Journal of the Chinese Medical Association : JCMA最新文献

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.

Type 2 diabetes mellitus and obesity have become the rising burden across various geographic and economic regions, and they are also the common causes of chronic kidney disease, which further contributes to the development and progression of cardiovascular disease. The recently proposed cardiovascular-kidney-metabolic syndrome-the new paradigm of recognizing excess or dysfunctional adipose tissue as the shared pathophysiology-has signaled the interconnection of type 2 diabetes mellitus, obesity, chronic kidney disease, and cardiovascular disease beyond the disturbance of glucose homeostasis, for which recently developed incretin-based therapy has offered an avenue of holistic management. Glucagon-like peptide-1 (GLP1) is one of the incretins and potentiates insulin secretion after food intake, additionally offering extra-pancreatic metabolic effects-reduced hepatic gluconeogenesis and steatosis, increased muscular glucose uptake, and increased lipolysis and glucose uptake in the adipose tissue. Seven different GLP1 receptor agonists have been licensed globally. For those with type 2 diabetes mellitus, GLP1 receptor agonists overall reduce major adverse cardiovascular events by 14% (hazard ratio 0.86, 95% confidence interval 0.80-0.93) and all-cause death by 18% (hazard ratio 0.82, 95% confidence interval 0.82-0.94), and semaglutide, a long-acting GLP1 receptor agonist for once weekly injection, reduces major renal events by 24% (hazard ratio 0.76, 95% confidence interval 0.66-0.88). For obese patients without diabetes mellitus, semaglutide results in a 12.4% (95% confidence interval -13.4 to -11.5) reduction in body weight and 20% lower in the risk of major adverse cardiovascular events (hazard ratio 0.80, 95% confidence interval 0.72-0.90), while the burden of heart failure can also be improved by 7.8 points (95% confidence interval 4.8-10.9) in those with heart failure with preserved ejection fraction and obesity. These findings highlight the transformative role of GLP1 receptor agonists in the management of cardiovascular-kidney-metabolic syndrome. We reviewed the updated clinical evidence of incretin-based therapy and summarized its outcome benefits.

Background: Hospital fires pose significant threats, yet Hospital Incident Command Centers (HICS) often lack standardized methods for assessing the evacuation devices and workforce needed for patients of varying illness severity. Frontline nurses typically rely on personal experience and paper-based assessments, leading to communication challenges and workforce shortages, particularly during night shifts. The Emergency Evacuation Information System (EEIS) was developed to connect hospital information systems and patient data, optimizing evacuation efficiency.

Methods: This mixed-methods study consisted of four phases: (1) Twenty-nine senior nurses participated in three expert group discussions, and the meeting minutes were thematically analyzed to develop a draft EEIS evacuation framework; (2) the accuracy of the EEIS draft algorithms was tested by retrieving evacuation data and validated through accuracy assessment methods; (3) the EEIS was implemented hospital-wide, with consistency between EEIS and nurse assessment data validated using kappa agreement; (4) think-aloud methods with four preset questions collected in-charge nurses' feedback during fire drills.

Results: In phase 1, an evacuation framework was established covering ward resources, patient evacuation devices, and hospital support resources. Phase 2 involved building the EEIS by integrating patient data from multiple systems, achieving 100% accuracy. In phase 3, EEIS-managed units in general wards and intensive care units showed excellent agreement with nurse assessments ( κ = 0.974, p < 0.000; 0.86, p < 0.000). In phase 4, feedback from 21 in-charge nurses after fire drills emphasized the need for accessible power outlets and wireless network connectivity outside the building to optimize response procedures.

Conclusion: The EEIS rapidly provides adequate resources to nurses and facilitates communication with the HICS, ensuring the efficient and safe evacuation of patients. This system can be implemented in other digitized hospitals, with future developments potentially integrating the EEIS with local fire departments to enhance rescue operations.

Background: The Montreal Cognitive Assessment (MoCA) may not be appropriately interpreted in Taiwan because of the lack of large-scale normative data. Moreover, examinees' demographic characteristics may influence their MoCA scores. However, previous studies have not adequately adjusted for these effects. This study aimed to use regression-based methods to establish demographically adjusted MoCA norms.

Methods: Participants were recruited from six hospitals and neighboring communities from all geographic areas of Taiwan. Multiple regression analyses were conducted to quantify the effects of age, education, and sex on MoCA total and domain scores, resulting in correction equations and adjusted cutoff scores.

Results: A total of 2310 cognitively healthy participants were included in the analysis. Age and education significantly affected the total and all domain scores. Sex affected naming, language, and abstract thinking domain scores. Correction equations and corresponding cutoffs were proposed for MoCA total and domain scores to support more precise clinical interpretations.

Conclusion: This study provides regression-adjusted norms for the MoCA, improving its accuracy and clinical utility in Taiwan. An adjusted total MoCA score of 23 points is recommended as the cutoff for identifying potential cognitive impairment, with domain-specific cutoffs further supporting individualized interpretation.