Journal of the Chinese Medical Association : JCMA最新文献

Background: Early prediction of recovery in sudden sensorineural hearing loss (SSNHL) remains challenging. Early hearing improvement (EHI) may serve as a simple prognostic marker, but its quantitative relationship with complete recovery (CR) has not been well defined. We investigated the association between EHI and CR and explored whether this relationship differed according to pretreatment hearing severity.

Methods: We conducted a retrospective case-control study of adults hospitalized for a first episode of unilateral SSNHL at a tertiary referral center in Taiwan between 2012 and 2022. Patients who achieved CR, defined as a final four-frequency pure-tone average ≤25 dB HL, were matched by pretreatment hearing grade to patients without CR. EHI was defined as the change in pure-tone average from baseline to the first follow-up audiogram within two weeks. Multivariable linear probability models and logistic regression were used to evaluate the association between EHI and CR.

Results: The study included 240 patients (120 with CR and 120 without CR). Younger age and a shorter onset-to-treatment interval were independently associated with a higher probability of CR (age: β per 1-year increase, -0.009; 95% CI, -0.013 to -0.005; p < 0.001; onset-to-treatment interval: β per 1-day increase, -0.013; 95% CI, -0.018 to -0.009; p < 0.001). Mean EHI was 14.9 ± 19.1 dB and increased with pretreatment hearing grade. Each 1-dB increase in EHI was associated with a 1.5% higher probability of CR (β = 0.015, 95% CI 0.012-0.017; p < 0.001). The strength of this association progressively decreased as pretreatment hearing severity increased. Findings were consistent in sensitivity analyses using logistic regression.

Conclusion: Early hearing improvement within two weeks is a readily obtainable and quantitatively informative predictor of complete recovery in SSNHL. Its prognostic value is greatest in patients with less severe pretreatment hearing loss and diminishes with increasing hearing severity.

Background: The cognitive consequences of COVID-19 in patients with dementia remain uncertain. This study examined whether COVID-19 infection was associated with cognitive decline.

Methods: From October 2020 to October 2022, COVID-19-naïve patients with dementia were recruited from a hospital-based memory clinic in Taipei. During follow-up, patients who developed COVID-19 were classified as the infected group, while others served as controls. For controls, baseline and follow-up were defined as two consecutive annual cognitive assessments. For infected patients, baseline and follow-up were the nearest assessments before and after COVID-19 infection, respectively. The mean assessment interval was approximately one year in both groups. Outcomes included the Mini-Mental State Examination (MMSE), Clinical Dementia Rating Sum of Boxes (CDR-SB), and Cognitive Abilities Screening Instrument (CASI). Linear mixed-effects models assessed whether cognitive trajectories differed by COVID-19 status.

Results: After excluding patients without eligible follow-up data, infected patients were matched with controls by age and sex. Overall, 44 patients with dementia who developed COVID-19 and 22 who remained uninfected were included in the study. Baseline demographic characteristics and cognitive scores were comparable. The mean age was 84.1 years, with 36% (24/66) male. At follow-up, cognitive performance did not differ significantly between infected and control groups. Within-group analyses showed significant declines in MMSE, CDR-SB, and CASI in the infected group, whereas controls declined significantly only in CASI. In adjusted mixed-effects models, the COVID-19 × time interaction was not significant (β = -0.427, p = 0.676), suggesting no significant difference in MMSE decline trajectory between groups. Higher education was associated with higher MMSE scores (β = 0.553, p = 0.002). Sensitivity analyses supported these findings.

Conclusion: After accounting for age, sex, education, and assessment interval, COVID-19 infection was not associated with faster cognitive decline. Participants with more education generally had higher MMSE scores, but education did not significantly alter the rate of decline.

Pulsatile tinnitus (PT) caused by sigmoid sinus (SS) wall anomalies, most commonly diverticulum and dehiscence, represents a prevalent and potentially reversible venous etiology. This narrative review summarizes contemporary concepts in diagnosis and treatment and proposes a practical framework for clinical decision-making. The characteristic features of venous-type PT are first outlined, with emphasis on strict clinicoradiologic correlation using high-resolution temporal bone computed tomography and magnetic resonance venography to distinguish SS wall abnormalities from other vascular causes, such as dural arteriovenous fistulas (AVFs), high-riding jugular bulbs, and idiopathic intracranial hypertension. Patient selection, contraindications, and clinical "red flags" are then discussed, with particular attention to scenarios in which transmastoid surgery may be ineffective or pose substantial risk and in which systemic therapy or venous sinus stenting should be prioritized. The main transmastoid strategies include sinus wall resurfacing, tailored re-roofing with autologous bone, and diverticulectomy with multilayer reconstruction. These strategies are compared with endovascular approaches in terms of their technical principles, indications, and reported outcomes. Particular attention is given to reconstructive materials, such as polymethylmethacrylate cement, hydroxyapatite, and bone grafts, with consideration of their short- to midterm performance and the current limitations of evidence regarding long-term durability. Integrating these considerations, a stepwise algorithm is proposed to guide the selection of conservative, surgical, or endovascular treatment based on symptom profiles and imaging findings. In carefully selected patients, these strategies can achieve high rates of PT improvement and meaningful gains in quality of life, while highlighting the need for prospective outcome studies with long-term follow-up.

Background: The standard first-line treatment for hormone receptor-positive metastatic breast cancer is a cyclin-dependent kinase 4/6 (CDK4/6) inhibitor, including palbociclib, ribociclib, or abemaciclib, combined with endocrine therapy. Hepatobiliary toxicity is an important adverse effect of ribociclib. This study compared the risk of hepatotoxicity between ribociclib and palbociclib and identified factors associated with hepatotoxicity.

Methods: This retrospective cohort study included patients with hormone receptor-positive breast cancer receiving ribociclib or palbociclib between January 1, 2018 and June 1, 2022. Hepatotoxicity was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 5.0, with grade 2 or higher considered as the study outcome. Kaplan-Meier analysis assessed time to hepatotoxicity, and a multivariable Cox proportional hazards model estimated adjusted hazard ratios.

Results: The mean age was 61 years, and all patients were women. Among 145 patients receiving ribociclib, 28 developed hepatotoxicity, compared with 19 of 153 patients receiving palbociclib. The median time to hepatotoxicity was 42 days in both groups. After adjustment for age, Charlson Comorbidity Index (CCI) score, history of hepatitis B virus (HBV) infection, fatty liver, and liver metastasis, the adjusted hazard ratio (HR) for palbociclib compared with ribociclib was 0.467 (95% confidence interval [CI], 0.233-0.936; p = 0.0320). In the overall population, liver metastasis (HR, 2.159; 95% CI, 1.175-3.966; p = 0.0131), history of HBV infection (HR, 2.216; 95% CI, 1.102-4.458; p = 0.0256), and fatty liver (HR, 3.536; 95% CI, 1.840-6.794; p = 0.0002) were associated with higher risk of hepatotoxicity.

Conclusion: Compared with palbociclib, ribociclib was associated with a higher risk of hepatotoxicity during the first six months of treatment. Closer monitoring of liver function may be warranted, particularly in patients with liver metastases, a history of HBV infection, or fatty liver who receive ribociclib.

Background: Minimally invasive myomectomy offers significant perioperative benefits including reduced pain and faster recovery. Current approaches include conventional laparoscopic myomectomy (LM), single-port LM, and mini-laparotomy. We developed a hybrid technique, termed suprapubic laparoscopic-assisted myomectomy (SLAM), that combines the superior visualization of laparoscopy with the tactile feedback and suturing efficiency of mini-laparotomy.

Methods: This retrospective comparative study evaluated the clinical rationale, safety, and feasibility of SLAM compared with conventional LM. Patients underwent conventional LM or SLAM according to patient preference following shared decision-making (SDM). Patients with a body mass index (BMI) > 30 or myoma(s) > 10 cm were excluded. All the procedures were performed by a single surgeon. Statistical analyses were performed using Student's t-test (results presented as mean ±standard deviation [SD] with 95% confidence intervals [CI]), the chi-square test, or Fisher's exact test.

Results: Thirty-six patients with symptomatic uterine myomas were included, with 16 undergoing SLAM and 20 undergoing conventional LM. The average hospitalization duration was 4.19 ± 0.40 days for SLAM and 4.15 ± 0.49 days for LM (p = 0.807). The operative time was comparable between the SLAM and LM groups (186.0 ± 59.3 min vs. 213.8 ± 48.8 min; p = 0.133). Although estimated blood loss was lower in the SLAM group (140.6±148.3 ml vs. 197.5±223.1 ml; p = 0.387), the difference did not reach statistical significance. Hemoglobin decrease was also comparable (1.14 ± 1.63 mg/dL vs. 1.06 ± 1.87 mg/dL; p = 0.897). The blood transfusion rates were 18.8% (3/16) for the SLAM group and 15.0% (3/20) for the LM group (p = 1.000). No major complications were observed in either group.

Conclusion: SLAM is a safe and feasible alternative to conventional LM and offers effective myometrial closure and specimen retrieval. While operative outcomes are comparable to conventional LM, SLAM provides a viable "hybrid" option for surgeons seeking to combine minimally invasive benefits with the precision of manual suturing.

Background: Acute radiation dermatitis (ARD) is common during head-and-neck radiotherapy (RT) and may impair skin-related quality of life (QoL). Whether intensity-modulated proton therapy (IMPT) improves patient-reported skin outcomes compared with volumetric modulated arc therapy (VMAT) remains uncertain. We compared longitudinal outcomes of skin toxicity between RT modalities and identified significant predictors of ARD and skin-related QoL.

Methods: This prospective and non-randomized cohort study enrolled adults with newly diagnosed head-and-neck cancer receiving curative-intent VMAT or IMPT at Kaohsiung Chang Gung Memorial Hospital. Skin-related QoL was assessed using Skindex-16 at baseline, end of RT, and 3 months after RT. ARD was graded weekly using Common Terminology Criteria for Adverse Events version 5.0. Longitudinal outcomes were analyzed using linear mixed-effects models, and predictors of ARD grade ≥2 and ≥10-point worsening in Skindex-16 Global score were evaluated using multivariable regression.

Results: Among 158 patients, 113 received VMAT and 45 received IMPT; the mean age was 56.5 years, and 130 patients (82.3%) were men. Clinically meaningful Global score worsening occurred in 37.0% of patients at the end of RT and 7.0% at 3 months after RT. Skindex-16 scores worsened significantly at the end of RT and improved by 3 months across all domains (all p<0.01), with no significant difference between VMAT and IMPT or time-by-modality interactions. Maximum ARD severity was comparable between VMAT and IMPT (grade 2: 30.0% vs 29.5%; grade 3: 7.0% vs 4.8%; p=0.85). Advanced nodal disease (N2-3) and RT dose ≥66 Gy independently predicted ARD grade ≥2 and Skindex-16 Global score worsening.

Conclusion: Acute patient-reported skin toxicity during contemporary head-and-neck RT was not associated with RT modality but with nodal extent and RT dose. These findings support risk-adapted planning and proactive supportive care, although interpretation is limited by the non-randomized design and lack of skin-specific dosimetry.

Background: Although urban-rural differences in dementia prevalence have been widely reported, little is known about whether vascular risk factors and health behaviors relate differently to cognitive function across urban and rural populations. This study investigated urban-rural differences in these factors and their associations with cognition.

Methods: We analyzed data on demographics, vascular risk factors, lifestyle factors, laboratory measures, and comprehensive neuropsychological assessments. Suboptimal cognition was defined as >1 SD below appropriate norms; predictors were examined using Firth's penalized likelihood logistic regression, followed by interaction analyses to assess region-specific associations.

Results: Overall, 1,284 non-demented older adults were included, comprising 949 and 335 from the rural and urban cohort, respectively. Compared with the urban cohort, participants in the rural cohort were younger (70.1 ± 6.8 vs 71.3 ± 3.6 years, p < 0.001), more often male (49.6% vs 30.4%, p < 0.001), and less educated (4.0 ± 4.6 vs 14.2 ± 3.1 years, p < 0.001). In the rural cohort, higher systolic blood pressure (1.02, 95% confidence interval (CI) 1.01-1.04), and male sex (2.56, 1.49-4.44) were associated with suboptimal global cognition, whereas smoking cessation was protective (0.40, 0.20-0.79). Low physical activity (1.95, 1.35-2.80) further predicted suboptimal visuospatial function. No statistically significant associations were observed in the urban cohort after correction for multiple comparisons. Interaction analyses indicated that the associations between smoking cessation and global cognition (p = 0.013) and between low physical activity and visuospatial function (p = 0.033) differed significantly between the rural and urban cohorts, with stronger associations in the rural cohort.

Conclusion: Health behaviors showed stronger associations with cognitive function in rural than in urban cohort, warranting region-tailored prevention strategies. Urban-rural comparisons were based on two independent community cohorts; future studies using a single population-based cohort are needed to validate these findings.

Background: Fine particulate matter (PM2.5) is a major component of ambient air pollution and is a significant environmental health concern. The conjunctiva is continuously exposed to airborne pollutants but the direct effects of PM2.5 on conjunctival epithelial repair remain poorly understood. This study investigated whether PM2.5 disrupts conjunctival epithelial homeostasis and examined the functional role of interleukin-8 (IL-8) in this process.

Methods: Immortalized human conjunctival epithelial cells (IM-HConEpiC) were exposed to PM2.5. Cell viability, apoptosis, epithelial migration, inflammatory mediators and cytokine profiles were evaluated using biochemical, functional and cytokine array analyses. The functional role of IL-8 was also determined using recombinant IL-8 supplementation and neutralization assays.

Results: PM2.5 exposure reduced conjunctival epithelial cell viability in a time- and concentration-dependent manner and induced mild apoptotic responses. More importantly, PM2.5 markedly impaired epithelial migration and wound closure. Cytokine profiling revealed that PM2.5 selectively remodeled inflammatory mediators, rather than eliciting a generalized inflammatory response. IL-8 was identified as the most prominently suppressed cytokine. Functional gain- and loss-of-function studies identified IL-8 as a key regulator of conjunctival epithelial repair. Specifically, recombinant IL-8 significantly restored PM2.5-induced impairment of epithelial migration and partially rescued the reduction in cell viability, whereas neutralization of endogenous IL-8 impaired epithelial migration under basal conditions, supporting a critical role for IL-8 in maintaining conjunctival epithelial homeostasis.

Conclusion: PM2.5 compromises conjunctival epithelial homeostasis, primarily by impairing epithelial repair, rather than inducing extensive cell death. This study identified IL-8 as an important regulator of conjunctival epithelial repair and suggests that suppression of IL-8 contributes to PM2.5-induced conjunctival dysfunction.

Background: To assess the association of sedentary time and physical activity with the occurrence of colorectal adenomas in asymptomatic participants.

Methods: We conducted a case-control study at Taipei Veterans General Hospital, Taiwan to examine sedentary time, physical activity, and their joint effects on colorectal adenoma risk among asymptomatic participants. Conditional logistic regression analysis was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

Results: Among 5,982 asymptomatic adults undergoing health screening, shorter sedentary time was independently associated with a lower risk of colorectal adenoma (n=3,616), after adjusting for other risk factors, including physical activity. The ORs (95% CIs) for each category of sedentary time >450, 300-450, and <300 minutes/day were 1.00 (reference), 1.10 (0.90-1.34), and 0.52 (0.40-0.69), respectively (p trend <0.001). Joint analysis demonstrated that higher physical activity was associated with a lower risk of colorectal adenoma, particularly among individuals with a sedentary time of 300-450 minutes/day. Moreover, within the moderate- and high physical activity categories, shorter sedentary time was consistently associated with additional risk reduction. A similar pattern was observed for advanced adenoma subgroup.

Conclusion: Sedentary time was independently associated with increased colorectal adenoma risk, whereas reducing sedentary time may lower advanced adenoma risk and augment the benefits of moderate- to high-physical activity among asymptomatic population in Taiwan.

Background: The increasing global prevalence of pediatric myopia has led to the widespread use of atropine for myopia control. Despite its proven efficacy, variable treatment responses and complex interactions among refractive error, treatment duration, and dosage make individualized treatment challenging. Therefore, clinicians require decision support tools for personalized treatment management.

Method: This retrospective study analyzed 1,545 pediatric myopic eyes treated with topical atropine at Shin Kong Wu Ho-Su Memorial Hospital (Taipei, Taiwan) between 2005 and 2008. The multivariate adaptive regression splines (MARS) approach was used to examine associations between baseline clinical characteristics, atropine exposure, changes in the spherical equivalent (SE), and myopic progression. Eight clinical predictors including age, sex, Baseline SE, intraocular pressure (IOP), IOP changes, treatment duration, and cumulative and average monthly atropine dosages were used. The model performance was evaluated via repeated cross-validation and benchmarked against standard linear regression.

Results: Baseline SE was the strongest predictor of myopic progression, followed by cumulative atropine exposure and average monthly dosage. The MARS model demonstrated robust predictive performance (root mean square error = 0.540) and identified the baseline SE, cumulative atropine exposure, and average monthly dosage as the principal predictors of myopic progression. The average monthly dosage showed a nonlinear V-shaped relationship with a transition point near 11.66 mg/month.

Conclusion: The baseline refractive status and atropine exposure were the principal factors associated with treatment response and may support individualized myopia management. The observed V-shaped pattern may reflect the treatment transition characteristics of the historical high-concentration atropine era (0.1-1.0%), during which the atropine dosage was frequently adjusted according to the clinical response. This nonlinear pattern suggests that the treatment response varied across different levels of atropine exposure, warranting further clinical interpretation. Therefore, children receiving intermediate monthly dosages may represent a heterogeneous group undergoing physician-directed dose escalation, resulting in an apparent nonlinear relationship. Accordingly, this pattern most likely reflects real-world treatment strategies, rather than the intrinsic pharmacological effects of intermediate atropine dosages. These findings should be used for hypothesis generation and require prospective validation before influencing clinical dosing decisions.