyethyl starch.