Journal of the Chinese Medical Association : JCMA最新文献

Background: The clinical reflection-oriented learning portfolio is widely applied in clinical rotation, but it is time-consuming for clinical trainees, and the effect on learning is still questionable. This study aims to provide evidence of the effectiveness of the learning portfolio by examining the association between portfolio appraisal and clinical performance.

Methods: From 2020 to 2022, data were evaluated to investigate the relationship between excellent portfolio award status, proficiency in entrustable professional activities (EPAs)-based assessments, and clinical competencies based on the core EPAs for entering residency of the American Association of Medical Colleges (AAMC), as well as eight core competencies evaluated every 2 weeks from each clinical department. In addition, clerks who continued their second-year clerkship at the research hospital (continuous follow-up group) were analyzed to further explore the association between first-year award status and second-year clinical outcomes.

Results: A total of 148 first-year clerks were included in the overall group (award recipients and non-recipients). Among them, 86 continued their clerkship at the research hospital in the second year (continuous follow-up group). In the overall group, compared with excellent learning portfolio non-recipients, award recipients demonstrated higher scores in 11 of the 13 EPAs and in all eight core competencies. Moreover, higher-frequency award winners obtained significantly higher scores compared to lower-frequency award winners. Stratified analyses based on gender yielded similar results during clerkship. However, this beneficial association was not observed in the continuous follow-up group.

Conclusion: This database study supports that better learning portfolio recording is associated with better clinical performance during the early stage of clerkship. Learning portfolio could be an effective tool to facilitate clinical learning in early clerkship.

Background: Sudden sensorineural hearing loss (SSNHL) is an otological emergency involving hearing loss greater than 30 dB across three consecutive frequencies within 72 hours. Prognosis is influenced by the initial pure-tone audiogram (PTA), with ascending and U-shaped patterns showing better outcomes and descending patterns linked to poorer outcomes. Traditional audiograms are classified into four to seven types based on hearing thresholds at four to six frequencies, such as flat, ascending, or descending types. However, the definitions of these patterns are often ambiguous and not easy to apply in clinical practice. This study aimed to compare the prognostic value of the traditional seven-type audiogram model with a novel three-type audiogram model.

Methods: This retrospective cohort study included SSNHL patients from 2012 to 2023. Hearing outcomes, measured by PTA, were classified using both the traditional seven-type audiogram model and a new three-type model based on the 4 kHz threshold (the best, intermediate, the worst). The traditional seven-type model classifies audiograms into flat, descending, ascending, tent-shaped, U-shaped, jagged, and profound types based on the threshold patterns at four frequencies (0.5, 1, 2, and 4 kHz). The novel three-type model classified audiograms according to the relative position of the 4 kHz threshold: (1) 4 kHz the best (lowest threshold), (2) 4 kHz intermediate (threshold in between), or (3) 4 kHz the worst (highest threshold). Complete recovery (CR) was defined as a final hearing threshold ≤25 dB HL. Multiple and stratified linear regression analyses assessed its association with the CR rate, defined as the proportion of patients achieving CR.

Results: In total, 965 patients with SSNHL were recruited (51.5% men; mean age 50.8 ± 15.1 years). Left ear involvement was more common (53.3%). CR was achieved in 21.1% of patients. The three-type audiogram model classification was significantly associated with CR (overall p < 0.001, multivariable logistic regression). 4 kHz was the worst, the CR rate was 20%, intermediate, 36%, the best, 49%. In contrast, the traditional seven-type audiogram model did not demonstrate such predictive characteristics.

Conclusion: The novel three-type audiogram model provides better prognostic predictions for SSNHL, with 4 kHz frequency being a key factor influencing recovery. Traditional audiogram classification is relatively complex, whereas the novel three-type audiogram model, which uses the 4 kHz threshold for classification, is simple, clear, and provides better prognostic prediction for SSNHL, making it more suitable for clinical application.

Background: Ambient fine particulate matter (PM2.5) has emerged as a critical environmental threat to ocular health; however, the underlying molecular mechanisms affecting the retinal pigment epithelium (RPE) remain largely uncharacterized. This study aimed to investigate transcriptomic alterations in RPE cells following PM2.5 exposure and to identify key regulatory pathways involved.

Methods: Next-generation sequencing (NGS) was used to investigate differential gene expression in ARPE-19 cells upon PM2.5 exposure. Bioinformatic analyses, including pathway enrichment and gene set enrichment analysis (GSEA), were performed to identify affected signaling cascades. Functional assays-including cell viability, wound healing, and Transwell migration-were conducted to evaluate phenotypic changes. Quantitative RT-PCR (Reverse Transcription Polymerase Chain Reaction) and ELISA (Enzyme-Linked Immunosorbent Assay) validated gene expression and transforming growth factor-beta (TGF-β) secretion. TGF-β stimulation and receptor inhibition were applied to dissect pathway involvement.

Results: Comprehensive analysis revealed substantial changes in gene expression profiles, with pathway enrichment highlighting the activation of cell migration-related pathways such as focal adhesion, regulation of actin cytoskeleton, extracellular matrix (ECM)-receptor interaction, tight junction, and adherens junction. Notably, the TGF-β, MAPK (Mitogen-Activated Protein Kinase), and PI3K/AKT (Phosphoinositide 3-Kinase / Protein Kinase B) pathways were significantly modulated. Functional assays showed that PM2.5 exposure enhanced ARPE-19 cell viability and migratory capacity. Among the differentially expressed genes, angiopoietin-like 4 (ANGPTL4) was markedly upregulated following PM2.5 stimulation. Pharmacological inhibition of TGF-β signaling abrogated PM2.5-induced ANGPTL4 expression, suggesting a pivotal role of the TGF-β pathway in mediating these effects.

Conclusion: These findings demonstrate that PM2.5 induces transcriptomic reprogramming and activates the TGF-β signaling cascade in RPE cells, thereby enhancing cellular migration. Specifically, ANGPTL4 was identified as a key downstream effector of this pathway. This study provides novel insights into the molecular mechanisms by which air pollution contributes to retinal disease pathogenesis and suggests potential therapeutic targets for preventing PM2.5-induced retinal injury.

Background: Liver cirrhosis with portal hypertension is a sequela of chronic hepatitis, characterized by liver fibrosis, poor portosystemic collateral vasoresponsiveness, increased mesenteric angiogenesis, and collateral formation. Antihistamines are frequently used to control pruritus in cirrhotic patients, and it has also been shown to reverse histamine-induced inflammation, fibrogenesis, angiogenesis, and vasodilatation. However, the relevant impacts on cirrhosis are not clear.

Methods: Liver cirrhosis was induced in rats with common bile duct ligation (BDL). Sham rats were surgical controls. Levocetirizine (0.5 mg/kg/day, oral gavage) or vehicle was administered from the 1st day after operations and experiments were performed on the 29th day to survey: (a) Systemic and splanchnic hemodynamic parameters; (b) serum liver and renal biochemistry parameters; (c) protein expressions of liver fibrogenesis factors; (d) portosystemic collateral vasoresponsiveness to vasopressin; (e) portosystemic shunting degree; and (f) mesenteric angiogenesis.

Results: Compared with the vehicle, levocetirizine decreased portal pressure, superior mesenteric artery flow, portal vein (PV) flow, and elevated PV resistance in BDL rats. Levocetirizine significantly down-regulated the hepatic TGF-β, p-Smad2, MMP-2, and TIMP-1 protein expressions in BDL rats. Levocetirizine did not affect the collateral vasoresponsiveness to vasopressin but tended to reduce the severity of portosystemic shunting and mesenteric angiogenesis.

Conclusion: Levocetirizine ameliorated liver fibrosis, portal hypertension, and splanchnic hyperdynamic circulation in cirrhotic rats, possibly through the downregulation of hepatic fibrogenesis factors. Antihistamines may be a therapeutic option to control portal hypertension. However, further investigations are required to clarify its clinical application.

Background: Muscle damage has recently been recognized as a complication of type 2 diabetes mellitus (T2DM). Impaired muscle function adversely affects physical activity, quality of life, and mortality risk. Moreover, waist circumference (WC) is associated with visceral fat and insulin resistance. This study investigated the correlation between relative muscle strength and WC in patients with T2DM.

Methods: Patients aged 50 years or older with T2DM were recruited from Taipei Veterans General Hospital. WC was measured at the umbilicus level. Total muscle mass was assessed using bioelectrical impedance analysis. The muscle strength of handgrip, knee extension, ankle dorsiflexion, and ankle plantar flexion were evaluated using a hand-held dynamometer.

Results: A total of 252 patients (mean age 69.4 years; 122 men and 130 women) were enrolled. They were stratified into three groups according to WC (<85, 85-94, >94 cm). Patients with a larger WC had a higher body mass index and greater muscle mass but had lower relative muscle strength of handgrip, knee extension, ankle dorsiflexion, and ankle plantar flexion. Of note, patients with abdominal obesity (WC ≥90 cm in men and WC ≥80 cm in women) had significantly lower relative muscle strength of handgrip and lower limb compared to those without in both sexes. Multivariable analyses revealed that WC was significantly and negatively correlated with relative muscle strength after adjusting for other clinical variables.

Conclusion: WC, independent of muscle mass, is a good determinant of relative muscle strength in patients with T2DM. Measuring WC can help identify patients with T2DM at a high risk of low relative muscle strength, thereby broadening the scope of health screening in this population.

Background: Goal-directed fluid therapy (GDFT) individualizes fluid administration to optimize oxygen delivery and tissue perfusion. Traditional static parameters, such as central venous and pulmonary artery wedge pressures, are inaccurate. Instead, GDFT employs dynamic variables like stroke volume variation (SVV) and pulse pressure variation (PPV) to assess preload responsiveness and guide fluid administration. However, the Trendelenburg position alters cardiovascular physiology, and the effects of different tilt angles on SVV, PPV, and other hemodynamic variables remain unclear.

Methods: This single-center, observational study enrolled patients undergoing elective surgery. Following induction of general anesthesia, patients were positioned supine (0°) and then in the Trendelenburg position, with the angle adjusted to 5°, 10°, 15°, and 25°. Dynamic variables, including SVV, PPV, contractility (d P /d t ), dynamic arterial elastance (Eadyn), and cardiac index (CI), at each angle were recorded and analyzed.

Results: A total of 27 patients (mean age 66.7 ± 11.7 years, 79% male) were included. Increasing the Trendelenburg tilt angle from 0° to 25° was associated with a significant reduction in SVV (12.21 ± 4.26% at 0° to 6.94 ± 2.37% at 25°, p < 0.001) and PPV (13.47 ± 4.27% at 0° to 6.81 ± 3.20% at 25°, p < 0.001). SVV and PPV measured in the supine position correlated significantly with values obtained at 5°, 10°, 15°, and 25° ( p < 0.001). d P /d t progressively declined from 711.85 ± 235.58 mmHg/s at 0° to 583.85 ± 166.19 mmHg/s at 25° ( p < 0.001), and CI decreased from 2.51 ± 0.59 L/min/m² to 2.27 ± 0.60 L/min/m² ( p = 0.001). Eadyn trended downward but did not reach statistical significance ( p = 0.088).

Conclusion: The thresholds of SVV and PPV for predicting fluid responsiveness decrease with progressive Trendelenburg tilt. These variables should therefore be interpreted cautiously in relation to tilt angle when guiding fluid management.

Background: Total gastrectomy and proximal gastrectomy (PG) are both treatment options for proximal gastric cancer. Currently, there is no consensus on which procedure is better. The aim of this study was to compare the operative outcomes between PG and total gastrectomy in the treatment of proximal gastric cancer.

Methods: Between January 2000 and October 2022, patients who underwent either PG with double tract reconstruction (PG-DTR) or total gastrectomy with Roux-en-Y reconstruction (TG-RY) for proximal gastric cancer were included. The clinicopathologic characteristics and operative outcomes were compared between the two groups. Propensity score matching was performed to compare the short- and long-term outcomes between the two groups.

Results: A total of 263 patients were included in the study. After propensity-score matching, there was no significant difference in clinicopathological characteristics between the two groups. The TG-RY group had more retrieved lymph nodes (37.8 ± 18.6 vs 28.7 ± 15.4; p = 0.022) and a longer hospital stay (13.6 ± 10.2 vs 9.4 ± 3.3 days; p = 0.036) than the PG-DTR group. Surgical complications were similar between the two groups. The PG-DTR group had a greater prevalence of reflux esophagitis (21.4% vs 7.1%; p = 0.034), a higher postoperative/preoperative body weight ratio (0.91 ± 0.08 vs 0.84 ± 0.14; p = 0.021), and a higher postoperative/preoperative serum albumin ratio (1.07 ± 0.11 vs 0.96 ± 0.18; p = 0.004) than the TG-RY group.

Conclusion: Compared with TG-RY, PG-DTR was associated with better postoperative nutritional status and comparable operative complications.