Medical students' perceptions of integrating social media into a narrative medicine programme for 5th-year clerkship in Taiwan: a descriptive qualitative study.

BACKGROUND: The growing demands in integrating digital pedagogies in learning (e.g., social media) contribute to disrupting many fields, including the medical humanities education. However, the strengths and barriers behind social media and medical humanities context are blurred and contradictive. We examined the perceptions of integrating social media - Facebook - into a narrative medicine (NM) programme for 5th -year clerkship in Taiwan. METHODS: We used purposive sampling to recruit participants. Sixteen medical students (Female/Male: 7/9) participated in four group interviews. Semi-structured focus group interviews were conducted to explore students' perceptions and experiences of the social media integrated into the NM programme. We analysed the data using a descriptive thematic analysis with a team-based approach. Data were managed and coded using ATLAS.ti version 9.0. RESULTS: We identified six main themes: (1) Positive experiences of social media integration; (2) Negative experiences of social media integration; (3) Barriers on writing and sharing NM stories in social media; (4) Barriers on reading NM stories in social media; (5) Barriers on reacting contents in social media; (6) Suggestions for future improvement. CONCLUSIONS: The study revealed the strengths and barriers from medical students' perceptions, when integrating social media into a NM programme. It is important to match students' experiences, barriers, and perceptions towards learning. Understanding participants' suggestions for future improvement are also crucial. With this knowledge, we might better develop the social media integration systems that achieve our desired outcomes based on the medical humanities education curricula.

Effect of national curriculum reform on medical students' preparedness for practice: a prospective cohort study from undergraduate to postgraduate periods.

BACKGROUND: In recent years, a national curriculum reform was implemented in undergraduate medical education in Taiwan to reduce clinical rotation training from 3 years to 2 years. The last generation of the old curriculum and the first generation of the new curriculum both graduated in 2019. This study aimed to compare the learning outcomes of the medical students in these two curriculum groups in terms of preparedness for practice during the transition from undergraduate to postgraduate study. METHODS: This was a 3-year prospective, longitudinal, comparative cohort study between 2017 and 2020. Medical students from both the 7-year and 6-year curriculum groups received biannual questionnaire surveys starting 18 months before graduation and running until 11 months after graduation. The measurement tools were the Preparedness for Hospital Practice Questionnaire (PHPQ) and Copenhagen Burnout Inventory (CBI). Personal demographic information was also collected. Linear mixed models were used to determine the effect of curriculum change on learners' preparedness and burnout levels. RESULTS: A total of 130 medical students from the two cohorts provided 563 measurements during the study period. Compared to their counterparts following the old curriculum, the participants following the new curriculum showed a lower level of preparedness when first entering clinical rotation (p = 0.027) and just after graduating (p = 0.049), especially in the domains of clinical confidence (p = 0.021) and patient management p = 0.015). The multivariate linear mixed model revealed gradual increases in preparedness and burnout in serial measurements in both curriculum groups. Students following the new curriculum, which involved a shortened clinical rotation, showed a slightly lower overall preparedness (p = 0.035) and the same level of burnout (p = 0.692) after adjustment. The factor of year of change did not show a significant effect on either preparedness (p = 0.258) or burnout (p = 0.457). CONCLUSION: Shortened clinical rotation training for medical undergraduates is associated with a decrease in preparedness for practice during the transition from undergraduate to postgraduate study. Clinical confidence and patient management are the main domains affected.

Understanding the lived experiences of medical learners in a narrative medicine course: a phenomenological study.

BACKGROUND: Reflection and various approaches to foster reflection have been regarded as an indispensable element in enhancing professional practice across different disciplines. With its inherent potential to engage learners in reflection and improvement, narrative medicine has been adopted in various settings. However, the relevance and effectiveness of reflection remains underexplored in the context of narrative medicine, specifically in regard to the concern about variability of learner acceptance and the way learners really make sense of these reflective activities. This study aimed to explore what medical learners experience through narrative medicine and the meanings they ascribe to the phenomenon of this narrative-based learning. METHODS: Using a transcendental phenomenology approach, twenty medical learners were interviewed about their lived experiences of taking a narrative medicine course during their internal medicine clerkship rotation. Moustakas' phenomenological analysis procedures were applied to review the interview data. RESULTS: Six themes were identified: feeling hesitation, seeking guidance, shifting roles in narratives, questioning relationships, experiencing transformation, and requesting a safe learning environment. These themes shaped the essence of the phenomenon and illustrated what and how medical learners set out on a reflective journey in narrative medicine. These findings elucidate fundamental elements for educators to consider how narrative approaches can be effectively used to engage learners in reflective learning and practice. CONCLUSION: Adopting Moustakas' transcendental phenomenology approach, a better understanding about the lived experiences of medical learners regarding learning in narrative medicine was identified. Learner hesitancy should be tackled with care by educators so as to support learners with strategies that address guidance, relationship, and learning environment. In so doing, medical learners can be facilitated to develop reflective capabilities for professional and personal growth.

How does narrative medicine impact medical trainees' learning of professionalism? A qualitative study.

BACKGROUND: Narrative medicine (NM) is an approach involving narrative skills and is regarded as a model for medical humanism and effective medical practice. This study aims to explore how NM impacts medical trainees' learning of professionalism during a clerkship in a Taiwanese clinical setting. METHODS: A qualitative interview study adopting a purposive sampling method was undertaken. Thirty medical trainees participated in this study, including five fifth-year medical students (MSs), ten sixth-year MSs, nine seventh-year MSs, and six postgraduate year (PGY) trainees. Thematic framework analysis was applied, and a modified realist evaluation approach was further used to analyse the interview data. RESULTS: We identified self-exploration, reflection, and awareness of professional identity as mechanisms explaining how NM impacted professionalism learning in our participants. Furthermore, empathy, communication, doctor-patient relationship and understanding patients were identified as the outcomes of the NM intervention for trainees' learning of professionalism. CONCLUSIONS: NM facilitates medical trainees' self-exploration, reflection, and awareness of professional identity, thereby affecting their learning of professionalism in clinical settings. Adopting NM as an educational intervention in undergraduate medical education could play an important role in professionalism learning, as trainees can thereby be supported to gradually develop self-exploration and reflection capabilities and heightened awareness of professional identity reflectively through a narrative process.

Active learning of medical students in Taiwan: a realist evaluation.

BACKGROUND: Active learning is defined as any instructional method that engages students in the learning process. Cultural differences in learning patterns can play an important role in engagement with active learning. We aimed to examine process models of active learning to understand what works, for whom and why. METHODS: Forty-eight sixth- and seventh-year medical students with experience of active learning methods were purposively selected to participate in ten group interviews. Interactions around active learning were analysed using a realist evaluation framework to unpack the 'context-mechanism-outcome' (CMO) configurations. RESULTS: Three core CMO configurations, including cultural, training and individual domains, were identified. In the cultural context of a strong hierarchical culture, the mechanisms of fear prompted students to be silent (outcome) and dare not give their opinions. In the training context of teacher-student familiarity alongside teachers' guidance, the mechanisms of learning motivation, self-regulation and enthusiasm were triggered, prompting positive learning outcomes and competencies (outcome). In the individual context of learning how to learn actively at an early stage within the medical learning environment, the mechanisms of internalisation, professional identity and stress resulted in recognising active learning and advanced preparation (outcomes). CONCLUSIONS: We identified three CMO configurations of Taiwanese medical students' active learning. The connections among hierarchical culture, fear, teachers' guidance, motivation, the medical environment and professional identity have been shown to affect the complex interactions of learning outcomes. Fear derived from a hierarchical culture is a concern as it is a significant and specific contextual factor, often sparking fear with negative outcomes.

Reduced suppressive effect of ß2-adrenoceptor agonist on fibrocyte function in severe asthma.

BACKGROUND: Patients with severe asthma have increased airway remodelling and elevated numbers of circulating fibrocytes with enhanced myofibroblastic differentiation capacity, despite being treated with high doses of corticosteroids, and long acting ß2-adrenergic receptor (AR) agonists (LABAs). We determined the effect of ß2-AR agonists, alone or in combination with corticosteroids, on fibrocyte function. METHODS: Non-adherent non-T cells from peripheral blood mononuclear cells isolated from healthy subjects and patients with non-severe or severe asthma were treated with the ß2-AR agonist, salmeterol, in the presence or absence of the corticosteroid dexamethasone. The number of fibrocytes (collagen I+/CD45+ cells) and differentiating fibrocytes (α-smooth muscle actin+ cells), and the expression of CC chemokine receptor 7 and of ß2-AR were determined using flow cytometry. The role of cyclic adenosine monophosphate (cAMP) was elucidated using the cAMP analogue 8-bromoadenosine 3',5'-cyclic monophosphate (8-Br-cAMP) and the phosphodiesterase type IV (PDE4) inhibitor, rolipram. RESULTS: Salmeterol reduced the proliferation, myofibroblastic differentiation and CCR7 expression of fibrocytes from healthy subjects and non-severe asthma patients. Fibrocytes from severe asthma patients had a lower baseline surface ß2-AR expression and were relatively insensitive to salmeterol but not to 8-Br-cAMP or rolipram. Dexamethasone increased ß2-AR expression and enhanced the inhibitory effect of salmeterol on severe asthma fibrocyte differentiation. CONCLUSIONS: Fibrocytes from patients with severe asthma are relatively insensitive to the inhibitory effects of salmeterol, an effect which is reversed by combination with corticosteroids.

Obstructive sleep apnoea accelerates FEV1 decline in asthmatic patients.

BACKGROUND: Although the prevalence of both obstructive sleep apnoea (OSA) and asthma are both increasing, little is known about the impact of OSA on the natural history of lung function in asthmatic patients. METHODS: A total of 466 patients from our sleep laboratory were retrospectively enrolled. Of them, 77 patients (16.5%) had asthma with regular follow-up for more than 5 years. Their clinical characteristics, pulmonary function, emergency room visits, and results of polysomnography results were analysed. RESULTS: The patients were divided into three groups according to the severity of the apnoea-hypopnea index (AHI). The decline in FEV1 among asthma patients with severe OSA (AHI > 30/h) was 72.4 ± 61.7 ml/year (N = 34), as compared to 41.9 ± 45.3 ml/year (N = 33, P = 0.020) in those with mild to moderate OSA (5 < AHI ≤ 30) and 24.3 ± 27.5 ml/year (N = 10, P = 0.016) in those without OSA (AHI ≤ 5). For those patients with severe OSA, the decline of FEV1 significantly decreased after continuous positive airway pressure (CPAP) treatment. After multivariate stepwise linear regression analysis, only AHI was remained independent factor for the decline of FEV1 decline. CONCLUSIONS: Asthmatic patients with OSA had substantially greater declines in FEV1 than those without OSA. Moreover, CPAP treatment alleviated the decline of FEV1 in asthma patients with severe OSA.

Impact of a narrative medicine programme on healthcare providers' empathy scores over time.

BACKGROUND: The cultivation of empathy for healthcare providers is an important issue in medical education. Narrative medicine (NM) has been shown to foster empathy. To our knowledge, there has been no research that examines whether a NM programme affects multi-professional healthcare providers' empathy. Our study aims to fill this gap by investigating whether a NM programme effects multi-professional healthcare providers' empathy. METHODS: A pre-post questionnaire method was used.142 participants (n = 122 females) who attended the NM programme were divided into single (n = 58) and team groups (n = 84) on the basis of inter-professional education during a period of 2 months. Perceptions of the NM programme were collected using our developed questionnaire. Empathy levels were measured using the Chinese version of Jefferson Scale of Empathy - Healthcare Providers Version (JSE-HP) - at three time points: prior to (Time 1), immediately after (T2), and 1.5 years (T3) after the programme. RESULTS: Participants' perceptions about the NM programme (n = 116; n = 96 females) suggested an in enhancement of empathy (90.5%). Empathy scores via the JSE-HP increased after the NM programme (T1 mean 111.05, T2 mean 116.19) and were sustainable for 1.5 years (T3 mean 116.04) for all participants (F(2297) = 3.74, p < .025). A main effect of gender on empathy scores was found (F(1298) = 5.33, p < .022). No significant effect of gender over time was found but there was a trend that showed females increasing empathy scores at T2, sustaining at T3, but males demonstrating a slow rise in empathy scores over time. CONCLUSIONS: NM programme as an educational tool for empathy is feasible. However, further research is needed to examine gender difference as it might be that males and females respond differently to a NM programme intervention.

Different perceptions of narrative medicine between Western and Chinese medicine students.

BACKGROUND: Western medicine is an evidence-based science, whereas Chinese medicine is more of a healing art. To date, there has been no research that has examined whether students of Western and Chinese medicine differentially engage in, or benefit from, educational activities for narrative medicine. This study fills a gap in current literature with the aim of evaluating and comparing Western and Chinese Medicine students' perceptions of narrative medicine as an approach to learning empathy and professionalism. METHODS: An initial 10-item questionnaire with a 5-point Likert scale was developed to assess fifth-year Western medical (MS) and traditional Chinese medical (TCMS) students' perceptions of a 4-activity narrative medicine program during a 13-week internal medicine clerkship. Exploratory factor analysis was undertaken. RESULTS: The response rate was 88.6% (412/465), including 270 (65.5%) MSs and 142 (34.5%) TCMSs, with a large reliability (Cronbach alpha = 0.934). Three factors were extracted from 9 items: personal attitude, self-development/reflection, and emotional benefit, more favorable in terms of enhancement of self-development/reflection. The perceptions of narrative medicine by scores between the two groups were significantly higher in TCMSs than MSs in all 9-item questionnaire and 3 extracted factors. CONCLUSIONS: Given the different learning cultures of medical education in which these student groups engage, this suggests that undertaking a course in Chinese medicine might enhance one's acceptance to, and benefit from, a medical humanities course. Alternatively, Chinese medicine programmes might attract more humanities-focused students.

Efficacy of omalizumab (Xolair®) in patients with moderate to severe predominately chronic oral steroid dependent asthma in Taiwan: a retrospective, population-based database cohort study.

BACKGROUND: Omalizumab (Xolair®), a recombinant monoclonal anti-IgE antibody, has demonstrated efficacy in clinical trials conducted in patients with moderate to severe persistent allergic asthma. We aimed to investigate the efficacy, discontinuation and medical resource utilization of omalizumab in the real-life setting in Taiwan. METHODS: This study was a retrospective, population-based database cohort study using the Taiwan NHIRD from 2007 to 2011 assessing the efficacy of omalizumab therapy over 4 months on changes in asthma medication, asthma control, frequency of exacerbations and hospitalization rates at baseline and after omalizumab discontinuation. RESULTS: There was a reduction in asthma medication post omalizumab therapy and severe exacerbations and hospitalizations from baseline (31.2%, n = 282) to the end of follow-up (11.8%, n = 144, p < 0.001). Nearly all the patients received chronic oral corticosteroids at baseline (92.4%). The number of ER visits decreased from 1.13 ± 2.04 to 0.29 ± 0.83, and the mean number of admissions decreased from 5.93 ± 16.16 to 2.75 ± 12.02 from baseline to the end of follow-up (p < 0.001). After discontinuation of omalizumab, the cost of ER medical expenses decreased from New Taiwan dollars (NTD) 3934 at 2 months to NTD 2860 at 12 months. CONCLUSIONS: Patients who received omalizumab therapy for over 4 months were more likely to reduce the use of other asthma medications and less likely to experience an asthma exacerbation, ER visits, and hospitalization, even after the discontinuation of omalizumab. These data suggest that omalizumab has efficacy in improving health outcomes in patients with moderate to severe predominately chronic oral steroid dependent asthma in the real-life setting in Taiwan.

Fibrocyte trafficking in patients with chronic obstructive asthma and during an acute asthma exacerbation.

BACKGROUND: Fibrocytes express several chemokine receptors (CCR7 and CXCR4) that regulate their recruitment and trafficking into tissue-damage sites in response to specific chemokine gradients (CCL19 and CXCL12). OBJECTIVE: We investigated whether these chemoattractants and S100A9, through the receptor for advanced glycation end-products (RAGE; ie, its receptor), are involved in fibrocyte trafficking in patients with chronic obstructive asthma (COA) and during an acute exacerbation (AE) in patients without airflow obstruction (Asthma AE group). METHODS: We collected peripheral blood from 14 asthmatic patients with normal pulmonary function, 14 patients with COA, 11 patients in the Asthma AE group, and 14 healthy subjects. Isolated circulating fibrocytes were used for migration assay. Expression of CCR7, CXCR4, S100A9, and RAGE in fibrocytes was measured by using flow cytometry. CCL19 and CXCL12 expression in bronchial tissues was determined by using immunohistochemistry and RT-PCR. RESULTS: There were higher numbers of circulating fibrocytes in patients in the Asthma AE group and patients with COA. The expression of CXCL12 in bronchial tissues and CXCR4 in circulating fibrocytes was higher in the Asthma AE group and, to a lesser extent, in patients with COA. The expression of CCL19 in bronchial tissues and CCR7 in fibrocytes was higher in patients with COA. CXCL12/CXCR4 and CCL19/CCR7 enhanced fibrocyte transmigration in the Asthma AE group and in patients with COA, respectively. The upregulated expression of S100A9 and RAGE in fibrocytes of patients in the Asthma AE group and those with COA contributes to the enhanced basal migratory motility of fibrocytes. CONCLUSION: The CXCR4/CXCL12 axis contributes to chemotaxis of fibrocytes in patients in the Asthma AE group, whereas the CCR7/CCL19 axis plays an important role in patients with COA. S100A9 enhances the basal migratory motility of fibrocytes from patients in the Asthma AE group and patients with COA.

Increased phenotypic differentiation and reduced corticosteroid sensitivity of fibrocytes in severe asthma.

BACKGROUND: Patients with severe asthma are less responsive to corticosteroid therapy and show increased airway remodeling. The mesenchymal progenitors, fibrocytes, may be involved in the remodeling of asthmatic airways. We propose that fibrocytes in severe asthma are different from those in nonsevere asthma. OBJECTIVES: To examine the survival, myofibroblastic differentiation, and C-C chemokine receptor 7 (CCR7) expression in blood fibrocytes from patients with severe and nonsevere asthma and study the effect of corticosteroids on fibrocyte function. METHODS: The nonadherent non-T-cell fraction of blood mononuclear cells was isolated from healthy subjects and patients with nonsevere and severe asthma. Total and differentiating fibrocytes were identified by their expression of CD45, collagen I, and α-smooth muscle actin using flow cytometry. The expression of CCR7 and of the glucocorticoid receptor was measured by using flow cytometry. RESULTS: Increased numbers of circulating fibrocytes, with greater myofibroblastic differentiation potential, were observed in patients with severe asthma. Dexamethasone induced apoptosis, leading to reduction in the number of cultured fibrocytes and total nonadherent non-T cells from healthy subjects and patients with nonsevere asthma but not from patients with severe asthma. Dexamethasone reduced CCR7 expression in fibrocytes from patients with nonsevere asthma but not from patients with severe asthma. Glucocorticoid receptor expression was attenuated in fibrocytes from patients with severe asthma. CONCLUSIONS: Patients with severe asthma have elevated numbers of circulating fibrocytes that show enhanced myofibroblastic differentiation and that are less responsive to the effects of corticosteroids.

Vocal cord dysfunction diagnosed by four-dimensional dynamic volume computed tomography in patients with difficult-to-treat asthma: A case series.

Patients with asthma may also have vocal cord dysfunction (VCD), which leads to poor control of the asthma. Once patients are diagnosed with difficult-to-treat asthma with poor control, VCD should be excluded or treated accordingly. The gold standard for diagnosis of VCD is to perform a laryngoscopy. However, this procedure is invasive and may not be suitable for patients with difficult-to-treat asthma. Four-dimensional (4D) dynamic volume computed tomography (CT) is a noninvasive method for quantification of laryngeal movement, and can serve as an alternative for the diagnosis of VCD. Herein, we present a series of five cases with difficult-to-treat asthma patients who were diagnosed with VCD by 4D dynamic volume CT. Clinicians should be alert to the possibility of VCD when poor control is noted in patients with asthma. Early diagnosis by noninvasive 4D dynamic volume CT can decrease excessive doses of inhaled corticosteroids.

The endothelin A receptor mediates fibrocyte differentiation in chronic obstructive asthma. The involvement of connective tissue growth factor.

RATIONALE: Fibrocytes possess increased differentiability into α-smooth muscle actin (α-SMA)(+) myofibroblasts in chronic obstructive asthma (COA) and contribute to pulmonary fibrosis. Endothelin-1 (ET-1) induces matrix-associated gene expression through the ETA receptor (ETAR) and promotes fibroblast differentiation. However, the mechanism of fibrocyte differentiation remains unclear. OBJECTIVES: To define the roles of the ETAR and connective tissue growth factor (CTGF) expression in fibrocytes in the development of fibrosis in COA. METHODS: Blood nonadherent non-T (NANT) cells were isolated, and fibrocytes expressing CD45, collagen I, CTGF, ETAR, or α-SMA were identified by flow cytometry. MEASUREMENTS AND MAIN RESULTS: We showed the accumulation of fibrocytes in bronchial walls and overexpression of CTGF in fibrocytes from patients with COA. After being cultured, CTGF was increased in fibrocytes from patients with COA, but not from those of normal participants or patients with asthma without obstruction. Serum levels of ET-1 and the expression of the ETAR in fibrocytes were significantly higher in patients with COA compared with normal participants and patients with asthma without obstruction. Treatment with the ETAR antagonist (BQ123), but not ETBR antagonist (BQ788), reduced the expression of CTGF and α-SMA in fibrocytes and fibrocyte differentiation in patients with COA. Furthermore, treatment with BQ123 or an anti-CTGF antibody attenuated α-SMA expression induced by ET-1 in fibrocytes from normal participants. CONCLUSIONS: Our findings demonstrate for the first time that the ETAR pathway is vital for CTGF expression, which results in fibrocyte differentiation in COA, and suggests that an ETAR antagonist may be a potential antifibrotic agent in preventing the development of fibrosis in patients with COA.

Mobile-phone-based home exercise training program decreases systemic inflammation in COPD: a pilot study.

BACKGROUND: Moderate-intensity exercise training improves skeletal muscle aerobic capacity and increased oxidative enzyme activity, as well as exercise tolerance in COPD patients. METHODS: To investigate whether the home-based exercise training program can reduce inflammatory biomarkers in patients with COPD, twelve patients using mobile phone assistance and 14 with free walk were assessed by incremental shuttle walk test (ISWT), spirometry, strength of limb muscles, and serum C-reactive protein (CRP) and inflammatory cytokines. RESULTS: Patients in the mobile phone group improved their ISWT walking distance, with decrease in serum CRP after 2 months, and sustained at 6 months. Patients in the control group had no improvement. Serum IL-8 in the mobile phone group was significantly reduced at 2, 3 and 6 months after doing home exercise training compared to baseline. IL-6 and TNF-α were significantly elevated at 3 and 6 months in control group, while there were no changes in mobile phone group. The strength of limb muscles was significantly greater compared to baseline at 3 and 6 months in the mobile phone group. CONCLUSIONS: A mobile-phone-based system can provide an efficient home endurance exercise training program with improved exercise capacity, strength of limb muscles and a decrease in serum CRP and IL-8 in COPD patients. Decreased systemic inflammation may contribute to these clinical benefits. (Clinical trial registration No.: NCT01631019).

CD14(+)S100A9(+) monocytic myeloid-derived suppressor cells and their clinical relevance in non-small cell lung cancer.

RATIONALE: Myeloid-derived suppressor cells (MDSCs) are a heterogeneous family of myeloid cells that suppress T-cell immunity in tumor-bearing hosts. Their clinical relevance remains unclear. OBJECTIVES: To identify subtypes of myeloid-derived suppressor cells in patients with non-small cell lung cancer (NSCLC) and their clinical relevance. METHODS: CD11b(+)CD14(-) and CD11b(+)CD14(+) cells, determined and phenotyped by fluorescence-activated cell sorter analysis, in the peripheral blood mononuclear cells (PBMCs) of treatment-naive patients with advanced NSCLC were correlated with clinical data. T-cell activation in response to CD3/CD28 costimulation was determined by carboxy-fluorescein diacetate succinimidyl ester (CFSE) staining and ELISA analysis of IFN-γ. The percentage of CD11b(+)CD14(+)S100A9(+) cells in PBMCs was correlated with and tested as a predictor for treatment response in a cohort of patients prospectively receiving first-line cisplatin-based chemotherapy. MEASUREMENTS AND MAIN RESULTS: Patients with NSCLC had a significantly higher ratio of CD11b(+)CD14(+) cells than healthy subjects, which was correlated with poor performance status and poor response to chemotherapy. The depletion of these cells in the PBMC reversed the suppression of CD8(+) and CD4(+) T cells. Isolated CD11b(+)CD14(+) cells suppressed CD8(+) T-cell proliferation and IFN-γ production, and the former effect was attenuated by the inducible nitric oxide synthase (iNOS) inhibitor aminoguanidine hydrochloride, arginase inhibitor N-hydroxy-nor-l-arginine (nor-NOHA), and blocking antibodies for IL-4Rα(+) and IL-10. CD11b(+)CD14(+) cells were monocyte-like, expressing CD33(+), CD15(-/low), IL-4Rα(+), and S100A9(+) and producing iNOS, arginase, and several cytokines. The ratio of S100A9(+) cells positively correlated with the suppressive ability of the CD11b(+)CD14(+) cells, was associated with poor response to chemotherapy, and predicted shorter progression-free survival. CONCLUSIONS: CD14(+)S100A9(+) inflammatory monocytes in patients with NSCLC are a distinct subset of MDSCs, which suppress T cells by arginase, iNOS, and the IL-13/IL-4Rα axis. The amount of these inflammatory monocytes is associated with poor response to chemotherapy. Clinical trial registered with www.clinicaltrials.gov (NCT 01204307).

Increased activation of fibrocytes in patients with chronic obstructive asthma through an epidermal growth factor receptor-dependent pathway.

BACKGROUND: Fibrocytes are circulating progenitor cells that are increased in asthmatic patients with chronic obstructive asthma (COA) and rapid decrease in lung function. Fibrocytes from patients with COA have a greater capacity for proliferation and differentiation. OBJECTIVE: We investigated whether epidermal growth factor receptor (EGFR) activation mediated the proliferation of fibrocytes in patients with COA and whether oxidative stress was involved in this activation. METHODS: Circulating fibrocytes from nonadherent non-T-cell mononuclear cell fractions from healthy subjects, asthmatic patients with normal pulmonary function, and patients with COA were determined by using flow cytometric coexpression of collagen I, CD45, and CD34 or EGFR or a disintegrin and metalloprotease domain 17 and placed in culture. RESULTS: Expression of EGFR was increased in fibrocytes from patients with COA compared with that seen in patients with NPF. AG1478 and gefitinib, inhibitors of EGFR tyrosine kinase, reduced fibrocyte proliferation and myofibroblast transformation. Increased expression of EGFR and fibrocyte proliferation and transformation were induced by hydrogen peroxide, and these effects were inhibited by N-acetylcysteine. CONCLUSIONS: Enhanced fibrocyte proliferation and transformation found in patients with COA might be mediated through an oxidant-sensitive EGFR-dependent pathway.

Reduced nuclear factor-κB repressing factor: a link toward systemic inflammation in COPD.

Chronic systemic inflammation is implicated in the systemic manifestations and, probably, the excess mortality risk of chronic obstructive pulmonary disease (COPD). The role of nuclear factor (NF)-κB repressing factor (NRF), a DNA-binding, protein-inhibiting NF-κB response gene, in human diseases has not been explored. We hypothesised that the NRF-negative regulatory mechanism is impaired in COPD peripheral blood mononuclear cells (PBMCs) leading to excessive interleukin (IL)-8/CXCL8 production. NRF expression, NF-κB activation, IL-8/CXCL8 release and intracellular oxidative stress were assessed in PBMCs of normal subjects and stable COPD patients. Primary PBMCs with NRF overexpression, NRF knockdown and exposure to H(2)O(2) were used to elucidate the mechanisms. Stable COPD patients, especially those with severe COPD, showed decreased NRF expression, enhanced NF-κB activation and increased IL-8/CXCL8 release in PBMCs compared with normal subjects. This was associated with reduced NRF and increased RNA polymerase II occupancy at the IL-8/CXCL8 promoter. NRF knockdown enhanced IL-8/CXCL8 production in normal PBMCs, whilst NRF overexpression attenuated IL-8/CXCL8 production. Intracellular oxidative stress was increased in COPD PBMCs. H(2)O(2)-decreased NRF expression and -enhanced IL-8/CXCL8 production was augmented in COPD PBMCs. NRF expression is reduced in PBMCs of stable COPD patients, probably through oxidative stress, leading to increased production of IL-8/CXCL8 and potentially chronic systemic inflammation.

Medical Humanities Education and Its Influence on Students' Outcomes in Taiwan: A Systematic Review.

Background: Medical education has emphasized the importance of integrating medical humanities training into the curriculum to benefit medical and nursing students' future practice, featuring in the list of national funding priorities for healthcare education research in Taiwan for many years. However, the extent to which this drive has resulted in medical humanities training, what rationales underpin its inclusion, and its efficacy is largely unknown. This study aims to address these issues across medical humanities programs within the Taiwanese context. Methods: We conducted a systematic review. Inclusion criteria included studies in English or Mandarin reporting outcomes of medical humanities courses in healthcare education settings in Taiwan between 2000 and 2019. We searched across five electronic databases (PubMed, Embase, ERIC, PsycInfo, Web of Science), following PRISMA guidelines. The Best Evidence Medical Education (BEME) Global Scale and Kirkpatrick Levels are used for identifying the strength of evidence. Results: 17 articles were extracted from the 134 identified. Intrinsic and instrumental rationales for the inclusion of medical humanities education were common, compared with epistemological-based and critical-based approaches. Several positive impacts were identified in relation to participation including modification of attitudes, knowledge, and skills. However, the highest level (i.e., unequivocal) of evidence characterized by effects on students' behaviors or ongoing interaction with colleagues and patients is lacking. Conclusion: Findings suggest that although medical humanities education is widely implemented in Taiwan, no clear consensus has been reached regarding the rationale for inclusion or how it is localized from Western to Asian contexts. Future research still needs to explore the long-term impact of medical humanities education for medical and nursing students and its impact on patient care. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42019123967.

Undergraduates' preparedness for practice is associated with professional identity and perception of educational environment: A validation study.

BACKGROUND: Medical schools prepare undergraduates for clinical practice. Clinical competencies build up gradually and continuously. Existing literature suggests that new graduates are often unprepared for independent practice. This study aims to validate a Chinese version of a Preparedness for Hospital Practice Questionnaire (PHPQ) in a Taiwanese undergraduate cohort. METHODS: The original eight-domain English version PHPQ was translated into Chinese and back-translated for expert panel discussion. The eight domains encompass interpersonal skills, confidence, collaboration, management, science, prevention, holistic care, and self-directed learning. Reliability and validity were checked by Cronbach's alpha and by confirmatory factor analysis (CFA), respectively. Participants were divided into higher and lower preparedness groups according to PHPQ results, and compared by age, sex, professional identity, and perception of educational environment. RESULTS: A total of 129 undergraduate medical students (55% males) participated in the study. The overall Cronbach's alpha was 0.94. Participants were found to be best prepared in the domain of disease prevention (M = 4.37, SD = 0.68) and least prepared in interpersonal skills (M = 2.68, SD = 0.77). A satisfactory goodness of fit data was yield from CFA with a CMIN/DF of 2.02. Higher levels of preparedness are associated with stronger professional identity (p < 0.001) and better perceived learning environment (p < 0.001). CONCLUSION: The Chinese version of PHPQ showed good reliability and validity. Preparedness for practice was associated with how learners feel about themselves as doctors and how well they had integrated into medical teamwork.