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Background Asthma is a prevalent noncommunicable disease worldwide, imposing significant burdens and diminishing the quality of life for those affected. Pay-for-Performance (P4P) programs are reimbursement models that offer incentives to healthcare providers based on their performance metrics. While P4P initiatives have been implemented across various medical conditions, their specific impact on asthma care remains uncertain. This study aims to compare the characteristics and quality of asthma care between patients enrolled in the P4P program and those who are not. Additionally, we will examine trends in these characteristics and care quality over time. Methods This study utilized a multiple cross-sectional design to analyze asthma patients diagnosed in 2010 and 2019, drawing data from Taiwan’s National Health Insurance claims database. We collected information on demographic characteristics, P4P program enrollment, medication usage, healthcare service utilization, and attributes of both patients and their primary treatment hospitals. To address the study objectives, we employed logistic regression models and applied 1:1 propensity score matching to mitigate selection bias. Results A total of 811,177 individuals diagnosed with asthma were identified, comprising 317,669 in 2010 and 493,508 in 2019. Our findings indicate that patients enrolled in the P4P program had higher prescription rates for inhaled corticosteroids (ICS) and experienced lower rates of hospital admissions and emergency department visits for acute asthma exacerbations compared to non-enrolled patients. We also observed that demographic characteristics influenced P4P enrollment, with these impacts evolving over time. Furthermore, the effects of the P4P program varied across different levels of hospital accreditation. Conclusion This study demonstrates that the P4P program positively influences the quality of asthma care. However, variations between P4P and non-P4P enrollers persist and have widened over time. Health authorities should address these disparities to ensure equitable care for all asthma patients. Clinical trial number Protocol #202203101RINC.

ObjectivesThis study aimed to investigate the evolution of burnout levels and cardiovascular risk among healthcare professionals during the COVID-19 pandemic, identifying associated risk factors, with a particular focus on the impact of working hours, job roles and working units.DesignA longitudinal, observational study was conducted.SettingThe study was carried out in a medical centre in central Taiwan, encompassing various healthcare settings.ParticipantsA total of 1502 healthcare workers participated, including nurses, medical technicians, resident doctors, attending physicians and administrative staff. Participants were selected based on consistent completion of a 4-year questionnaire, with exclusion criteria for those who did not complete.Primary and secondary outcome measuresThe primary outcome measured was burnout levels using the Chinese version of the Copenhagen Burnout Inventory. The secondary outcome was cardiovascular risk calculated from employees’ health check-up data using the Framingham Risk Score.ResultsCardiovascular risk showed an upward trend over 4 years. Personal and work-related burnout significantly decreased from 2019 to 2020 but increased from 2020 to 2022, aligning with changes in weekly working hours. Nurses exhibited the most pronounced fluctuations, likely due to their younger average age, shorter professional tenure and frequent direct patient contact, which may heighten vulnerability to pandemic-related stressors. In contrast, attending physicians demonstrated age as a protective factor against burnout, as greater seniority, clinical experience and professional maturity may buffer stress and foster resilience. Participants who worked in COVID-related units generally had elevated burnout levels and working hours. During the initial outbreak in 2020, employees working in COVID-related units had reduced working hours but stable burnout levels, while employees in non-COVID-related units experienced decreased burnout.ConclusionsThis study highlights the critical impact of long working hours on burnout among healthcare professionals during the COVID-19 pandemic. Nurses emerged as a vulnerable group, sensitive to pandemic-induced changes, while attending physicians exhibited more resilience. COVID-related units face greater stress and are less likely to benefit from reductions in patient numbers and working hours during the pandemic. Our findings underscore the urgent need for tailored interventions, such as regulated work hours, flexible scheduling and enhanced organisational and peer support, to protect healthcare workers’ well-being. These strategies can strengthen workforce resilience and sustainability in future public health crises.

Background Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic interstitial lung disease (ILD) with limited treatment options and poor prognosis. Differentiating IPF from connective tissue disease–associated ILD (CTD-ILD) is clinically challenging due to overlapping features, and reliable circulating biomarkers are lacking. Recent studies suggest that multi-marker proteomic models combined with machine learning may enhance diagnostic precision and prognostic assessment in fibrotic ILDs. Methods We prospectively analyzed plasma samples from Taiwanese patients with fibrotic ILDs (IPF, n  = 22; CTD-ILD, n  = 66) using the Olink inflammation panel (92 proteins). Differentially expressed proteins were identified and subjected to integrative network analyses. Predictive classification models were developed using generalized linear modeling (GLM), decision tree, and random forest approaches. Prognostic relevance was evaluated with Kaplan–Meier and Cox regression analyses, and findings were validated in public transcriptomic datasets. Results Among 92 proteins profiled, 23 showed significant differences between IPF and CTD-ILD. Four candidates—MMP-10, FGF-19, ADA, and TWEAK (TNFSF12)—consistently emerged as key discriminatory markers. The GLM model incorporating FGF-19, ADA, and TWEAK achieved the highest diagnostic accuracy (AUC 0.870; sensitivity 0.97; specificity 0.82), outperforming decision tree and random forest models. Transcriptomic validation confirmed TWEAK downregulation in ILD lung tissues and in TGF-β1–stimulated fibroblasts, linking it to canonical profibrotic signaling. Survival analysis showed significantly worse outcomes in IPF versus CTD-ILD (log-rank p  < 0.001), with MMP-10 associated with poor prognosis (HR 2.08, p  = 0.007) and TWEAK with favorable prognosis (HR 0.04, p  < 0.001). Conclusions This study identifies distinct plasma proteomic signatures that differentiate IPF from CTD-ILD and highlights TWEAK as both a diagnostic and prognostic biomarker. A multi-marker GLM model demonstrated excellent diagnostic performance, supporting the clinical utility of plasma proteomics combined with machine learning to improve disease classification and risk stratification in fibrotic ILDs. Clinical implication Integrating plasma proteomics with machine learning enables development of a multi-marker model that enhances diagnostic accuracy and prognostic evaluation in fibrotic interstitial lung diseases, supporting more precise disease classification and risk stratification in clinical practice. Key Point Plasma proteomics combined with machine learning improves IPF vs CTD-ILD classification and identifies prognostic biomarkers, advancing precision diagnosis in fibrotic interstitial lung disease.

Background and Aims: Gastric cancer remains a major health burden in East Asia. Gastrectomy is a primary treatment, yet postoperative malnutrition—particularly inadequate protein intake—adversely affects outcomes. This study assessed the association between achieving ≥70% of the recommended protein intake one year after gastrectomy and three-year survival. Methods: In this prospective, single-center, observational study, 69 patients with newly diagnosed gastric cancer who underwent gastrectomy between January 2021 and August 2023 were enrolled. Four patients who died within one year postoperatively were excluded, leaving 65 patients for analysis. Protein intake achievement rate (PIAR) at 12 months was calculated based on a recommended intake of 1.2 g/kg/day, and patients were stratified as PIAR ≥ 70% or <70%. Overall survival was analyzed using time-to-event methods, with a median follow-up of 2.1 years. Results: Among the 65 patients (median age 62 years, IQR 56–68; 56.9% male), 75.4% underwent subtotal gastrectomy. At 12 months, 7 patients (10.8%) failed to achieve a PIAR ≥ 70%. Compared with patients achieving adequate protein intake, those with inadequate intake more frequently underwent total gastrectomy (71.4% vs. 19.0%, p = 0.008) and had advanced-stage disease (Stage III–IV: 85.7% vs. 39.7%, p = 0.039). Kaplan–Meier analysis demonstrated significantly lower survival in the inadequate protein group, with a hazard ratio of 13.02 (95% CI 2.53–66.93); the wide confidence interval reflects the small number of patients with inadequate intake (n = 7). Conclusions: Failure to achieve ≥70% of recommended protein intake one year after gastrectomy is a strong independent predictor of mortality, associated with a 13-fold higher risk of death. Nutritional monitoring and early intervention are crucial, particularly for patients with total gastrectomy or advanced disease.

The influence of inhaled corticosteroids (ICS) on COVID-19 outcomes remains uncertain. To address this, we conducted a systematic review and meta-analysis, analyzing 30 studies, to investigate the impact of ICS on patients with COVID-19. Our study focused on various outcomes, including mortality risk, hospitalization, admission to the intensive care unit (ICU), mechanical ventilation (MV) utilization, and length of hospital stay. Additionally, we conducted a subgroup analysis to assess the effect of ICS on patients with chronic obstructive pulmonary disease (COPD) and asthma. Our findings suggest that the prior use of ICS did not lead to significant differences in mortality risk, ICU admission, hospitalization, or MV utilization between individuals who had used ICS previously and those who had not. However, in the subgroup analysis of patients with COPD, prior ICS use was associated with a lower risk of mortality compared to non-users (OR, 0.95; 95% CI, 0.90–1.00). Overall, while the use of ICS did not significantly affect COVID-19 outcomes in general, it may have beneficial effects specifically for patients with COPD. Nevertheless, more research is needed to establish a definitive conclusion on the role of ICS in COVID-19 treatment. PROSPERO registration number: CRD42021279429 .

Chronic pulmonary aspergillosis (CPA) often manifests in patients with a history of pulmonary tuberculosis and is typically characterized by recurrent hemoptysis, weight loss, and frequently coexists with poorly controlled diabetes. While weight gain is acknowledged as a valuable clinical marker for monitoring therapeutic responses in CPA, there is a scarcity of case reports exploring this aspect. Furthermore, the impact of stringent blood sugar management in diminishing CPA activity and preventing the recurrence of hemoptysis is also underreported. In this context, we present the case of a 64‐year‐old male who experienced massive hemoptysis. He had a background of uncontrolled diabetes and a history of fully treated pulmonary tuberculosis. Following therapeutic embolization, he was diagnosed with CPA that had transformed into invasive pulmonary aspergillosis (IPA) and underwent antifungal therapy for 9 months. Notably, we observed an inverse correlation between the patient's improved blood sugar control and weight gain with the serum IgG levels for Aspergillosis. This case highlights the potential benefits of non‐invasive monitoring of CPA activity and the identification of treatment responders through effective blood sugar management and weight gain. In this report, we present a complex case involving poorly controlled diabetes that manifested as massive hemoptysis due to invasive pulmonary aspergillosis, a consequence of chronic pulmonary aspergillosis (CPA) transformation. Interestingly, the patient's improved blood sugar control and weight gain inversely correlated with serum IgG levels for Aspergillosis. This case also illustrates the potential for non‐invasive monitoring of CPA activity and identifying treatment responders through improved blood sugar management and weight gain.

Background Early identification of functional decline in fibrotic interstitial lung disease (F-ILD) is crucial for timely treatment and improved survival. While the 6-minute walk test (6MWT) is the standard for functional evaluation, it has practical limitations. The 1-minute sit-to-stand test (1MSTS) offers a simpler alternative; however, its correlation with the 6MWT in F-ILD patients remains unclear. This study aims to establish reference values for the 1MSTS in assessing functional capacity, evaluate its correlation with the 6MWT, and explore its utility in predicting 18-month mortality in F-ILD patients. Methods This prospective study enrolled participants diagnosed with F-ILD based on multidisciplinary team discussions. Assessments included the 1MSTS, 6MWT, pulmonary function test (PFT), GAP score, mMRC scale, and Charlson Comorbidity Index (CCI). The association between 1MSTS repetitions and other variables was calculated using Spearman’s rho. Bland-Altman plots assessed the agreement between 1MSTS repetitions and the 6MWT. Predictors of 18-month mortality were evaluated using ROC curve and Kaplan-Meier curve. Results Of the 150 F-ILD patients, 37 (24.6%) had idiopathic pulmonary fibrosis (IPF), and 113 (75.4%) had connective tissue disease-related ILD (CTD-ILD). Using ≤ 23 repetitions as the cutoff for functional impairment in 1MSTS, 74 (47.3%) patients were classified as impaired. The 1MSTS significantly predicted 18-month mortality and demonstrated moderate correlations with GAP score (rs = -0.49), mMRC scale (rs = -0.47), and 6MWT distance (rs = 0.65). Bland-Altman analysis indicated agreement between 1MSTS repetitions and 6MWT distance. Using ≤ 23 repetitions as the cutoff value for the 1MSTS to predict 18-month mortality, the mortality rate was 76.4%, with an AUC of 0.81. Conclusions The findings suggest that ≤ 23 repetitions in the 1MSTS can serve as an indicator of functional impairment, demonstrate a good correlation with 6MWT distance, and effectively predict 18-month mortality in patients with F-ILD. Clinical trial number Not applicable.

Background The diagnostic process for fibrotic interstitial lung disease (F-ILD) is notably intricate, necessitating a multidisciplinary discussion to achieve consensus based on both clinical and radiological features. This study investigated the shared and distinctive long-term mortality predictors among the two primary phenotypes of F-ILD, namely idiopathic pulmonary fibrosis (IPF) and connective tissue disease-associated interstitial lung disease (CTD-ILD). Methods We included patients with F-ILD diagnosed from December 2018 to December 2019 and conducted follow-up assessments until February 2023. Age, gender, usual interstitial pneumonia (UIP) pattern, gender–age–physiology (GAP) score, modified Medical Research Council (mMRC) dyspnea score, antifibrotic agent use, pulmonary function test parameters, and six-minute walking test (6MWT) parameters were recorded at baseline and used as mortality predictors in a multivariate Cox regression model. Results We enrolled 104 ILD patients. The survival rate of non-IPF patients was more than twice that of IPF patients (78.9% vs. 34%, p  < 0.001), and the survival rate of patients with a GAP score of 0–2 was more than twice that of patients with a score of > 2 (93.2% vs. 36.6%, p  < 0.001). Older age, male gender, definite UIP pattern, higher GAP score, higher mMRC dyspnea score, lower forced expiratory volume in one second/forced vital capacity (FEV1/FVC), shorter 6MWT distance, and lower initial and final SpO2 were also associated with higher long-term mortality ( p  < 0.05). In multivariable analysis, only a GAP score of > 2 (hazard ratio [HR]:16.7; 95% confidence interval [CI] 3.28–85.14; p  = 0.001) and definite UIP pattern (HR: 4.08; 95% CI 1.07–15.5; p  = 0.039) were significantly associated with overall mortality. Conclusion The long-term mortality rate of IPF patients was higher than that of CTD-ILD patients . The GAP score and UIP patterns were significant mortality predictors for both IPF and CTD-ILD patients.

Pulmonary embolism is a life-threatening disease. Its development is generally thought to be due to causes collectively known as the Virchow’s triad. Chronic inflammations are associated with the activation of coagulation and increased risks of venous thromboembolic events. Asthma is one of the chronic inflammatory diseases associated with procoagulants and antifibrinolytic activities in the airways. Coagulation is activated in patients with asthma with the following steps of pathophysiology: Increased tissue factor expression in various cell types, decreased activity of the anticoagulant protein C system and inhibition of fibrinolysis through over-production of plasminogen activator inhibitor type 1 (PAI-1). Asthma is therefore likely a risk factor for pulmonary embolism, especially in those patients with severe disease conditions together with frequent exacerbation. Here we present a case of severe asthma associated with coagulopathy and complicated by massive pulmonary embolism, presented with typical S1Q3T3 on electrocardiography (ECG) and massive thrombosis on computed tomography angiography, successfully treated with directed catheter thrombolytic therapy.

Background Whether the long-term survival of patients with idiopathic pulmonary fibrosis (IPF) is worse than that of patients with IPF combined with emphysema after anti-fibrotic therapy is unclear. This study aimed to compare treatment outcomes between the two groups and identify potential predictors of mortality. Methods This retrospective cohort study was conducted in seven hospitals across Taiwan between August 2015 and August 2022 and included patients with IPF who received anti-fibrotic agents covered by national insurance. Based on the extent of emphysema observed on high-resolution chest tomography, patients with IPF were categorized into two groups: IPF only; and IPF with emphysema. Baseline characteristics and survival outcomes were compared between the groups. Cox proportional hazards models were used for multivariable analysis to identify factors associated with overall mortality during the follow-up period. Results Of the 275 patients included, 126 (45.8%) had IPF with emphysema and 149 (54.2%) had IPF only. The emphysema group had a higher proportion of males and patients with a smoking history, finger clubbing, comorbidities, or a definite usual interstitial pneumonia (UIP) pattern compared to the IPF-only group. Additionally, this group had a higher forced vital capacity (FVC, %) and forced expiratory volume in 1 s (FEV₁, L), while FEV₁ (%) was similar and FEV₁/FVC (%) was lower. During a median follow-up of 3.7 years, the overall survival rates were comparable (IPF only: 45.6%; IPF with emphysema: 48.4%). The overall survival of patients with probable UIP was significantly better than that of patients with definite UIP (53.5% vs. 34.6%). Likewise, the survival rate of the group with a diffusing capacity of the lung for carbon monoxide (DLCO) > 49% was higher than that of the group with DLCO ≤ 49% (53.9% vs. 31.4%). After adjusting for confounders, lower body mass index (BMI) (adjusted hazard ratio [aHR] = 0.95) and comorbid pulmonary hypertension (aHR = 2.27) were independently associated with increased overall mortality. Neither the presence of emphysema nor the type of anti-fibrotic agent was associated with mortality. Conclusions The survival outcomes of patients with IPF and emphysema and those of patients with IPF only are comparable after treatment with anti-fibrotic agents. Lower BMI and comorbid pulmonary hypertension are significant predictors of increased mortality.