Shuo Ju Chiang

Influencing factors on cardiac structure and function beyond glycemic control in patients with type 2 diabetes mellitus

BackgroundWe hypothesized that clinical factors other than glycemic control may influence abnormal cardiac function in patients with type 2 diabetes mellitus (T2DM). We aimed to investigate the independent factors for abnormal cardiac function among clinical factors in T2DM.MethodsWe studied 148 asymptomatic patients with T2DM without overt heart disease. Echocardiographic findings were compared between diabetic patients and 68 age-matched healthy subjects. Early (E) and late (A) diastolic mitral flow velocity and early diastolic mitral annular velocity (e’) were measured for assessing left ventricular (LV) diastolic function. We evaluated insulin resistance, non-esterified fatty acid, high-sensitive CRP, estimated glomerular filtration rate, waist/hip ratio, abdominal visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT) and other clinical characteristics in addition to glycemic control. VAT and SAT were quantified by computed tomography.ResultsIn T2DM, E/A and e’ were significantly lower, and E/e’, left atrial volume and LV mass were significantly greater than in control subjects. In multivariate liner regression analysis, VAT was an independent determinant of left atrial volume (β =0.203, p=0.011), E/A (β =−0.208, p=0.002), e’ (β =−0.354, p<0.001) and E/e’ (β=0.220, p=0.003). Age was also an independent determinant, whereas fasting plasma glucose and hemoglobin A1c levels were not. In addition to systolic blood pressure, waist-hip ratio (β=0.173, p=0.024) and VAT/SAT ratio (β=0.162, p=0.049) were independent determinants of LV mass.ConclusionExcessive visceral fat accompanied by adipocyte dysfunction may play a greater role than glycemic control in the development of diastolic dysfunction and LV hypertrophy in T2DM.

Association between mitral valve prolapse and open-angle glaucoma

Objective Proteoglycans and glycosoaminoglycans play many roles in connective tissue formation, their accumulation in myxomatous tissues may influence the associated mechanical behaviour of the mitral valve, as well as the extracellular matrix of the eye. Open-angle glaucoma (OAG) and mitral valve prolapse (MVP) may share similar phathophysiology. We hypothesised that MVP increased the risk of developing glaucoma. Methods The research was a retrospective cohort study using a longitudinal health insurance database from the National Health Insurance programme. The database was a randomly sampled population of 1 073 891 followed for 13 years from 1996 to 2008. There were 21 677 subjects with MVP, and 86 708 subjects without MVP were propensity score matched and served as a comparison group. Cox proportional hazards analysis was performed and adjusted for several comorbidities to evaluate the adjusted HR for OAG in the MVP group. Results The incidence rate of OAG in patients in the non-MVP and MVP groups were 10.17 and 16.05 per 10 000 person-years, respectively. The adjusted HR for OAG in the MVP group was 1.88 (95% CI 1.58 to 2.23). A significantly elevated risk of OAG in patients with MVP was also identified in the four stratified age groups. The cumulative incidence of OAG was assessed by Kaplan–Meier analysis. The analysis revealed that the MVP group had a higher incidence of OAG than the comparison group during the follow-up period (p<0.001). Conclusions This population-based study demonstrated that pre-existing MVP is a significant predictor for the development of OAG, after adjusting for possible confounding factors.

A telehealth service model for the treatment of hypertension

Summary We evaluated the effectiveness of a home telehealth service in hypertension control. Patients with hypertension were divided into two groups based on the frequency that they measured blood pressure (BP) at home: the regular group made >3 measurements per week and the irregular group made ≤ 20 measurements per month. Both groups were provided with home monitoring equipment (the Citizen Telemedical Care Service System, CTCS) which contained a computer and video communication device. A total of 160 participants were enrolled and 156 completed the 12-month study. There were 101 participants in the regular BP measurement group and 55 in the irregular group. There was a significant reduction in the average systolic BP from baseline after 6 months in the regular group (P < 0.001) and after 1 month in the irregular group (P < 0.001). There was no difference in average diastolic BP between the two groups. For both groups, the systolic BP control was good, especially for irregular group. The results suggest that patients who used CTCS tele-monitoring achieved better BP control than those who self-measured BP at home only.

Significance of Coronary Artery Disease and Left Ventricular Afterload in Unoperated Asymptomatic Aortic Stenosis.

BACKGROUND Because the covariates of cardiovascular events in unoperated patients with asymptomatic aortic stenosis (AS) have not been adequately evaluated, we aimed to identify them. METHODSANDRESULTS A total of 230 patients with asymptomatic severe AS were retrospectively enrolled. The patients were divided into 2 groups based on aortic valve replacement (AVR) after enrollment: a non-AVR group (n=112), and an AVR group (n=118). The primary clinical endpoint was cardiovascular events, which were defined as cardiovascular death or hospitalization. Coronary artery disease [hazard ratio (HR): 3.62, 95% confidence interval (CI): 1.585-8.245, P<0.01] and high valvulo-arterial impedance (HR: 3.08, 95% CI: 1.261-7.532, P<0.05) were identified as independent covariates of cardiovascular events in the non-AVR group. The relative risk of cardiovascular events rose with an increase in the number of risk factors (P<0.0001). CONCLUSIONS In unoperated patients with asymptomatic AS, the presence of coronary artery disease and increased global left ventricular afterload may be associated with a poor prognosis.

Allopurinol, benzbromarone and risk of coronary heart disease in gout patients: A population-based study.

BACKGROUND The effect of gout on the risk of developing coronary artery disease (CAD) is uncertain. Some studies have found that gout is a risk factor for acute myocardial infarction. This study examined the changes in risk of CAD in gout patients taking allopurinol and/or benzbromarone, and analyzed the dose-response relationship of both drugs with CAD incidence. METHODS The medical records of one million subjects from 2000 to 2011 were provided by the Taiwan National Health Insurance Research Database. Cox proportional hazard ratio was used to compare the risk of CAD in gout patients taking allopurinol or/and benzbromarone with those taking neither drug. Hazard ratios (HR) were adjusted for possible confounding factors, including age, gender, hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease, and relevant medications. RESULTS Of 8047 gout patients, 1422 were treated with allopurinol (Group A), 4141 with benzbromarone (Group B), and 2484 with both drugs (Group A/B) during the follow-up period. Our results showed the incidence of CAD after adjusting for covariates for Group A, Group B, and Group A/B did not significantly differ from the comparison group. However, after adjustment for covariates in dose-response analyses, treatment with over 270 defined daily doses (DDDs) of allopurinol, and over 360 DDDs of benzbromarone, was associated with a significantly reduced risk of CAD. CONCLUSION We found that the use of allopurinol and benzbromarone, whether alone or in combination, had a linear dose-response relationship between the numbers of defined daily doses and the risk of CAD, especially in higher DDDs.

When and how aortic stenosis is first diagnosed: A single-center observational study

BACKGROUND The development of clinical symptoms is associated with cardiovascular events in patients with aortic stenosis (AS). Thus, early diagnosis of AS is clinically important. However, there are few data on symptom status or the severity of AS when patients are first diagnosed, or on how AS is detected in routine practice. We aimed to investigate when and how AS patients are first diagnosed in our hospital. METHODS We retrospectively enrolled 198 AS patients diagnosed from 1989 to 2009, and identified their symptoms and AS severity at the time of the first diagnosis. We also assessed the reasons why they came to the hospital based on their medical records. RESULTS Of the 198 patients, 82 (41.6%) had voluntarily visited or been referred to our hospital after developing clinical symptoms (Symptomatic group). The remaining 116 patients (58.4%) had been asymptomatic, and cardiovascular disease was suspected during an annual or occasional health checkup (Asymptomatic group). The initial findings in the Asymptomatic group that led to the diagnosis of AS were: a systolic murmur on auscultation (62%), abnormal electrocardiography (27%), or abnormal echocardiography (11%). The Symptomatic group had significantly greater AS severity and an increased left ventricular mass index, and experienced more cardiac events (valve replacement or cardiac death) during the follow-up period. CONCLUSIONS About 40% of the AS patients in this study were not diagnosed until they developed clinical symptoms, suggesting that many other patients in the community might have a latent risk of cardiovascular events. Auscultation plays an important role in the early diagnosis of AS.

Taipei Smart Medical Package

The aim of Taipei Smart Medical Package is to develop a mobile, low cost and stable telehealth model. The Taipei Smart Medical Package boasted several advantages. First, it supported Linux on SoC (System on a Chip) platform from Intel running on X86 architecture, which ensured stability and saved investment on hardware and software R & D. AA battery combining industrial fanless design reduced maintenance cost. Second, the mobile terminal equipment allowed convenient installation and budget transportation. Third, cloud hosting was an economic, maintenance-saving and effective solution. The program adopted innovative case management by attaching health risk assessment report to out-of-pocket health checkup clients, as a way to enlarge client base and extend service period. In order to understand peoples opinions on the Taipei Smart Medical Package, this study carried out an acceptability questionnaire survey. Those willing to pay for Taipei Smart Medical Package accounted for 20.6 % of the health center clients at the hospital, 27.9 % of the local clinic patients and 51.5% of the electronics shoppers (p<;0.001). Among those willing to pay 84.6% had private insurance; 77.9% had regular health examination (p<;0.001). More than half (55.8%) of the middle class (monthly income at USD967~2,900) were willing to pay for the package. It clearly indicated that a demand existed not only in the higher income population. Our research discovered the advantage of combining insurance and health screening. Collaboration among healthcare facilities, health examination centers and insurance companies is expected to consolidate the market while integration of health screening, ICT and consumer products generates multiple sources of income.

The Citizen Telehealth Care Service model in Taipei: A case study

In this study we developed the integrated model, the Citizen Telemedical Care Service (CTCS) for hypertension based on the smart medical services system for managing chronic disease. A total of 160 participants were collected, of whom 4 (2.5%) withdrew from this study, leaving 156 (97.5%) for further statistical analyses. After controlling for participant socioeconomic characteristics, the odds ratios for high BP still reached a significant level in the sixth month (OR=0.84, p<;.0001), the third month (OR=0.79, p<;.0001) and the first month (OR=0.80, p<;.0001). As for the total BP readings in one month, there was no significant difference between the sixth month and the first month. The overall findings suggested that CTCS Model interventions have shown promise as an effective mode of technologies, and specific health problems. There are implications for incorporating this approach in the treatment for people with chronic health conditions.

Reconsideration of Inferior Vena Cava Parameters for Estimating Right Atrial Pressure in an East Asian Population ― Comparative Simultaneous Ultrasound-Catheterization Study ―

BACKGROUND Ultrasound measurements of the inferior vena cava (IVC) diameter (IVCD), together with its respiratory variation, provide a noninvasive estimate of right atrial pressure (RAP). However, there is a paucity of studies that have compared this technique with simultaneous catheterization. We explored the best cut-off values of IVC parameters for elevated RAP in comparison with RAP measured by catheterization.Methods and Results:We prospectively enrolled 120 East Asian patients who were scheduled for catheterization. The IVCD and IVC collapsibility index (IVCCI) were measured according to the current guidelines. The optimal maximum IVCD (IVCDmax) and IVCCI cut-offs for detecting elevated RAP (RAP ≥10 mmHg) were 17 mm and 40%, respectively. When we combined both in proportion to the guidelines, the sensitivity and specificity for detecting elevated RAP were 75% and 94%, respectively. When the cut-off values from the current guidelines (>21 mm and <50%) were applied, the respective sensitivity and specificity were 42% and 99%. Interestingly, the cut-off value of the optimal IVCDmax indexed by body surface area (11 mm/m2) was similar to previous Western population data. When we combined both cut-off values (11 mm/m2and 40%), the sensitivity and specificity were 75% and 95%, respectively. CONCLUSIONS The optimal absolute IVCDmax and IVCCI cut-offs to detect elevated RAP were smaller than those in the current guidelines. Indexed IVCDmax may be an IVC parameter that can be used internationally.