Journal of the Chinese Medical Association : JCMA最新文献

Background: Alpha-fetoprotein (AFP) has been the primary biomarker for hepatocellular carcinoma (HCC), but a subset of patients with HCC have normal serum levels of AFP (<20 ng/mL). Reliable biomarkers for predicting prognosis in this population remain limited. Protein induced by vitamin K absence or antagonist II (PIVKA-II) has emerged as a promising diagnostic marker for HCC, but its prognostic value for patients with normal AFP has not been well established. Therefore, this study investigated its prognostic significance in such patients.

Methods: We retrospectively analyzed 330 consecutive treatment-naïve patients with HCC who had normal serum levels of AFP and were diagnosed between 2020 and 2023 at Taipei Veterans General Hospital. Patients were stratified into two groups according to serum levels of PIVKA-II (>100 vs ≤100 mAU/mL). Prognostic factors for overall survival (OS) were assessed using multivariate Cox proportional-hazards models.

Results: There were 169 (51.2%) patients in the study population who had elevated PIVKA-II levels (>100 mAU/mL). These patients demonstrated more aggressive tumor characteristics, including larger tumor size, multinodularity, macrovascular invasion, and extrahepatic metastases compared to those with PIVKA-II ≤100 mAU/mL, despite having comparable liver functional reserves. Patients with high PIVKA-II levels were also less likely to undergo curative treatment (53.3% vs 83.2%, p < 0.001). After a median follow-up of 17 months (interquartile range: 8.0-27.0), 50 patients had died, and the overall 3-year OS rate was 77%. OS was significantly lower in the high-PIVKA-II group than the low-PIVKA-II group (54.9% vs 87.1%, p < 0.001). Multivariate analysis identified elevated PIVKA-II as an independent predictor for poor OS (hazard ratio: 2.422, 95% CI, 1.128-5.198, p = 0.023).

Conclusion: Serum PIVKA-II is an independent prognostic biomarker for patients with HCC who have normal AFP levels and can be used to stratify patients into distinct risk groups.

Background: Advances in endovascular treatments have improved surgical outcomes for patients with aortic pathologies. However, for patients with comorbid aortic dissection and degenerative abdominal aortic aneurysm (AAA), effective surgical treatment is often a challenge. Here, we analyzed the outcomes of endovascular treatment in patients who concurrently had acute DeBakey type 3A aortic syndrome and degenerative infrarenal AAA.

Methods: From 2012 to 2019, 11 patients were diagnosed concurrently with acute type 3A aortic syndrome and degenerative infrarenal AAA that met intervention criteria (typical acute descending aortic dissection, or thickness of hematoma or ulceration greater than 10 mm in intramural hematomas [IMH] or penetrating aortic ulcers [PAU], in addition to AAA diameter >5 cm). Three patients had a typical dissection, three had IMH, and five had PAU.

Results: Four men underwent a one-stage operation, and preoperative cerebrospinal fluid lumbar drainage was instituted in three patients. The other seven patients underwent a two-stage operation consisting of endovascular aneurysm repair (EVAR) followed by thoracic endovascular aortic repair (TEVAR) over a period ranging from 3 to 52 months. Follow-up continued until the end of 2022. No spinal cord ischemia (SCI) was present in either group. In the one-stage group, one patient died of intracranial hemorrhage 1.5 months after the operation. The other three patients did not experience any aortic event requiring reintervention. In the two-stage group, four patients required reintervention, including one type I endoleak, 2 type II endoleaks, and one visceral artery stent compromise. In this group, four patients died during follow-up.

Conclusion: Mid-term outcomes were acceptable in patients with concurrent acute type 3A aortic syndrome and degenerative infra-renal AAA, managed with EVAR and TEVAR, both simultaneously and sequentially. The incidence of SCI was low, and aortic coverage spared the segment from T8 to L1.

A well-functioning vascular access is essential for delivering adequate hemodialysis in patients with end-stage renal disease. However, vascular access dysfunction, particularly stenosis and thrombosis, remains a leading cause of morbidity, repeated interventions, and hospitalization in this patient population. Vascular access monitoring and surveillance are designed to detect hemodynamically significant stenosis early, thereby reducing the risk of thrombosis and maintaining access patency. Evidence from meta-analyses and randomized controlled trials suggests that access blood flow (Qa)-based surveillance may lower thrombosis rates in arteriovenous fistulas (AVFs), while the benefit appears less consistent for arteriovenous grafts (AVGs). Consequently, most guidelines recommended incorporating Qa surveillance into routine clinical monitoring for AVFs, but not as a standard practice for AVGs. However, previous studies have notable limitations, including heterogeneous surveillance protocols and variable definitions of access dysfunction. More rigorously designed randomized controlled trials are needed to clarify the role of Qa surveillance and inform optimal strategies. Looking ahead, emerging technologies such as artificial intelligence and wearable devices for continuous monitoring hold promise for enhancing diagnostic accuracy, enabling earlier detection of dysfunction, and reducing the need for intervention rates. Integrating these innovations with standardized surveillance protocols and individualized patient risk stratification has the potential to improve vascular access longevity, reduce the healthcare burden, and improve outcomes in the hemodialysis population, although further validation is required.

Background: Vitamin D plays a role in immune regulation and may influence coronavirus disease 2019 (COVID-19) outcomes. This study examined the association between serum vitamin D levels and COVID-19 infection and mortality in symptomatic patients in Taiwan.

Methods: This retrospective cohort study included symptomatic patients who underwent COVID-19 real-time polymerase chain reaction (RT-PCR) assay between 2020 and 2023. Serum 25-hydroxyvitamin D (25(OH)D) levels were categorized as deficient (<20 ng/mL), insufficient (20-30 ng/mL), or sufficient (≥30 ng/mL). Logistic regression models were used to evaluate the impact of vitamin D levels on COVID-19 infection and mortality, adjusting for potential confounders including age, sex, and comorbidities.

Results: Among the 481 participants (mean age: 58.2 years; 66.7% female), 96 (19.96%) tested positive for COVID-19. Vitamin D level was not associated with COVID-19 infection (odds ratio [OR] = 1.00, 95% CI, 0.99-1.02; p = 0.687); however, vitamin D deficiency significantly increased the risk of COVID-19-related mortality (OR = 10.68; 95% CI, 1.18-96.45; p = 0.035). The mortality rate in patients aged 65 to 74 years was higher compared to those aged 19 to 44 years (OR = 12.91; 95% CI, 1.29-128.83; p = 0.029).

Conclusion: Vitamin D levels were not associated with susceptibility to COVID-19 infection. However, vitamin D deficiency, particularly in older patients, was associated with an increased risk of mortality among those diagnosed with COVID-19. These findings support the role of vitamin D in reducing COVID-19 mortality and emphasize the importance of maintaining sufficient levels in high-risk populations.

Background: The clinical association between cytomegalovirus (CMV) DNA detection in stool samples and patient outcomes remains underexplored. This study aimed to assess prognostic factors and viral kinetics in patients with positive stool CMV polymerase chain reaction (PCR).

Methods: This retrospective cohort study included adult patients with positive stool CMV-PCR results at Taipei Veterans General Hospital (2016-2021). Clinical data, plasma, and stool viral loads (VLs) were analyzed. Receiver operating characteristic (ROC) curves and area under the curve (AUC) evaluated 30-day mortality prediction, with optimal cutoffs maximizing sensitivity and specificity. Kaplan-Meier survival analyses and Cox proportional hazards models identified predictors of 30-day mortality.

Results: A total of 114 patients (mean age: 64.0 years, 64% male) were included. The median stool CMV VL was 629 copies/mL (interquartile range [IQR]: 263-7949). Plasma CMV DNA was detected in 76% with a median VL of 341 copies/mL (IQR: 10-1771). Stool and plasma VLs showed moderate correlation ( ρ = 0.38, p < 0.0001). ROC analysis identified cutoffs for predicting 30-day mortality: stool 9654 copies/mL (AUC = 0.54; sensitivity 42%; specificity 81%) and plasma 1738 copies/mL (AUC = 0.60; sensitivity 47%; specificity 70%). In multivariate Cox analysis, stool CMV VL >9,654 copies/mL (adjusted hazard ratio: [HR] 2.69, 95% confidence interval [CI]: 1.06-6.84; p = 0.04) and plasma CMV VL >1738 copies/mL (adjusted HR: 2.66, 95% CI: 1.14-6.17; p = 0.02) were independent predictors of 30-day mortality. Septic shock and steroid use were also associated with increased mortality, whereas antiviral therapy ≥7 days was independently protective (adjusted HR: 0.26, 95% CI: 0.10-0.64; p = 0.003).

Conclusion: Stool and plasma CMV VLs, antiviral treatment duration, and host factors such as immune status may influence outcomes in patients with intestinal CMV reactivation. Larger studies are needed to validate optimal VL thresholds for risk stratification.

Background: Cardiac magnetic resonance (CMR) imaging is a critical tool for the diagnosis and evaluation of pulmonary hypertension (PH). This study aimed to investigate the temporal changes in cardiac morphological and functional characteristics in PH using CMR, with the goal of identifying early indicators of adverse clinical outcomes.

Methods: This retrospective study included patients diagnosed with PH using right heart catheterization. Each patient underwent two CMR sessions, approximately 1.5 years apart, for follow-up. CMR characteristics, including morphological and functional parameters such as myocardial strain, were analyzed in relation to the primary adverse events endpoint, defined as a composite of heart failure hospitalization and all-cause mortality.

Results: A total of 36 patients (8 men and 28 women, mean age 48.0 ± 13.3 years) were enrolled. Eleven patients (30.6%) experienced adverse events after the second CMR. High right ventricular (RV) volume and worse RV strain at follow-up were observed in patients who experienced future events (RV end-diastolic volume [RVEDV], 247.2 vs 182.3 mL, p = 0.029; and right ventricular global longitudinal strain [RVGLS], -12.0% vs -17.1%, p = 0.021, respectively). In contrast, an increase in left ventricular ejection fraction (LVEF) and left ventricular (LV) volume was noted in patients without events, whereas a decrease in LV end-diastolic volume was associated with subsequent events (111.6 vs 123.9 mL, p = 0.024). An increase in LVEF was observed in patients without events (61.5% vs 57.3%, p = 0.030), underscoring the predictive value of LV function.

Conclusion: This study emphasizes the value of CMR in monitoring patients with PH, particularly for assessing ventricular function as a predictor of future outcomes. The observed trends in myocardial strain highlight its potential as a prognostic marker, warranting further research to confirm its clinical utility.

Background: With the advent of novel therapies and advanced imaging modalities, prostate cancer patients are living longer, but biochemical recurrence has become increasingly common. Prostate-specific membrane antigen (PSMA) PET imaging demonstrates high sensitivity in detecting recurrence at low prostate-specific antigen (PSA) levels, surpassing conventional imaging. While salvage radiotherapy traditionally targets the prostate fossa, PSMA PET enables focal dose escalation to PSMA-avid lesions. This study evaluated whether PSMA PET-guided salvage radiotherapy improves disease control compared with androgen deprivation therapy (ADT) alone, while maintaining an acceptable toxicity profile.

Methods: Patients with suspected recurrent prostate cancer underwent PSMA PET, with eligibility defined as a PSMA score >3. Salvage treatment consisted of high-dose radiotherapy to the prostate fossa with focal boost to PSMA-avid lesions (with or without ADT) or ADT alone. The primary endpoint was failure-free survival (FFS). Secondary endpoints included treatment-related toxicities.

Results: Fifty-six patients were included (mean age, 70.3 years). The mean initial PSA was 25.2 ng/mL, and the mean PSA before PSMA PET was 2.47 ng/mL. Patients who had previously undergone radical prostatectomy demonstrated significantly longer FFS compared with those initially treated with radiotherapy (41.2 vs 31.5 months, p = 0.045), although baseline PSA was higher in the radiotherapy group. Salvage radiotherapy yielded significantly longer FFS than ADT alone (42.1 vs 23.4 months, p < 0.001). Acute grades 1 and 2 gastrointestinal or genitourinary toxicities occurred in 23 patients (46.9%), late grades 1 and 2 events in 16 patients (32.7%), and grade 3 hematuria requiring intervention in 4 patients (8.2%).

Conclusion: PSMA PET-guided salvage radiotherapy is an effective and personalized strategy for patients with biochemically recurrent prostate cancer. Compared with ADT alone, it provides superior failure-free survival with manageable toxicity, supporting its role as a standard component of salvage management.