腸內菌與巴金森氏症及糖尿病 (Gut Microbiota, Parkinson’s Disease, and Diabetes)

 

作者： 蔡昇達

人們早早就知道腸子中的細菌對人的健康很重要，所以排便不順暢的大人或是小孩常會服用益生菌，近二十年來，醫師及科學家們從臨床的觀察：「巴金森氏症發病前十幾年，有相當高比例的人會有便祕的症狀」，接著由一系列的觀察性研究、介入性研究、動物實驗等，證實「腸-腦軸線(gut-brain axis)」的存在，即腸子中的細菌會經由代謝、基因等作用，影響腦部，而開啟了眾多的腸道菌研究，我個人覺得最清楚易懂的是下方的表格(出自盧森堡的團隊)，其中藍色格子代表「正常人比巴金森氏症病人還多的細菌」，紅色表示「巴金森氏症病人比正常人還多的細菌」： 

有趣的是益生菌常見之成份、我們喜歡的乳酸桿菌(Lactobacillaceae)，竟然很一致的顯示在巴金森氏症的病人較多！這啟發我的好奇心： 或許對於巴金森氏症的病人，補充益生菌並不一定有益處？之後做了許多文獻的搜索，也發現對於急性胰臟炎的病人，若補充含有乳酸桿菌及比菲德氏桿菌屬的益生菌(Lactobacillus acidophilus, Lactobacillus casei, Lactobacillus salivarius, Lactococcus lactis, Bifidobacterium bifidum, and Bifidobacteriumlactis，Lancet 2008; 371: 651–59)，其死亡率較未補充益生菌者為高，亦有文章談到商業利益對科學研究與發表的影響(Faecal transplantation, Pro- and Prebiotics in Parkinson’s Disease; Hope or Hype?)，提醒科學家們謹慎看待。

2024 年法國團隊在新英格蘭醫學雜誌(NEJM)發表一篇重磅的研究，發現 Lixisenatide，一種 GLP1 agonist (糖尿病用藥)，可以減緩巴金森氏症動作症狀的惡化(Meissner WG, Remy P, Giordana C, Maltête D, Derkinderen P, Houéto J-L, et al. (2024). Trial of lixisenatide in early Parkinson’s disease. N Engl J Med, 390:1176-1185.)，表示此二重要疾病應有其關聯性，故中醫大神經內科與新陳代謝科陳主任合作，交叉比對，並篩選到屬及種(以前學的「界門綱目科屬種」)、並排除服用益生菌的病人，發現 Lactobacillus salivarius 及 genus Akkermansia 在巴金森氏症病人及糖尿病病人族群，均較健康人為多，或許可從一個角度推出巴金森氏症與糖尿病的關聯性，供後續的研究參考。(亦可參考本院出版的刊物： 中國醫訊 220 期第 19 頁)

此臨床研究很感謝計劃助理佳均、家甄、嘉嘉協助收案、建檔、簽同意書……等、感謝蔡崇豪院長及呂明桂主任協助收案，感謝檢驗部薛院長的指導、賴博、逸堯的資料分析、感謝已故的新陳代謝科陳清助主任的一同合作、感謝陳佳陽醫師幫忙收集臨床資料、感謝藝瀚、楊醫師在統計方面的協助、感謝 Mayo Clinic Marina 教授的合作分析，這篇文章經歷了四次的退稿，最後一次有位 reviewer 的評論亦相當嚴竣，感謝逸堯協助依 reviewer 的意見重做分析、展現高度的誠意，終被接受刊登，很高興與各位分享此研究，另外，建議您在補充益生菌前先詢問醫師的意見，或許補充益生菌不一定對您有好處。

本團隊發表在《科學報告》的全文如下：

Elevated Lactobacillus salivarius and genus Akkermansia in fecal samples of Taiwanese patients with Parkinson’s disease and diabetes mellitus

English version:

Title: Gut Microbiota, Parkinson’s Disease, and Diabetes

For centuries, people have recognized the importance of gut bacteria in maintaining health. Adults and children with constipation often take probiotics, reflecting a widespread belief that “good bacteria” support gastrointestinal function. Over the past two decades, however, clinical observations and biomedical research have extended this understanding far beyond digestion.

One key clinical observation is that more than ten years before the onset of Parkinson’s disease (PD), a substantial proportion of patients already exhibit chronic constipation. Subsequent observational studies, interventional trials, and animal experiments have confirmed the presence of the gut–brain axis—a bidirectional communication network through which gut microbes influence brain physiology through metabolic, genetic, and immunologic mechanisms. This has catalyzed an explosion of gut-microbiome research.

Among many studies, a 2018 investigation by a research team in Luxembourg produced what I consider one of the most intuitive summary tables. In their analysis, blue cells represent bacterial taxa more abundant in healthy individuals, while red cells represent taxa more abundant in patients with Parkinson’s disease.

The Surprising Role of Probiotics in Parkinson’s Disease

A particularly intriguing finding is that Lactobacillaceae—a family of bacteria commonly found in probiotic supplements and widely regarded as beneficial—appears consistently elevated in Parkinson’s disease patients. This led me to question whether probiotic supplementation is universally beneficial.

Further literature review uncovered additional concerns:

A landmark randomized trial in The Lancet (2008; 371:651–659) showed that patients with acute pancreatitis who received probiotics containing Lactobacillus acidophilus, L. casei, L. salivarius, Lactococcus lactis, Bifidobacterium bifidum, and B. lactis experienced higher mortality compared with those who did not receive probiotics. Other commentaries have also raised questions regarding commercial influence on probiotic research (e.g., Faecal transplantation, Pro- and Prebiotics in Parkinson’s Disease: Hope or Hype?), reminding scientists to remain cautious and critical.

New Evidence Linking Parkinson’s Disease and Diabetes

In 2024, a French research group published a groundbreaking trial in the New England Journal of Medicine, demonstrating that lixisenatide, a GLP-1 receptor agonist used in diabetes treatment, slows the progression of motor symptoms in early Parkinson’s disease:

Meissner WG, Remy P, Giordana C, Maltête D, Derkinderen P, Houéto J-L, et al. (2024). Trial of lixisenatide in early Parkinson’s disease. N Engl J Med, 390:1176–1185.

This finding suggests a mechanistic connection between diabetes and Parkinson’s disease.

In light of this, our neurology and endocrinology teams collaborated to analyze microbiome datasets. After cross-comparison, genus- and species-level filtering, and exclusion of patients taking probiotic supplements, we found that:

Lactobacillus salivarius, and Genus Akkermansia were elevated not only in Parkinson’s disease patients but also in patients with diabetes, compared with healthy controls. These shared microbial patterns provide a potential clue linking the two disorders, offering a valuable direction for future research.

Here is the link for our published article (on Scientific Reports): 

Elevated Lactobacillus salivarius and genus Akkermansia in fecal samples of Taiwanese patients with Parkinson’s disease and diabetes mellitus

Acknowledgments

This clinical study would not have been possible without the dedicated support of many colleagues. I am grateful to:

Project assistants Chia-Chun, Chia-Chen, and Chia-Chia for case enrollment, data entry, and consent procedures

Dean Chon-Haw Tsai and Director Ming-Kuei Lu for assistance with recruitment

Director Hsueh of the Laboratory Medicine Department for guidance

Dr. Lai and Yi-Yao for data analysis

The late Director Chen Ching-Chu (Endocrinology & Metabolism), whose collaboration and generosity made this study possible

Dr. Chen Chia-Yang for collecting clinical information

Dr. Yi-Han Hu and Dr. Chia-Chun Yang for statistical support

Professor Marina of Mayo Clinic for collaborative analyses

This manuscript went through four rounds of rejection, and the final reviewer’s critique was demanding. I am especially thankful to Yi-Yao, who re-analyzed the dataset in full alignment with the reviewer’s concerns. That rigorous effort demonstrated our sincerity and ultimately led to acceptance.

I am pleased to share these findings with you. Finally, I recommend consulting your physician before taking probiotic supplements—because, as research increasingly shows, probiotics may not always be beneficial for everyone.

秋末烏鴨 Late-Autumn Crows

作者： 蔡昇達

11/6(四)做了整天的實驗，下午開始天氣快速變冷，五點多時開車回家換厚外套，回實驗室時很高興的停在距離門口最近的樹下(難得有這麼近的空停車位)，想不到九點多做完實驗出來，整車竟然滿滿的皆是烏鴨大便！四個小時的時間，我得到了實驗數據，也得到了滿滿的鳥大便。

圖一、四小時累積的烏鴨大便

回來查了資料，原來明尼蘇達州羅徹斯特市的烏鴉問題已經困擾了幾十年，從 1980 年代就開始了。主要是天冷時城市較溫暖，吸引烏鴨群聚，且幼鳥已養育得差不多，成鳥有較多社交的行為……等，甚至因造成城市居民的困擾及健康風險，去年政府派出神槍手，用塑膠子彈驅趕烏鴨。

圖二、2024 年羅徹斯特市的新聞

過去一年半，我皆是自己洗車(想說美國人工太貴)，但此次實在太驚人，不得不到洗車場請人幫忙，沒想到比想像的便宜許多(含稅 11 美元)，且服務甚佳。洗車的年輕人還請我搖下車窗，問我到底是怎麼了？怎麼可以這麼誇張！

圖三、洗車時從車內拍出去的洗車廠內部

圖四、免費的超強力吸塵器，自助使用

解鎖了洗車服務，以後不必再辛苦的自己洗車、吸塵，為此次最大的收穫。感謝骨科學長介紹的洗車廠。

圖五、花 11 美元清掉滿滿的烏鴨大便，實在值得！

English version:

On Thursday, November 6, I spent the entire day running experiments. By afternoon, the weather had suddenly turned cold. Around five o’clock I drove home to change into a thicker coat. When I returned to the lab, I happily parked under the tree closest to the entrance — a rare empty spot that near!

Unexpectedly, when I finished my experiments and came out around nine o’clock, I found my entire car completely covered with crow droppings. In just four hours, I obtained both my experimental data and a car full of bird excrement.

After checking the internet, I discovered that the crow problem in Rochester, Minnesota, has actually troubled the city for decades — dating back to the 1980s. In winter, the city’s slightly warmer temperature attracts large gatherings of crows. By this season, the young have already been raised, and the adult birds engage in more social behaviors. The situation has caused such nuisance and potential health risks to residents that last year the government even sent sharpshooters armed with plastic bullets to drive the crows away.

For the past year and a half, I’ve always washed my car myself (labor costs in the U.S. are high, after all). But this time the mess was so extraordinary that I had no choice but to go to a car wash and ask for help. To my surprise, it was much cheaper than I expected — only $11 including tax — and the service was excellent.

One of the young workers even asked me to roll down my window and exclaimed, “I am curious what on earth happened? How could your car get this bad? I will get it off.”

By “unlocking” the car-wash service, I no longer need to struggle washing and vacuuming the car by myself — truly the greatest reward from this episode. Many thanks to my orthopedic senior colleague (Dr. Sam Chen) who recommended this car wash!

Lake Superior 蘇必略湖

作者： 蔡昇達

美國明尼蘇達州境內有許多湖，號稱「萬湖之州」，其中最大的為蘇必略湖(Lake Superior)，來到這邊一年多，終於有時間探訪這世界上面積最大的淡水湖。

日落時的蘇必略湖，紅藍混合的顏色很夢幻

五大湖的形成源於第四紀(Quaternary Period，距今約一萬年前)的巨大冰川(勞倫泰德冰蓋)往南移動時的冰蝕作用，因壓力造成地殼下沉，形成低漥的凹地，成為五大湖的基底，待氣候變暖時冰川融化，形成大型的淡水湖，其中最大的即為蘇必略湖。

1866 年，地質學家 Henry H. Eames 在明尼蘇達州北部發現豐富的高品質鐵礦，1891 年 Duluth, Missabe and Northern Railway (DM&N, DMN)鐵路公司成立，1892 年第一批鐵礦石通過此鐵路送到蘇必略湖畔的碼頭運出。(參考影片： Duluth, Missabe and Iron Range Railway, The Last Days - FULL VIDEO (2004))

紅色即表示在蘇必略湖附近發現的鐵礦(來自維基百科)，最主要的為 Mesabi (= Missabi) Range

最早運送鐵礦的 Duluth, Missabe and Iron Range Railway

Duluth 的秋景、鐵礦(在港口邊，放大才看得清楚)、及鐵路

1905 年 11 月底，繁忙的蘇必略湖風雪漸大，晚上時一艘貨船(Madeira 號)撞上岸邊礁石，許多人喪生，故幾年後在該地建造了燈塔，維護行船的安全，燈塔運行的數十年間，未再有貨船觸礁。

高聳峭壁上的燈塔 Split Rock Lighthouse，是全美排名很前面的熱門觀光燈塔

因北方的明尼蘇達州提供高品質的鐵礦、東部的阿帕拉契山脈（Appalachian Mountains）擁有豐富煤炭，加上五大湖的水運系統(如下照片)，使五大湖區成為理想的重工業帶，1920–1960年間，該區人口迅速增長，出現典型的工業城市，例如：底特律被稱為「汽車之都」，匹茲堡為「鋼鐵之城」，克里夫蘭為「機械之心」。

五大湖的通航路線圖，可以直接由最上游的蘇必略湖接到北大西洋

1970 年代後因海外低價鋼鐵與汽車競爭、高利率致美元升值……等因素，產業外移至美國南部或亞洲（如日本、韓國)、大量工廠關閉、失業率上升、城市人口外移，因而出現著名的「鐵鏽帶(Rust Belt)」，意思是曾經輝煌的重工業基地，如今設備生鏽、經濟停滯。

橘紅色為鐵鏽帶、灰色區為前面提到的煤炭產區(阿帕拉契山脈)
Source: Brendan H. Jennings--Saline County, Illinois, historian (2010).

不過 Lake Superior 附近的鐵礦至今仍持續開採中，且 Duluth 仍然為重要的港口、及觀光勝地，相當值得一訪。

Duluth 港出口處的 Aerial lift bridge，有船隻通過時即會升起

蘇必略湖北岸公路旁的 Gooseberry falls

Aerial lift bridge 夜景

而明尼蘇達州在 20 世紀後期經濟轉型，從農業與採礦業轉向服務業、金融與醫療保健，許多著名公司的總部皆在此，如 3M Health Care, Medtronic, UnitedHealth Group......等，當然還有最富盛名的 Mayo Clinic。明州在預期壽命、醫療水平與教育質量方面名列前茅，人均收入高於全美平均。

與合作的神外學長，陳醫師，在 Mayo 圖書館之梅約兄弟畫像前合照

English version:

Minnesota, known as the “Land of 10,000 Lakes,” is home to countless bodies of water, the largest of which is Lake Superior. Having lived here for more than a year, I finally found the time to visit this magnificent natural wonder — the largest freshwater lake by surface area in the world.

The formation of the Great Lakes dates back to the Quaternary Period (around ten thousand years ago), when the massive Laurentide Ice Sheet advanced southward. The glacier’s immense pressure eroded and depressed the Earth’s crust, carving out vast basins that later became the foundation of the Great Lakes. As the climate warmed and the glaciers melted, these basins filled with meltwater, forming a chain of immense freshwater lakes — among which Lake Superior is the largest.

In 1866, geologist Henry H. Eames discovered abundant high-grade iron ore in northern Minnesota. The Duluth, Missabe and Northern Railway (DM&N) was established in 1891, and by 1892, the first shipments of iron ore were transported by rail to the docks along Lake Superior for export.

(Reference video: “Duluth, Missabe and Iron Range Railway, The Last Days – FULL VIDEO (2004)”).

In late November 1905, a severe snowstorm struck busy Lake Superior. That night, the freighter Madeira crashed against the rocky shore, resulting in heavy loss of life. In response, a lighthouse was later built at the site to ensure maritime safety. During the many decades the lighthouse operated, no shipwrecks occurred in that area again.

Because northern Minnesota supplied high-quality iron ore, the Appalachian Mountains in the east provided abundant coal, and the Great Lakes offered an efficient inland waterway system (as shown in the photo below), the region became an ideal location for heavy industry. Between 1920 and 1960, the population of the Great Lakes area surged, and numerous industrial cities emerged: Detroit became known as the “Motor City,” Pittsburgh as the “Steel City,” and Cleveland as the “Heart of Machinery.”

However, after the 1970s, competition from low-cost foreign steel and automobiles, together with high interest rates and the rising value of the U.S. dollar, led to industrial decline. Many factories relocated to the southern United States or overseas (such as Japan and South Korea), resulting in widespread plant closures, soaring unemployment, and urban depopulation. This transformation gave rise to the so-called “Rust Belt,” referring to once-prosperous industrial centers now characterized by rusting facilities and economic stagnation.

Nevertheless, iron mining near Lake Superior continues today, and Duluth remains both an important port and a popular tourist destination — well worth a visit.

In the latter half of the 20th century, Minnesota underwent an economic transformation, shifting from agriculture and mining to service industries, finance, and healthcare. Many renowned companies are headquartered here, such as 3M Health Care, Medtronic, and UnitedHealth Group… and of course, the most prestigious of all, the Mayo Clinic. Minnesota ranks among the top in life expectancy, healthcare standards, and education quality, with a per capita income above the national average.

環境的影響

 

作者： 蔡昇達

去年帶五歲大的女兒來美國念幼稚園，女兒一開始相當不適應，不想去上學、不想聽英文和講英文，可能因心情不好，前幾週皆沒有什麼食慾，吃得很少。

照片一： 第一天到幼稚園上學 (RASA)

幾個月來感謝其他台灣家庭的陪伴，讓她有說中文的朋友們可以一起玩，漸漸克服想家的情緒。

照片二： 有趣的復活節撿蛋活動 (Easter egg hunt)

今年三月開始(來美國七個月左右)，在家中不時會說出英文，如看到小熊軟糖，說「That's gummy bear」，想吃棒棒糖時會說要「lolipop」，某天我在修改論文，她在旁邊跟我說，「Why are you changing the upper case to lower case?」著實嚇了我一跳，原來在這個全英文的環境，她已自動學習了許多。上個月搭機飛波士頓，整理行李時她想帶上喜歡的小白鯨，但空間有限，她看著行李箱跟我說「Let's take them out and fill with another way」，之後把餅乾打散重放，挪出空間來。

照片三： 行李箱，左上為她最愛的小白鯨

這讓我相當震驚，七個月來沉浸在全英文的環境，已經讓她自動用英文思考和表達，縱然每天上學的時數不多，回家也皆和我講中文，亦沒有上課後任何的才藝或是運動課程。讓我體會到以前英文老師常講的，「不要先想中文再翻成英文，要直接用英文思考」，而我從來沒有做到過，也無法想像，看到女兒，才理解這個概念。也想到以前神經科學讀過的(1997 年的 Nature 文章)，「母語」和第二外語使用的腦區(尤其在 Broca's area)是完全不同的，且對我們而言，閱讀英文的速度就是比讀中文慢了五倍，讓我們在讀期刊上較美國人花去較多的時間，尤其在寫 systemic review、meta-analysis 時感受特別強烈。

圖片： 在 Broca's area，母語(紅色)和第二外語(黃色)的處理腦區不同(出自 1997 年刊登在 Nature 的文章)

感謝女兒願意離開熟悉的家，遠道到地球的另一端陪我度過一年，期許今年培養的英語能力，能讓她未來多些機會，也持續觀察未來是否能發展成「雙母語」的腦袋。

English version:

Last year, I brought my five-year-old daughter to the U.S. to attend kindergarten. At first, she had a hard time adjusting—she didn’t want to go to school, didn’t want to listen to or speak English. Perhaps due to her low mood, she had little appetite and ate very little in the first few weeks.

Over the past few months, we are grateful for the companionship of other Taiwanese families, which gave her Mandarin-speaking friends to play with. Slowly, she overcame her homesickness.

Starting this March (around seven months after arriving in the U.S.), she began to occasionally speak English at home. For example, when she saw gummy bears, she said, “That's gummy bear.” When she wanted a lollipop, she said she wanted a “lollipop.” One day, while I was editing a manuscript, she looked at me and asked, “Why are you changing the upper case to lower case?” I was quite startled—clearly, she had learned a lot just from being in an English-speaking environment. Last month, when we were flying to Boston, she wanted to bring along her beloved little white whale. But space was limited. Looking at the suitcase, she said, “Let's take them out and fill with another way.” Then she broke up some cookies and repacked them to make room.

I was deeply amazed—after just seven months immersed in an English-speaking environment, she had already begun to think and express herself naturally in English. Even though her school hours each day are limited, and she only speaks Mandarin with me at home, and doesn’t take any extracurricular classes or sports lessons, she has picked it up on her own. This made me truly appreciate something English teachers often say: “Don’t think in Chinese first and then translate into English—think directly in English.” I’ve never been able to do this, and couldn’t even imagine it—until I saw it in my daughter.

It also reminded me of something I read in neuroscience—an article published in Nature in 1997—which explained that the brain regions used for a native language and a second language (especially in Broca’s area) are entirely different. For us, reading English takes about five times longer than reading Chinese, which means we spend significantly more time reading academic papers than native English speakers—especially when working on systematic reviews or meta-analyses.

I'm thankful that my daughter was willing to leave the familiar comforts of home and accompany me to the other side of the globe for a year. I hope the English abilities she developed this year will give her more opportunities in the future, and I’ll continue to observe whether she might develop a truly “bilingual” brain.

Reference: Kim, K., Relkin, N., Lee, KM. et al. Distinct cortical areas associated with native and second languages. Nature 388, 171–174 (1997). https://doi.org/10.1038/40623

晨昏定省

作者：蔡昇達

《禮記．曲禮》：「凡為人子之禮，冬溫而夏凊，昏定而晨省。」

《弟子規》 

冬則溫　夏則凊　晨則省　昏則定

出必告　反必面　居有常　業無變

正值壯年的復健科醫師，在美國波士頓執業，每天早上及晚上都會打電話給台灣的媽媽請安，2023 年一月回台陪爸媽過農曆春節，幾天後飛回美國，下飛機即回醫院準備上班，卻暫時失去意識，跌倒造成頭部撕裂傷，前往醫院做傷口縫合，傷口處理完約兩個小時後卻在醫院內再次失去意識、心跳停止……

隔天媽媽覺得不對勁，飛機已經到了，貼心的兒子卻沒有打電話來請安，立刻聯絡醫院，才知道兒子已在加護病房……

照片一： Peter Bent Bigham Hospital

2025 年四月我來到波士頓開會，看到美麗的城市，及世界知名的麻省總醫院布萊根醫療系統(原本的麻州總醫院和布萊根婦女醫院合併) ，百感交集，想到這位學長的故事：

照片二： 布萊根婦女醫院門口

起死回生是急重症醫師最大的成就感，身為神經內科醫師，則是醒腦開竅，GCS 3 到 15，是病人和我們的共同目標，復健科學長在波士頓的醫院做完低溫治療、早期復健後轉回台灣，希望結合中醫，幫助他早日恢復意識。為何希望結合中醫？因為波士頓的大醫院已說明病況嚴重、癲癇難控制，醒來的機會幾近於零，但在復健科病房時，有次學長在接受針灸治療後雙眼變得有神，似乎可聽懂家人說的話，故家人經討論後決定轉回中醫大後續治療。

圖片： 急救後的腦部核磁共振(T2 series)，可見腦迴邊緣變得較白(hyperintensity)，表示缺氧的損傷嚴重

這種超級 VIP 一般會找各科的主任，故我聽說這個會診時沒有太在意，但前輩林醫師託我幫忙看看，剛好是一個值班的週末，便走到復健科的病房，陪在旁的是一位新加坡的胸腔內科、重症科學長，是復健科學長的好朋友，他很誠懇、仔細的為我說明前端的治療過程、醫師對預後的分析……等，難過時數度流淚，讓我對他們的友誼產生深刻印象，新加坡醫師為了他，請假飛到波士頓，陪伴在旁，並再陪他回到台灣治療。

之後某個週三下午的門診，學長的哥哥掛了號前來，坐下來誠懇的與我討論弟弟的病情，時間雖不長，但我明顯可感受到他對弟弟的用心、也理解到家人們想到為學長多做一些的希望，讓我決定將學長從他科轉過來，負責整個意識障礙的治療決策。

意識障礙(白話：人不清醒，嚴重者即為俗稱的「昏迷」、或是「植物人」)，就台灣(及世界多數國家)的醫療常規而言，沒有專門的部門來做仔細的評估和計劃擬定，因多數的昏迷是已知原因造成，如腦中風、心跳停止，多在可處理的原因處理完後即安排下一步的安置，如轉至地區醫院、或是養護機構。經由學長的案例，讓我認識在此領域深耕很久的藍亭教授，除了科學之外，藍亭教授持續的教育大眾意識障礙的概念(如他的中文、英文文章)、且為植物人的研究募款、改善他們的處境，我們亦邀請藍亭教授一同幫忙我們評估、討論計劃。

治療期間減低癲癇藥劑量、安排腦部檢查、與中醫師討論針灸方向……，著實讓我成長不少，也在神經部蔡部長的建議下，引用最新發表的文獻(Brain Stimul. 2023 May-Jun;16(3):819-827.)，給予三叉神經電刺激治療，並在臨床神經生理學會呂主任的指導下調整刺激的參數，亦從英國購買了一條特製的電源線，終可開始執行。

照片三：用各種神經電生理機器組合起來的三叉神經電刺激設備，用電腦跑我們設定的參數

某天，跟著我的住院醫師(一個月輪換一次)在看完病人後問我，「這樣治療到底有什麼意義？！」讓我印象深刻，也理解到許多人對植物人、昏迷病人的想法，體會到藍亭教授多年來持續碰到的困難。

還記得有天早上查房，學長的媽媽在看好萊塢電影，好奇的跟媽媽聊聊她看的電影，她說「這部電影是在波士頓拍的，就在他工作醫院的旁邊。」原來媽媽並不是在看電影，而是在思念兒子。

治療期間，家屬向我介紹了一本書，是加拿大神經科學家，Adrian Owen 的研究，利用功能性核磁共振掃描，請病人想像「打網球」及「在家中走路」分別來回答「是」或「否」的問題，因歐文(Owen)團隊發現，有的病人無法透過身體表達想法，卻可以用這兩個方法來與外界溝通(引用文獻、影片等)，我們也用相同的方法為病人測了兩次，可惜未能得到肯定的答覆，可能是學長當時想睡覺、無法完成想像、或者是意識程度沒有好到那個程度。

經過一陣子的治療，學長的昏迷評估量表有所進步(CRS-R score= 4-> 7)，但對醫療團隊而言，未能呈現出有意義的溝通(GCS= E4VtM4)，階段治療完成後家人帶他回老家照顧，回到小時候成長的地方，有爸爸、媽媽、哥哥的陪伴。

快出院時，我由學長爸爸的口中得知，當初哥哥為了將他從波士頓送回台中，訂了 12 個長榮的機位，以放置病床，但起飛前幾天，因台美段機位需求大，這些機位一一被售出，學長無法返台，後來勞煩父親出動老關係聯絡長榮高層，終順利返台。面對近兩個月的艱辛和高壓，一肩扛起弟弟的一切，在機位確認後哥哥第一次落下了男兒淚。(未選擇醫療包機，是因為包機較小，中途需降落加油，家人擔心增加移動的風險，故選擇大型的民航客機。)

也了解到哥哥為了弟弟的病情，辭去了科技業高薪的工作，每天陪伴在弟弟身邊，找遍各種資源來幫忙他，爸爸媽媽則是將家中改建，專門建一個適宜照顧的房間，並聘請專人照顧學長，學長的人生旅程仍在寧靜的繼續著，所幸之前相關的文章提到，「無法表達想法」的狀態，並不會讓他的內心變得比較不快樂。

許多人會覺得他們家是因為經濟條件佳，才能讓病人得到很好的照顧，但我感受到的是家人們投入的全心全意、還有對醫療團隊的理解和尊重，如果沒有哥哥特地掛號來門診，坐下來談、沒有胸腔科醫師為麻吉流下的眼淚、沒有爸爸含蓄但深刻的請託，我可能心中沒能有力量面對許多的質疑。

走過布萊根婦女醫院的建築，我再到麻州總醫院，參觀古老的 Ether Dome，是世界上第一例用乙醚麻醉做手術的地方，回顧醫學史，醫師常在遇到問題、解決問題時促進了醫學的突破，相信不久的將來，我們在意識障礙的診斷與治療也可有所突破。

照片四： 麻州總醫院的 Ether Dome，1946年10月，醫學史上第一例的乙醚麻醉手術(頸部腫瘤切除)即在此進行，持相機的是中國附醫神經外科林鈺翔學長，他花一年時間在麻州總醫院精進腦部及脊椎手術。

「凡為人子之禮，冬溫而夏凊，昏定而晨省。」雖人在海外，每天仍向父母請安，我覺得這是學長雖面對重大變故，仍履次化險為夷的關鍵，佛法中說，父母為具力業門，「由福田門故力大者。謂於三寶，尊重，似尊，父母等所，於此雖無猛利意樂，略作損益，能得大福及大罪故。(廣論第 131 頁)」，儒家也說「孝」為根本，我也該打電話向媽媽請安了。

English version:

The Book of Rites – “Qu Li” (Summary of Rituals):

"A son’s proper conduct includes keeping his parents warm in winter and cool in summer, settling them in the evening and checking on them in the morning."

Standards for Being a Good Student and Child:

Keep parents warm in winter and cool in summer,

Check on them in the morning and settle them at night.

Inform them before leaving, report back upon returning.

Maintain regular habits and consistent work.

A rehabilitation physician practicing in Boston, U.S., called his mother in Taiwan every morning to express his love and care. In January 2023, he returned to Taiwan to celebrate the Lunar New Year with his parents. Just a few days later, he flew back to the U.S. and went straight to the hospital upon landing to prepare for work. However, he suddenly lost consciousness, collapsed, and suffered a head laceration. He was rushed to the hospital for stitches. Around two hours after the wound was treated, he lost consciousness again—this time, his heart stopped.

The next day, his mother felt something was wrong. Her son’s flight had already landed, but the thoughtful daily warm call never came. She immediately contacted the hospital and was shocked to learn her son was in the ICU...

In April 2025, I came to Boston for a conference. Seeing the beautiful city and the world-renowned Massachusetts General Brigham hospital system (formed from the merger of the former Massachusetts General Hospital and Brigham and Women’s Hospital) stirred deep emotions. I thought of this senior's story.

Bringing patients back from the brink of death is the greatest achievement for critical care physicians. As a neurologist, our goal is to help patients "wake up"—from a Glasgow Coma Scale (GCS) score of 3 to 15. After undergoing hypothermia therapy and early rehabilitation at a Boston hospital, the rehabilitation physician was transferred back to Taiwan. His family hoped to incorporate traditional Chinese medicine to aid in regaining consciousness. Why? Because the hospital in Boston had clearly stated that the condition was severe, seizures were difficult to control, and the chance of waking up was near zero. However, during rehabilitation, after one acupuncture session, his eyes suddenly became alert, and he seemed to understand what his family said. This led the family to decide, after much discussion, to transfer him to China Medical University Hospital for further treatment.

This kind of super VIP case usually involves consultations with department chiefs. So when I first heard about this consult, I didn’t think much of it. But when Dr. Lin asked me to take a look, it happened to be a weekend on call. I walked over to the rehab ward and met a senior from Singapore, a pulmonologist and critical care specialist, who was a close friend of the patient. He sincerely and thoroughly explained the previous treatments and prognoses to me. He even cried several times as he spoke, leaving me deeply moved by their friendship. This Singaporean doctor took leave to fly to Boston, stayed by his friend’s side, and accompanied him back to Taiwan.

One Wednesday afternoon during clinic, the patient’s older brother registered for a consultation. He sat down and sincerely discussed his younger brother’s condition with me. Although the conversation was brief, I could clearly sense his dedication. I understood the family’s wish to do everything possible for the patient, and this moved me to transfer the case under my care and take charge of all treatment decisions related to consciousness disorders.

Consciousness disorders—commonly referred to as coma or a vegetative state—do not have a dedicated department in Taiwan (or most countries) for thorough evaluation and planning. Most comas are caused by known events, like strokes or cardiac arrest. Once the acute issues are handled, patients are typically sent to regional hospitals or care institutions. Through this case, I became acquainted with Professor Timothy Joseph Lane, who has long worked in this field (see the two links below), and invited him to join our team for assessments and planning.

Liberty Times Health: https://health.ltn.com.tw/article/breakingnews/5002551

Taipei Times: https://www.taipeitimes.com/News/editorials/archives/2024/12/04/2003827917

During treatment, we reduced the dosage of anti-epileptic drugs, conducted brain imaging, and consulted with traditional Chinese medicine practitioners about acupuncture plans. Under the guidance of Neurology Department Head Dr. Tsai, we also tried a new technique from recent literature (Brain Stimul. 2023 May-Jun;16(3):819-827.): trigeminal nerve stimulation. With advice from Clinical Neurophysiology Chair Dr. Lu, we adjusted the stimulation parameters. We even imported a specially made power cable from the UK to begin treatment.

One day, after making rounds with my resident (residents rotate monthly), he asked me, “What’s the point of this treatment? He is not going to regain consciousness.” That question stuck with me—it reflected how many people view coma and vegetative states, and helped me understand the persistent challenges Professor Lane has faced in this field.

I remember one morning during rounds, the patient’s mother was watching a Hollywood movie. Curious, I asked her what she was watching. She said, “This movie was filmed in Boston, right next to the hospital where he worked.” I realized that she wasn’t just watching a film—she was missing her son.

During treatment, the family introduced me to a book by Canadian neuroscientist Adrian Owen. His research (Science. 2006 Sep 8;313(5792):1402. doi: 10.1126/science.1130197.) used functional MRI scans to ask patients to imagine playing tennis or walking through their home—responses that corresponded to “yes” or “no.” His team found that some patients who couldn’t express themselves physically could still communicate through these tasks (as documented in his publications and videos). We tried the same method twice with our patient, but unfortunately, didn’t receive conclusive responses. Perhaps he was too tired, unable to focus, or his consciousness wasn’t clear enough yet.

After some time, the patient’s Coma Recovery Scale-Revised (CRS-R) score improved from 4 to 7. However, he still could not communicate meaningfully (GCS = E4VtM4). When this phase of treatment concluded, the family took him back to their hometown to care for him—back to where he grew up, surrounded by his parents and brother.

Just before discharge, I learned from the patient’s father that to bring him back from Boston to Taichung, the brother had booked 12 seats on an EVA Airlines flight to accommodate the stretcher. But due to high demand for U.S.–Taiwan flights, those seats were gradually sold off. The transfer seemed impossible until the father reached out through old connections to the airline’s top management. Finally, the transfer was arranged. After nearly two months of stress and hardship, carrying everything on his shoulders, the brother broke down in tears for the first time after the flight seats were confirmed. (They did not choose a medical charter flight because smaller planes would require refueling stops, increasing risk. Instead, they chose a large commercial aircraft.)

I also learned that the brother quit a high-paying tech job to care for his sibling full-time, seeking out every possible resource. Their parents renovated their home to create a special care room and hired professionals to look after the patient. His journey continues quietly. Fortunately, previous literature has shown that being unable to express thoughts does not necessarily mean someone is unhappy inside (Orphanet J Rare Dis. 2015 Jul 19:10:88. doi: 10.1186/s13023-015-0304-z.).

Many people might think the family could provide such care because they are financially well-off. But what I felt was their wholehearted dedication, and their respect and understanding for the medical team. Without the brother visiting my clinic, without the pulmonologist’s tears for his dear friend, without the father’s quiet but heartfelt request—I might not have had the strength to face so much doubt and pressure.

As I passed Brigham and Women’s Hospital again, I visited the historic Ether Dome at Mass General, where the world’s first surgery under ether anesthesia was performed. Reflecting on medical history, breakthroughs often came from confronting and solving problems. I believe we’ll also see advances in diagnosing and treating consciousness disorders in the near future.

"A son’s proper conduct includes keeping his parents warm in winter and cool in summer, settling them in the evening, and checking on them in the morning." Though he was living abroad, he still greeted his parents every day. I believe this devotion played a crucial role in his repeated survival through such adversity.

Buddhist teachings regard parents as a powerful source of karmic merit. In The Great Treatise on the Stages of the Path (Volume 1, p. 231), under the section The Varieties of Karma, it states:

“There is strength in actions directed toward the three jewels, gurus, those who are like gurus, parents, and the like, for, though you direct no intense thoughts toward them and do them only small harm or help, the ensuing misdeed and merit is great.”

Confucianism also holds filial piety as a foundational virtue. Perhaps it’s time I called my mother too.

民族熔爐 (Melting pot)

作者： 蔡昇達

Author: Sheng-Ta Tsai

國高中讀地理、歷史，知道美國是著名的移民國家、民族的大熔爐、自由世界的燈塔，自己實際住了一年後，才有較深刻的感受。

In high school geography and history classes, I learned that the United States is a famous immigrant country, a great melting pot of nations, and a beacon of the free world. However, it wasn’t until I actually lived here for a year that I truly grasped its significance.

Photo 1： 自由女神雕像，是西元 1886 年法國送給美國的禮物. The Statue of Liberty, a gift from France to the United States in 1886.

自由女神島的旁邊，有個埃利斯島(Ellis Island)，是早期移民管理局的所在地，來自世界各地的移民皆在此進入美國，現在已改建為移民博物館，保留了當年移民面試的大廳、窄小的上下舖，更記錄了許多移民的故事。

Next to Liberty Island is Ellis Island, which once housed the early immigrant inspection and processing station. Immigrants from all over the world entered the United States through this facility. Today, it has been transformed into the Ellis Island Immigration Museum, preserving the registration hall where interviews took place, the cramped bunk beds, and countless stories of immigrants.

 

Photo 2： 埃利斯島(大樓前方的小島). Ellis Island (the island in front of the high buildings)

Photo 3： 移民睡的窄床，上下舖. Dormitory with small beds.

Photo 4： 移民面試的大廳，當年可是滿滿的排除人潮. Registration hall for interview.

最讓我動容的是下面這個展區，分析人們為什麼離開自己的家園，如 1975 年越戰結束後，許多難民逃離赤化的越南，照片即是有名的「越南船民(Vietnamese boat people)」，許多是華裔，北越的執政者(越共)知道他們較有錢，拿走他們的黃金後，把他們送到船上，在海上漂泊，有的人被救到外國、也有許多人死亡。這個大展牆記錄了全世界的苦難，讓我佇足良久。

The most touching exhibit for me was the section analyzing why people leave their homelands. For example, after the Vietnam War ended in 1975, many refugees fled communist-controlled Vietnam. One famous case is the "Vietnamese boat people," many of whom were of Chinese descent. The ruling North Vietnamese government knew these people were wealthier, so they confiscated their gold before sending them out to sea. Some were rescued by foreign countries, while many died. This large display wall, documenting global suffering, left me standing in contemplation for a long time.

Photo 5： 為什麼離開？ Why people leave?

移民抵達美國後要想辦法生存，在美國的各個角落努力，這一年期間，我也聽了許多前輩們的移民故事，真的是一部部的血淚史。現在在全美排名第一的醫院，妙佑醫療國際(Mayo Clinic)，也遇到從中國、中南美洲、非洲、中東、東歐……等來的醫師、研究員，每個人皆非常努力，拚盡全力想要留下來，改變自己的生活。

After arriving in the U.S., immigrants must find a way to survive and work hard in all corners of the country. Over the past year, I’ve heard many immigrant stories from my predecessors—each one a tale of struggle and hardship. At Mayo Clinic, the No. 1 ranked hospital in the U.S., I have met doctors and researchers from China, Latin America, Africa, the Middle East, Eastern Europe, and beyond. Each person is working tirelessly, doing everything they can to stay and transform their lives.

 

Photo 6： 跨國生活. Transnational lives

Photo 7： 元宵節的台灣文化表演，電音三太子. Taiwanese Lantern Festival in 2025.

Photo 8： 來自埃及的朋友，相當努力，每天工作到半夜. My friend, Elgohary Mohamed, an Egyptian, works very hard at Mayo Clinic

Photo 9： 適應生活後成為美國人. Becoming American

幾個月前亦讀了 NIH 的同事，資料科學家、同時也是名作家，Kristen Levine 的書，Little Rock (改編自 阿肯色州小岩城的事件)，談 1957 年代的種族隔離，對於在單一民族國家長大的我而言，完全無法想像有這種事情，看了書很感動，找作者簽名。

A few months ago, I also read a touching book by a colleague at the NIH, Kristen Levine, who is both a data scientist and an author. Her book, The Lions of Little Rock, discusses the racial segregation events of 1957 in Little Rock, Arkansas. Growing up in a country with a single ethnic majority, I could not fathom such events happening.

Photo 10： 名作家 Kristin Levine，同時也是美國國家衛生研究院的資料科學家. A famous author and an excellent data scientist at National Institute of Health

每天送小孩去幼稚園，皆會看到不同膚色、族裔的家長，彼此幫忙打開門、溫暖寒暄，真的是民族的大熔爐，我想這應該是美國所以強大的其中一項原因吧。

Every day when I drop off my child at preschool, I see parents of different ethnicities and skin colors, helping each other hold the door open and exchanging warm greetings. It truly is a great melting pot of cultures, and I believe this is one of the reasons why America is so strong.