Publications by authors named "Kuo-Chun Hung"

91 Publications

Long-Term Outcomes of Acute Kidney Injury After Different Types of Cardiac Surgeries: A Population-Based Study.

J Am Heart Assoc 2021 May 21;10(9):e019718. Epub 2021 Apr 21.

Division of Thoracic and Cardiovascular Surgery Department of Surgery Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University Taoyuan City Taiwan.

Background Dialysis-requiring acute kidney injury (D-AKI) is a major complication of cardiovascular surgery that results in worse prognosis. However, the incidence and impacts of D-AKI in different types of cardiac surgeries have not been fully investigated. Methods and Results Patients admitted for cardiovascular surgery between July 1, 2004, and December 31, 2013, were identified from the National Health Insurance Research Database of Taiwan. The patients were grouped into D-AKI (n=3089) and non-D-AKI (n=42 151) groups. The outcome was all-cause mortality and major adverse kidney event. The long-term outcomes were worse in the D-AKI group than the non-D-AKI group (hazard ratio [HR], 3.89; 95% CI, 3.79-3.99 for major adverse kidney event; HR, 2.89; 95% CI, 2.81-2.98 for all-cause mortality). Patients who underwent aortic surgery had higher risk for D-AKI than other types of surgeries, but they were also more likely to recover. The long-term dialysis rate for the patients who recovered from D-AKI was also lowest in those who underwent aortic surgery. Among all types of cardiac surgeries with D-AKI, patients who had heart valve surgery exhibited the greatest risks of all-cause mortality (HR, 6.04; 95% CI, 5.78-6.32). Conclusions Compared with other heart surgeries, aortic surgery resulted in a higher incidence of D-AKI but better renal recovery, better short-term outcome, and lower incidences of long-term dialysis.
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http://dx.doi.org/10.1161/JAHA.120.019718DOI Listing
May 2021

Effects of Fluoroquinolones on Outcomes of Patients With Aortic Dissection or Aneurysm.

J Am Coll Cardiol 2021 Apr;77(15):1875-1887

Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan. Electronic address:

Background: Recent population-based studies have revealed that the use of fluoroquinolones (FQs) is associated with an increased risk of aortic dissection (AD) and aneurysm (AA). However, no evidence is available on whether FQs increase adverse events in patients who had been diagnosed with AD or AA.

Objectives: This study investigated whether the use of FQs increases the risk of aortic-related adverse events and death in this high-risk population.

Methods: A retrospective cohort study was conducted by using the Taiwan National Health Insurance Research Database. A total of 31,570 adult patients who survived after admission for AD or AA between 2001 and 2013 were identified. We divided each calendar year into 6 data units (2 months) for each patient and each year during follow-up. Covariates and exposure of interest (FQs) were reassessed every 2 months. We used another common antibiotic, amoxicillin, as a negative control exposure.

Results: Exposure to FQs was associated with a higher risk of all-cause death (adjusted hazard ratio: 1.61; 95% confidence interval: 1.50 to 1.73), aortic death (adjusted hazard ratio: 1.80; 95% confidence interval: 1.50 to 2.15), and later aortic surgery. However, amoxicillin exposure was not significantly associated with risk of any of the outcomes. A subgroup analysis revealed that the effect of FQs was not significantly different between the AD and AA groups.

Conclusions: Relative to amoxicillin use, FQ exposure in patients with AD or AA was associated with a higher risk of adverse outcomes. FQs should not be used by high-risk patients unless no other treatment options are available.
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http://dx.doi.org/10.1016/j.jacc.2021.02.047DOI Listing
April 2021

Effect of Permanent Pacemaker Implantation After Valve Surgery on Long-Term Outcomes.

Circ J 2021 Mar 19. Epub 2021 Mar 19.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University.

Background: Patients are prone to permanent pacemaker implantation (PPM) after valve surgery, yet current data on the effects of postoperative PPM are scarce and large-scale studies are lacking. The aim of this study was to determine rates and long-term outcomes of PPM after cardiac valve surgery.Methods and Results:A total of 24,014 patients who received valve surgery from 2000 to 2013 were identified from the Taiwan National Health Insurance Research Database. The number of valve surgeries and the proportion of PPM implantations after valve surgery increased (P<0.001). After 1 : 5 propensity score matching, 602 and 3,010 patients were categorized to the PPM and non-PPM groups, respectively. Late outcomes included all-cause mortality, cardiovascular death, sepsis, and readmission due to any cause. The mean follow up was 4.3 years. PPM was associated with a higher all-cause mortality rate (33.6% vs. 29.8%; hazard ratio [HR], 1.14; 95% confidence interval [CI], 0.98-1.32), though not significant at the threshold of P<0.05. PPM was also associated with higher all-cause mortality rates in subgroups that received mitral valve (MV) replacement surgery, combined aortic valve replacement (AVR) with MV surgeries, and combined AVR with tricuspid valve surgeries.

Conclusions: The PPM rate after valve surgery is increasing, and is associated with short-term adverse effects. Patients with PPM may have a higher long-term mortality rate.
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http://dx.doi.org/10.1253/circj.CJ-20-0905DOI Listing
March 2021

Enhanced detection of cardiac arrhythmias utilizing 14-day continuous ECG patch monitoring.

Int J Cardiol 2021 Jun 13;332:78-84. Epub 2021 Mar 13.

Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.

Background: To evaluate the performance of a single‑lead, 14-day continuous electrocardiogram (ECG) patch for the detection of arrhythmias compared to conventional 24-h monitoring.

Methods: This prospective clinical trial enrolled patients suspected of arrhythmias but not diagnosed by 12‑lead ECGs. Each patient underwent a 24-h Holter and 14-day ECG patch simultaneously. Seven types of arrhythmias were classified: supraventricular tachycardia (SVT, repetitive atrial beats >4 beats), irregular SVT without P wave (>4 beats), AF/AFL (irregular SVT without P wave ≥30 s), pause ≥3 s, atrioventricular block (AVB; Mobitz type II, third-degree, two to one or high degree AVB), ventricular tachycardia (VT), and polymorphic VT.

Results: A total of 158 patients were recruited (mean wear time:12.3 ± 3.2 days). The overall arrhythmia detection rate was higher with 14-day ECG patches (59.5%) compared to 24-h Holter (19.0%, P < 0.001). Up to 87.2% of arrhythmias recorded with 14-day ECG patches were not associated with symptoms. The 14-day ECG patch was associated with higher detection rates compared to the 24-h Holter in patients with SVT (52.5% versus 15.8%, P < 0.001), irregular SVT without P wave (12.7% versus 4.4%, P = 0.002), AF/AFL (9.5% versus 3.8%, P = 0.042), and critical arrhythmias (pause ≥3 s, AVB, VT, polymorphic VT) (16.5% versus 2.5%, P < 0.001). The 14-day ECG patch detected more than 2 types of arrhythmias in 5.1% of patients. No serious adverse events in patients wearing the 14-day ECG patch were reported.

Conclusions: The 14-day ECG patch outperformed 24-h Holter to detect overall, asymptomatic, critical and multiple arrhythmias. It is safe and has the potential to identify individuals with hidden arrhythmias, especially those with critical arrhythmias.
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http://dx.doi.org/10.1016/j.ijcard.2021.03.015DOI Listing
June 2021

Level of serum soluble lumican and risks of perioperative complications in patients receiving aortic surgery.

PLoS One 2021 4;16(3):e0247340. Epub 2021 Mar 4.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.

Objective: Several serum biomarkers have been investigated for their potential as diagnostic tools in aortic disease; however, no study has investigated the association between serum biomarkers and outcomes after aortic surgery. This study explored the predictive ability of serum soluble lumican in postoperative outcomes after aortic surgery.

Methods: In total, 58 patients receiving aortic surgery for aortic dissection or aneurysm at Linkou Chang Gung Memorial Hospital in Taiwan in December 2011-September 2018 were enrolled. Blood samples were collected immediately upon patients' arrival in the intensive care unit after aortic surgery. The diagnostic properties of soluble lumican levels were assessed by performing receiver operating characteristic (ROC) curve analysis. The confidence interval (CI) of the area under the ROC curve (AUC) was measured using DeLong's nonparametric method and the optimal cutoff was determined using the Youden index.

Results: The serum soluble lumican level distinguished prolonged ventilation (AUC, 73.5%; 95% CI, 57.7%-89.3%) and hospital stay for >30 days (AUC, 78.2%; 95% CI, 61.6%-94.7%). The optimal cutoffs of prolonged ventilation and hospital stay for >30 days were 1.547 and 5.992 ng/mL, respectively. The sensitivity and specificity were respectively 100% (95% CI, 71.5%-100%) and 40.4% (95% CI, 26.4%-55.7%) for prolonged ventilation and 58% (95% 27.7%-84.8%) and 91.3% (95% CI, 79.2%-97.6%) for hospital stay for >30 days.

Conclusions: The serum soluble lumican level can be a potential prognostic factor for predicting poor postoperative outcomes after aortic surgery. However, more studies are warranted in the future.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247340PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7932520PMC
March 2021

Association of Long-term Use of Antihypertensive Medications With Late Outcomes Among Patients With Aortic Dissection.

JAMA Netw Open 2021 Mar 1;4(3):e210469. Epub 2021 Mar 1.

Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.

Importance: The associations between long-term treatment of aortic dissection with various medications and late patient outcomes are poorly understood.

Objective: To compare late outcomes after long-term use of β-blockers, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or other antihypertensive medications (controls) among patients treated for aortic dissection.

Design, Setting, And Participants: This population-based retrospective cohort study using the National Health Insurance Research Database in Taiwan included 6978 adult patients with a first-ever aortic dissection who survived to hospital discharge during the period between January 1, 2001, and December 31, 2013, and who received during the first 90 days after discharge a prescription for an ACEI, ARB, β-blocker, or at least 1 other antihypertensive medication. Data analysis was conducted from July 2019 to June 2020.

Exposure: Long-term use of β-blockers, ACEIs, or ARBs, with use of other antihypertensive medications as a control.

Main Outcomes And Measures: The primary outcomes of interest were all-cause mortality, death due to aortic aneurism or dissection, later aortic operation, major adverse cardiac and cerebrovascular events, hospital readmission, and new-onset dialysis.

Results: Of 6978 total participants, 3492 received a β-blocker, 1729 received an ACEI or ARB, and 1757 received another antihypertension drug. Compared with patients in the other 2 groups, those in the β-blocker group were younger (mean [SD] age, 62.1 [13.9] years vs 68.7 [13.5] years for ACEIs or ARBs and 69.9 [13.8] years for controls) and comprised more male patients (2520 [72.2%] vs 1161 [67.1%] for ACEIs or ARBs and 1224 [69.7%] for controls). The prevalence of medicated hypertension was highest in the ACEI or ARB group (1039 patients [60.1%]), followed by the control group (896 patients [51.0%]), and was lowest in the β-blocker group (1577 patients [45.2%]). Patients who underwent surgery for type A aortic dissection were more likely to be prescribed β-blockers (1134 patients [32.5%]) than an ACEI or ARB (309 patients [17.9%]) or another antihypertension medication (376 patients [21.4%]). After adjusting for multiple propensity scores, there were no significant differences in any of the clinical characteristics among the 3 groups. No differences in the risks for all outcomes were observed between the ACEI or ARB and β-blocker groups. The risk of all-cause hospital readmission was significantly lower in the ACEI or ARB group (subdistribution hazard ratio [HR], 0.92; 95% CI, 0.84-0.997) and β-blocker group (subdistribution HR, 0.87; 95% CI, 0.81-0.94) than in the control group. Moreover, the risk of all-cause mortality was lower in the ACEI or ARB group (HR, 0.79; 95% CI, 0.71-0.89) and the β-blocker group (HR, 0.82; 95% CI, 0.73-0.91) than in the control group. In addition, the risk of all-cause mortality was lower in the ARB group than in the ACEI group (HR, 0.85; 95% CI, 0.76-0.95).

Conclusions And Relevance: The use of β-blockers, ACEIs, or ARBs was associated with benefits in the long-term treatment of aortic dissection.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.0469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930924PMC
March 2021

Sport disciplines and cardiac remodeling in elite university athletes competing in 2017 Taipei Summer Universiade.

Medicine (Baltimore) 2020 Nov;99(45):e23144

Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.

Cardiac remodeling is common in the athletes. Little data is available regarding the cardiac remodeling on the recently proposed 4 sport disciplines among the elite university athletes.A total of 7639 athletes participated in the 2017 Taipei Summer Universiade. Cardiac evaluation via history, ECG, and echocardiography were performed in 826 athletes who signed up for Check Up Your Heart. Athletes were grouped into one of 4 sport disciplines Skill, Power, Mixed, and Endurance.After excluding 66 participants with missing demographic data, 13 missing echocardiographic data, and 24 inadequate echocardiographic images, a total number of 723 university athletes (mean age 23 ± 3 years, 419 males) from 99 countries engaging in 25 different sporting events were analyzed. Electrocardiograms showed that Endurance group had a slower heart rate and higher percentage of left ventricular (LV) hypertrophy (39%). Echocardiograms showed there were significant differences in LV mass index (P < .001), LV geometry (P < .001), left atrial (LA) dilatation (P = .026), right ventricular (RV) dilatation (P < .001), right atrial (RA) dilatation (P < .0001), and tricuspid annular plane systolic excurse (P = .006). LV ejection fraction, LV strain, RV strain, and LV diastolic function showed no difference in 4 sport disciplines.Eccentric LV hypertrophy was the most common type of cardiac remodeling in the university athletes participated in 2017 Taipei Summer Universiade. Adaptive changes in chamber size were more commonly seen in Endurance sport. RA dilatation was the most sensitive to hemodynamic demand, followed by RV dilatation, LA dilatation, and LV dilatation.
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http://dx.doi.org/10.1097/MD.0000000000023144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647536PMC
November 2020

Nationwide cohort study of tricuspid valve repair versus replacement for infective endocarditis.

Eur J Cardiothorac Surg 2021 Apr;59(4):878-886

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.

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Objectives: The aim of this study was to compare the outcomes of tricuspid valve (TV) repair versus replacement for patients with infective endocarditis (IE).

Methods: In this nationwide population-based cohort study, we identified 704 patients from Taiwan National Health Insurance Research Database who underwent TV surgery due to IE between 2000 and 2013. Of them, 412 (58.5%) underwent TV repair and 292 (41.5%) underwent TV replacement, and their perioperative and late outcomes were analysed. Confounding was reduced using the inverse probability of treatment weighting on propensity score.

Results: After inverse probability of treatment weighting, the in-hospital mortality rate between the 2 groups was not significantly different. However, patients who received TV repair had lower rates of perioperative complications, including massive blood transfusion, de novo dialysis and deep wound infection; longer ICU and hospital stays; and higher hospital cost. Regarding late outcomes, TV repair was associated with lower risks of all-cause readmission [subdistribution hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.60-0.78; P < 0.001], readmission for adverse liver outcomes (subdistribution HR 0.75, 95% CI 0.58-0.97; P = 0.025), new permanent pacemaker implantation (subdistribution HR 0.27, 95% CI 0.15-0.48; P < 0.001) and all-cause mortality (HR 0.60, 95% CI 0.51-0.71; P < 0.001) than TV replacement.

Conclusions: For IE, TV repair is associated with better early and late outcomes than TV replacement. A repair-first strategy is recommended for patients with IE for whom TV surgery is indicated.
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http://dx.doi.org/10.1093/ejcts/ezaa390DOI Listing
April 2021

Codelivery of Sustainable Antimicrobial Agents and Platelet-Derived Growth Factor via Biodegradable Nanofibers for Repair of Diabetic Infectious Wounds.

ACS Infect Dis 2020 10 28;6(10):2688-2697. Epub 2020 Sep 28.

Department of Mechanical Engineering, Chang Gung University, Tao-Yuan 33302, Taiwan.

More than half of diabetic wounds demonstrate clinical signs of infection at presentation and lead to poor outcomes. This work develops coaxial sheath-core nanofibrous poly(lactide--glycolide) (PLGA) scaffolds that are loaded with bioactive antibiotics and platelet-derived growth factor (PDGF) for the repair of diabetic infectious wounds. PDGF and PLGA/antibiotic solutions were pumped, respectively, into two independent capillary tubings for coaxial electrospinning to prepare biodegradable sheath-core nanofibers. Spun nanofibrous scaffolds sustainably released PDGF, vancomycin, and gentamicin for 3 weeks. The scaffolds also reduced the phosphatase and tensin homologue content, enhanced the amount of angiogenesis marker (CD31) around the wound area, and accelerated healing in the early stage of infected diabetic wound repair. Antibiotic/biomolecule-loaded PLGA nanofibers may provide a very effective way to aid tissue regeneration at the sites of infected diabetic wounds.
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http://dx.doi.org/10.1021/acsinfecdis.0c00321DOI Listing
October 2020

The role of Asprosin in patients with dilated cardiomyopathy.

BMC Cardiovasc Disord 2020 09 7;20(1):402. Epub 2020 Sep 7.

Department of Cardiology, Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, 5 Fu-Hsing Street, Taoyuan, 333, Taiwan.

Background: Asprosin is a novel fasting glucogenic adipokine discovered in 2016. Asprosin induces rapid glucose releases from the liver. However, its molecular mechanisms and function are still unclear. Adaptation of energy substrates from fatty acid to glucose is recently considered a novel therapeutic target in heart failure treatment. We hypothesized that the asprosin is able to modulate cardiac mitochondrial functions and has important prognostic implications in dilated cardiomyopathy (DCM) patients.

Methods: We prospectively enrolled 50 patients (86% male, mean age 55 ± 13 years) with DCM and followed their 5-year major adverse cardiovascular events from 2012 to 2017. Comparing with healthy individuals, DCM patients had higher asprosin levels (191.2 versus 79.7 ng/mL, P < 0.01).

Results: During the 5-year follow-up in the study cohort, 16 (32.0%) patients experienced adverse cardiovascular events. Patients with lower asprosin levels (< 210 ng/mL) were associated with increased risks of adverse clinical outcomes with a hazard ratio of 7.94 (95% CI 1.88-33.50, P = 0.005) when compared patients with higher asprosin levels (≥ 210 ng/mL). Using cardiomyoblasts as a cellular model, we showed that asprosin prevented hypoxia-induced cell death and enhanced mitochondrial respiration and proton leak under hypoxia.

Conclusions: In patients with DCM, elevated plasma asprosin levels are associated with less adverse cardiovascular events in five years. The underlying protective mechanisms of asprosin may be linked to its functions relating to enhanced mitochondrial respiration under hypoxia.
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http://dx.doi.org/10.1186/s12872-020-01680-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7487662PMC
September 2020

Corrigendum to 'Outcome of extracorporeal membrane oxygenation support in patients with liver cirrhosis: a nationwide population-based cohort study'.

Eur J Cardiothorac Surg 2020 09;58(3):665

Department of Surgery, Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.

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http://dx.doi.org/10.1093/ejcts/ezaa217DOI Listing
September 2020

Impact of massive blood transfusion during adult extracorporeal membrane oxygenation support on long-term outcomes: a nationwide cohort study in Taiwan.

BMJ Open 2020 06 23;10(6):e035486. Epub 2020 Jun 23.

Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan

Objectives: Bleeding is a common problem during adult extracorporeal membranes oxygenation (ECMO) support, requiring blood transfusion for correction of volume depletion and coagulopathy. The goal of this study is to investigate the long-term outcomes for adults under support of ECMO with massive blood transfusion (MBT).

Design: Retrospective nationwide cohort study.

Setting: Data were provided from Taiwan National Health Insurance Research Database (NHIRD).

Participants And Interventions: Totally 2757 adult patients were identified to receive MBT (red blood cell ≥10 units) during ECMO support from 2000 to 2013 via Taiwan NHIRD.

Main Outcome Measures: The outcomes included in-hospital major complications/mortality, all-cause mortality, cardiovascular death, newly onset end-stage renal disease and respiratory failure during the follow-up period.

Results: Patients with MBT had higher in-hospital mortality (65.6% vs 52.1%; OR 1.74; 95% CI 1.53 to 1.98) and all-cause mortality during the follow-up (47.0% vs 35.8%; HR 1.46; 95% CI 1.25 to 1.71) than those without MBT. Not only higher incidences of post ECMO sepsis, respiratory failure and acute kidney injury, but also longer duration of ECMO support, ventilator use and intensive care unit stay were demonstrated in the MBT group. Moreover, a subdistribution hazard model presented higher cumulative of respiratory failure (19.8% vs 16.2%; subdistribution HR 1.36; 95% CI 1.07 to 1.73) for the MBT cohort. Positive dose-dependent relationship was found between the amount of transfused red blood cell product and in-hospital mortality. In the MBT subgroup analysis for the impact of transfused ratio (fresh frozen plasma/packed red blood cell) on in-hospital mortality, ratio ≥1.0 had higher mortality.

Conclusions: Patients with MBT during ECMO support had worse long-term outcomes than non-MBT population. The transfused amount of red blood cell had positive dose-dependent effect on in-hospital mortality.
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http://dx.doi.org/10.1136/bmjopen-2019-035486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7312286PMC
June 2020

Regulation of autophagy in leukocytes through RNA N-adenosine methylation in chronic kidney disease patients.

Biochem Biophys Res Commun 2020 07 18;527(4):953-959. Epub 2020 May 18.

Department of Cardiology, Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Taiwan.

Patients with chronic kidney diseases have multiple cellular dysfunctions leading to increased atherosclerosis, impaired immunity, and disturbed metabolism. However, it is unclear what is the fundamental signaling served as a marker or as a mediator for the dysregulated function in their leukocytes or tissues. Here we hypothesized that the N-Methyladenosine (mA) modification of the RNA in the leukocytes is responsible for the cellular dysfunction in chronic kidney diseases. Patients with chronic kidney diseases had significantly less mA abundances in leukocytes and elevated RNA demethylase FTO proteins. The uremic toxin, indoxyl sulfate, activated the autophagy flux through modulation of FTO and mA modifications in RNA. Notably, knockdown of FTO or inhibit the mA by 3-deazaadenosine blocks the effects of indoxyl sulfate on autophagy activation in cells. These findings provide new insights into the mechanisms underlying chronic kidney disease-associated cellular dysfunction. Targeting RNA mA modification may be a novel strategy for the treatment of chronic kidney diseases and autophagy.
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http://dx.doi.org/10.1016/j.bbrc.2020.04.138DOI Listing
July 2020

Outcome of extracorporeal membrane oxygenation support in patients with liver cirrhosis: a nationwide population-based cohort study.

Eur J Cardiothorac Surg 2020 09;58(3):519-527

Department of Surgery, Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.

Objectives: Extracorporeal membrane oxygenation (ECMO) is used for life support in patients with liver cirrhosis (LC). However, there have been no studies evaluating the outcome of ECMO support in patients with LC.

Methods: Using Taiwan's National Health Insurance (NHI) database, we retrospectively evaluated patients with LC who received veno-venous or veno-arterial ECMO between 1 January 2000 and 31 December 2013. The outcomes included ECMO-related complications, in-hospital mortality, all-cause mortality and long-term outcomes in patients with and without LC.

Results: A total of 7003 patients who received ECMO, of whom 233 (3.3%) had LC, were eligible for analysis. The LC patients who received ECMO support had a significantly higher risk of in-hospital mortality than the non-LC group (76.4% vs 60.7%; odds ratio 1.97; 95% confidence interval 1.44-2.70). The LC group also had a higher risk of complications, including de novo dialysis and massive blood transfusion with >10 units of red blood cells. Patients ≥65 years of age, patients with respiratory disease, patients with hypoalbuminaemia and liver transplant patients had higher in-hospital and 1-year mortality. The mortality rates for patients with 2 or more risk factors were 90.3% and 95.8%, respectively. LC was associated with a higher incidence of all-cause mortality and liver-related outcomes during follow-up.

Conclusions: Our findings raise questions regarding the utility of ECMO for LC patients, especially when >2 risk factors have been identified. ECMO support for LC patients should be used with caution and with careful patient selection.
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http://dx.doi.org/10.1093/ejcts/ezaa089DOI Listing
September 2020

Nationwide cohort study of outcomes of acute myocardial infarction in patients with liver cirrhosis: A nationwide cohort study.

Medicine (Baltimore) 2020 Mar;99(12):e19575

Department of Cardiology.

Liver cirrhotic predisposes patients to coagulopathy and bleeding. Little is known about outcomes of acute myocardial infarction (AMI) in cirrhotic patients.Data from Taiwan National Health Insurance Research Database during 2001 to 2013 were retrieved for patients admitted with cirrhosis and AMI. We excluded patients with missing information, <20 years old, previous AMI, previous coronary intervention, and liver transplant. Patients were separated into cirrhotic and non-cirrhotic. Primary outcomes included all-cause mortality, recurrent myocardial infarction (MI), major cardiac and cerebrovascular events (MACCE: recurrent MI, revascularization, ischemic stroke, and heart failure), and liver outcomes (hepatic encephalopathy, ascites tapping, spontaneous peritonitis, and esophageal varices bleeding).A total of 3217 cirrhotic patients and 6434 non-cirrhotic patients were analyzed, with a mean follow up of 2.8 ± 3.3 years. In cirrhotic patients with AMI, subsequent coronary and cerebrovascular events were lower in comparison to non-cirrhotic patients, with higher all-cause mortality observed from adverse liver related outcomes and bleeding. There were significantly lower cumulative incidence of both recurrent MI and MACCE in cirrhotic patients with AMI compared with non-cirrhotic patients with AMI (hazard ratio [HR] 0.82, confidence interval [CI] 0.71-0.94, P = .006 and HR 0.86, 95% CI 0.79-0.92, P < .001, respectively). There was significantly higher cumulative incidence of liver related outcome in cirrhotic patients with AMI compared with non-cirrhotic patients with AMI (HR 2.27, 95% CI 2.06-2.51, P < .001). And there was significantly higher all-cause mortality in cirrhotic patients with AMI compared with non-cirrhotic patients with AMI (HR 1.30, 95% CI 1.23-1.38, P < .001).In cirrhotic cohort with AMI, a decreased in coronary and cerebrovascular events were observed. However, these patients also had higher all-cause mortality due to adverse liver outcomes and bleeding.
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http://dx.doi.org/10.1097/MD.0000000000019575DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7220517PMC
March 2020

The effect of pilocarpine on dental caries in patients with primary Sjögren's syndrome: a database prospective cohort study.

Arthritis Res Ther 2019 11 27;21(1):251. Epub 2019 Nov 27.

Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong District, Kaohsiung City, 833, Taiwan.

Background: Primary Sjögren's syndrome (pSS) is associated with dental caries. Pilocarpine, a salivary stimulant, can improve the amount and flow rate of saliva in patients with pSS. This study aimed to assess whether the risk of dental caries decreases with the use of pilocarpine in patients with pSS.

Methods: For this prospective cohort study, we identified pSS patients from the catastrophic illnesses registry of the National Health Insurance Research Database of Taiwan between 2009 and 2013. We divided participants into pilocarpine and non-user groups based on the pilocarpine prescriptions available during the first 3-month follow-up. The primary endpoint was dental caries. The secondary endpoints were periodontitis and oral candidiasis. We compared the risk of these oral manifestations using the Cox proportional hazard model.

Results: A total of 4973 patients with new-onset pSS were eligible for analysis. After propensity score matching, we included 1014 patients in the pilocarpine group and 2028 patients in the non-user group. During the mean follow-up of 2.6 years, the number of events was 487 in the pilocarpine group (48.0%) and 1047 in the non-user group (51.6%); however, the difference was not significant (hazard ratio [HR] 0.93, 95% confidence interval [CI] 0.82 to 1.06). Furthermore, there was no significant difference between groups regarding risk of periodontitis (HR 0.91, 95% CI 0.81 to 1.03) and oral candidiasis (HR 1.16, 95% CI 0.70 to 1.94).

Conclusion: Pilocarpine may have no protective effect on dental caries, periodontitis, or oral candidiasis in patients with pSS.
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http://dx.doi.org/10.1186/s13075-019-2031-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6882320PMC
November 2019

Core-shell insulin-loaded nanofibrous scaffolds for repairing diabetic wounds.

Nanomedicine 2020 02 8;24:102123. Epub 2019 Nov 8.

Department of Mechanical Engineering, Chang Gung University, Tao-Yuan, Taiwan; Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Linkou, Tao-Yuan, Taiwan. Electronic address:

Patients with diabetes mellitus have up to a 15% lifetime risk of non-healing and poorly healing wounds. This work develops core-shell nanofibrous bioactive insulin-loaded poly-D-L-lactide-glycolide (PLGA) scaffolds that release insulin in a sustained manner for repairing wounds in diabetic rats. To prepare the biodegradable core-shell nanofibers, PLGA and insulin solutions were fed into two capillary tubes of different sizes that were coaxially electrospun using two independent pumps. The scaffolds sustainably released insulin for four weeks. The hydrophilicity and water-containing capacity of core-shell nanofibrous insulin/PLGA scaffolds significantly exceeded those of blended nanofibrous scaffolds. The nanofibrous core-shell insulin-loaded scaffold reduced the amount of type I collagen in vitro, increased the transforming growth factor-beta content in vivo, and promoted diabetic would repair. The core-shell insulin-loaded nanofibrous scaffolds prolong the release of insulin and promote diabetic wound healing.
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http://dx.doi.org/10.1016/j.nano.2019.102123DOI Listing
February 2020

Nanofibrous vildagliptin-eluting stents enhance re-endothelialization and reduce neointimal formation in diabetes: in vitro and in vivo.

Int J Nanomedicine 2019 13;14:7503-7513. Epub 2019 Sep 13.

Department of Mechanical Engineering, Chang Gung University, Tao-Yuan, Taiwan.

Background: The high lifetime risk of vascular disease is one of the important issues that plague patients with diabetes mellitus. Systemic oral vildagliptin administration favors endothelial recovery and inhibits smooth muscle cell (SMC) proliferation. However, the localized release of vildagliptin in the diabetic vessel damage has seldom been investigated.

Research Design And Methods: In this work, nanofiber-eluting stents that loaded with vildagliptin, a dipeptidyl peptidase-4 enzyme (DPP-4) inhibitor, was fabricated to treat diabetic vascular disease. To prepare nanofibers, the poly (D,L)-lactide-co-glycolide (PLGA) and vildagliptin were mixed using hexafluoroisopropanol and electrospinning process. In vitro and in vivo release rates of the vildagliptin were characterized using high-performance liquid chromatography.

Results: Effective vildagliptin concentrations were delivered for more than 28 days from the nanofibrous membranes coating on the surface of the stents in vitro and in vivo. The vildagliptin-eluting PLGA membranes greatly accelerated the recovery of diabetic endothelia and reduced SMC hyperplasia. The type I collagen content of the diabetic vascular intimal area that was treated by vildagliptin-eluting stents was lower than that of the non-vildagliptin-eluting group.

Conclusion: The experimental results revealed that stenting with vildagliptin-eluting PLGA membranes could potentially promote healing for diabetic arterial diseases.
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http://dx.doi.org/10.2147/IJN.S211898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6751553PMC
January 2020

Dual antiplatelet therapy in patients with cirrhosis and acute myocardial infarction - A 13-year nationwide cohort study.

PLoS One 2019 3;14(10):e0223380. Epub 2019 Oct 3.

Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan.

Background: Patients with cirrhosis and acute myocardial infarction (AMI) present dilemma whether dual antiplatelet therapy (DAPT) should be used.

Methods: Electronic medical records between 2001-2013 were retrieved from Taiwan National Health Insurance Research Database. Patients were excluded for missing information, age <20 years old, history of AMI, liver transplant, autoimmune disease, coagulopathy, taking DAPT 3 months before index date, follow-up <3 months, anticoagulation user, without DAPT, and events of myocardial infarction (MI), ischemic stroke, major bleeding, and heart failure within 3-month of enrollment. Primary outcomes were 1-year all-cause mortality, recurrent MI, major bleeding, and gastrointestinal bleeding.

Results: A total of 150,887 patients with AMI retrieved. After exclusion criteria and propensity score-matching, 914 cirrhotic and 3,656 non-cirrhotic patients with AMI on DAPT were studied. During 1-year follow-up, there was significantly increased mortality in cirrhotic patients compared to non-cirrhotic patients (HR = 1.49, 95% CI = 1.28-1.74). There was significantly decreased recurrent MI in cirrhotic patients compared to non-cirrhotic patients (subdistribution HR [SHR] = 0.71, 95% CI = 0.54-0.92). However, non-significantly increased major bleeding (SHR = 1.23, 95% CI = 0.87-1.73) and significantly increased gastrointestinal bleeding (SHR = 1.49, 95% CI = 1.31-1.70).

Conclusions: In cirrhotic patients with AMI, DAPT offers benefit with decreased recurrent MI at the expense of increased gastrointestinal bleeding.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0223380PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6776333PMC
March 2020

Selection of β-Blocker in Patients With Cirrhosis and Acute Myocardial Infarction: A 13-Year Nationwide Population-Based Study in Asia.

J Am Heart Assoc 2018 10;7(19):e008982

6 Department of Cardiology Chang Gung Memorial Hospital Chiayi Taiwan.

Background It is not clear whether β-selective or nonselective β-blockers should be used in patients with cirrhosis and acute myocardial infarction. Methods and Results Medical records were retrieved from Taiwan NHIRD (National Health Insurance Research Database) during 2001-2013. Patients were excluded for age <20, previous acute myocardial infarction, contraindication to β-blockers, chronic obstructive pulmonary disease, asthma, or atrioventricular conduction disease. Patients who died during index admission, had a follow-up <6 months, had a medication ratio of either β-selective or nonselective β-blocker <80%, or who switched between β-blockers were also excluded. Patients on β-selective blockers and nonselective β-blockers were propensity score matched and compared for outcome. Primary outcomes were 1- and 2-year cardiovascular events, liver adverse outcomes, and all-cause mortality. A total of 203 595 patients with acute myocardial infarction were enrolled, of whom 6355 had cirrhosis. After screening for exclusion criteria, 1769 patients (655 patients on β-blockers and 1114 patients not on β-blockers) were eligible for analysis. Among patients on β-blockers, propensity score matching was performed, and 218 patients on β-selective blockers and 218 patients on nonselective β-blockers were studied. During a 2-year follow-up, patients on β-selective blockers had significantly fewer major cardiac and cerebrovascular events (hazard ratio=0.62; 95% confidence interval=0.42-0.91; P=0.014), a trend toward lower all-cause mortality (hazard ratio=0.66; 95% confidence interval=0.38-1.14; P=0.135), and nonworsening liver outcome (hazard ratio=0.66; 95% confidence interval=0.38-1.14; P=0.354). Conclusions In patients with cirrhosis and acute myocardial infarction, selecting a β-blocker is a clinical dilemma. Our study showed that the use of β-selective blockers is associated with lower risks of major cardiac and cerebrovascular events.
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http://dx.doi.org/10.1161/JAHA.118.008982DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404872PMC
October 2018

Sutureless aortic bioprosthesis replacement in elderly Asian patients with aortic stenosis: Experience in a single institution.

Biomed J 2018 08 6;41(4):265-272. Epub 2018 Sep 6.

Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan. Electronic address:

Background: Sutureless aortic valve replacement (SU-AVR) has emerged as a promising alternative for the treatment of patients with aortic valve stenosis. This study aims to assess the safety and efficacy of SU-AVR in an elderly Asian population.

Methods: From June 2015 to May 2016, 15 adults with severe aortic stenosis (9 females) with a median age of 79 years underwent Perceval sutureless bioprosthesis (LivaNova, UK) implantation in a single Taiwanese institution; peri-operative recovery, clinical improvement, and valve performance were analyzed.

Results: Three (20%) patients underwent concomitant procedures (coronary artery bypass grafting, 1 patient; maze, 2 patients) and 6/12 (50%) patients underwent J-ministernotomy for isolated SU-AVR. Median cardiopulmonary bypass and cross-clamp time were 105 min and 69 min, respectively. All sutureless bioprosthesis were implanted successfully without conversion to a traditional valve, but 2 patients (13.3%) need intraoperative valve repositioning because of paravalvular leakage. Median extubation time and intensive care unit stay were 5 h and 2 days, respectively. One patient experienced in-hospital mortality due to sudden collapse thought secondary to high degree atrioventricular block. Serial echocardiographic evaluations were performed preoperatively and at 1, 3, and 6 months postoperatively. The final echocardiographic exams showed nothing greater than mild aortic insufficiency and the median mean trans-valvular gradient was 13.2 (range, 6.0-26.3) mmHg.

Conclusions: By simplified procedure and improved hemodynamics, SU-AVR can be implanted safely in elderly Asian population with excellent valvular performance.
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http://dx.doi.org/10.1016/j.bj.2018.04.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6198014PMC
August 2018

Promoting vascular healing using nanofibrous ticagrelor-eluting stents.

Int J Nanomedicine 2018 5;13:6039-6048. Epub 2018 Oct 5.

Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan.

Objective: The current treatment of atherosclerotic coronary heart disease with limus-eluting stents can lead to incomplete endothelialization and substantial impairment of arterial healing relative to treatment with bare-metal stents. The sustained and local delivery of ticagrelor, a reversibly binding P2Y12 receptor inhibitor, using hybrid biodegradable nanofibers/stents, was developed to reduce neointimal formation and endothelial dysfunction.

Methods: In this investigation, a solution of ticagrelor, poly(D,L)-lactide-co-glycolide, and hexafluoro isopropanol was electrospun to fabricate ticagrelor-eluting nanofibrous drug-eluting stents. The in vitro and in vivo ticagrelor concentrations were measured using a high-performance liquid chromatography assay. The effectiveness of ticagrelor-eluting stents was examined relative to that of sirolimus-eluting stents.

Results: Adequate ticagrelor levels were detected for four weeks in vitro. Less HES5-positive labeling was found near the ticagrelor-eluting stented vessels (0.33±0.12) than close to the sirolimus-eluting stented vessels (0.57±0.15) (<0.05). Four weeks after deployment, the ticagrelor-eluting stent also exhibited an up-regulated local expression of SOD1 in the stenting area (<0.001). The ticagrelor-eluting stent substantially preserved endothelial function and re-endothelialization, minimized inflammatory responses, and inhibited neointimal hyperplasia.

Conclusion: Ticagrelor-eluting stents may provide an alternative route for treating patients at a high risk of bleeding to preserve endothelial recovery and to reduce smooth muscle proliferation.
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http://dx.doi.org/10.2147/IJN.S166785DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6179723PMC
November 2018

Excessive irisin increases oxidative stress and apoptosis in murine heart.

Biochem Biophys Res Commun 2018 09 6;503(4):2493-2498. Epub 2018 Jul 6.

Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan. Electronic address:

Irisin is an exercise-related myokine. The abundance of irisin is associated with many diseases, such as myocardial infarction, chronic kidney disease, metabolic syndrome, obesity, and diabetes mellitus. In cardiomyocytes, irisin modulates the mitochondrial thermogenesis, regulates ischemic responses, and affects calcium signaling. Previous studies suggested that irisin increases cardiomyoblast mitochondrial functions and protects ischemic and reperfusion injury in ex vivo murine heart. In human, clinical studies have shown that acute myocardial infarction patients with more elevated serum irisin abundances are associated with increased major adverse cardiovascular events. However, the mechanisms responsible for this discrepancy between in myocardial infarction patients and ex vivo murine heart is unclear. Based on the clinical observations, we hypothesized that excessive irisin might lead to mitochondrial dysfunctions and cardiomyocyte damages. Our data showed that overexpression of irisin in mice with the adenovirus resulted in enhanced mitochondrial respiration with a higher oxygen consumption rate. Enhanced irisin expression in heart and irisin treatment in cardiomyocytes increased reactive oxygen species production. Furthermore, irisin treatment in cardiomyocytes enhanced the apoptosis and the cleaved caspase 9 levels in hypoxic condition. Pathway analysis in the murine heart with the overexpression of irisin showed that angiopoietin-Tie2, IL-8, IL-13, TGF-β, and thrombopoietin signaling were affected by irisin. Collectively, these results supported that excessive irisin causes mitochondrial overdrive with a higher reactive oxygen species production, which results in increased apoptosis of cardiomyocytes in a hypoxic environment.
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http://dx.doi.org/10.1016/j.bbrc.2018.07.005DOI Listing
September 2018

Early Detection of Left Ventricular Diverticulum by Transthoracic Echocardiography.

J Med Ultrasound 2017 Oct-Dec;25(4):232-234. Epub 2017 Sep 8.

Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan.

Left ventricular diverticulum is a very rare entity to be found in adults. Noninvasive echocardiography can offer useful information prior to contrast-enhanced computer tomography or invasive angiography. We evaluated a patient with left ventricular apical diverticulum but complained no symptoms. Transthoracic echocardiography demonstrated a outpouching at left ventricle apex. A 640-slice computed tomography later confirmed the left ventricular diverticulum.
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http://dx.doi.org/10.1016/j.jmu.2017.08.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6029325PMC
September 2017

Serum irisin levels are associated with adverse cardiovascular outcomes in patients with acute myocardial infarction.

Int J Cardiol 2018 06;261:12-17

Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan. Electronic address:

Irisin, a recently identified myokine, regulates mitochondrial function and energy expenditure. The concentration of irisin is significantly altered after ST-elevation myocardial infarction (STEMI). We hypothesized that serum irisin concentration is associated with adverse cardiovascular outcomes after myocardial infarction. Serum irisin concentrations were measured using enzyme-linked immunosorbent assay (ELISA) in 399 patients 28d after the onset of STEMI in a prospective single-center cohort study. We assessed the association between irisin concentrations and adverse cardiovascular events during a 3-year follow-up. The excess risks of cardiovascular mortality, stroke, heart failure, and revascularization were predominantly seen among those with the highest concentrations of irisin, with concentrations higher than 75th percentile of the overall distribution had a ~4-fold increase in risk (hazard ratio=3.96, 95% confidence interval 1.55 to 10.11, P<0.01). Our findings showed that serum concentrations of irisin are elevated in post-STEMI patients with increased risk for adverse cardiovascular events. Novel therapies targeting irisin may represent a new direction in the treatment of STEMI.
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http://dx.doi.org/10.1016/j.ijcard.2017.11.072DOI Listing
June 2018

Novel bifurcation stents coated with bioabsorbable nanofibers with extended and controlled release of rosuvastatin and paclitaxel.

Mater Sci Eng C Mater Biol Appl 2018 Jul 2;88:61-69. Epub 2018 Mar 2.

Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan.

A novel bifurcation stent coated with bioabsorbable nanofibers that deliver the extended and controlled release of rosuvastatin and paclitaxel was developed. Bioabsorbable bifurcation stents, consisting of a double-slit tubular main body and two spiral branches, were manufactured. Bi-layered poly (lactic-co-glycolic acid) nanofibers that contained rosuvastatin and paclitaxel were used for treating the stents. Various properties of the fabricated stents, including compression strengths, collapse pressure, water contact angle and flow properties within a circulation model, were quantified. In vitro nanofibrous elution chromatography assays from the drug-loading bifurcation stents were carried out for the release patterns of pharmaceuticals. The effectiveness of eluted rosuvastatin and paclitaxel in inhibiting the adhesion of platelets as well as the proliferation of smooth muscle cells (SMCs) were studied, respectively. The experimental results suggest that bioabsorbable nanofibrous bifurcation stents released high concentrations of rosuvastatin and paclitaxel for 27 and 70 days, respectively. The eluted drugs of rosuvastatin and paclitaxel effectively reduced adherent platelets and the proliferation of SMCs. The developed bioabsorbable nanofibrous bifurcation stents herein may provide a promising means of treating cardiovascular bifurcation lesions.
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http://dx.doi.org/10.1016/j.msec.2018.02.027DOI Listing
July 2018

Albuminuria and neck circumference are determinate factors of successful accurate estimation of glomerular filtration rate in high cardiovascular risk patients.

PLoS One 2018 2;13(2):e0185693. Epub 2018 Feb 2.

Big Data Research Center, Fu-Jen Catholic University, Taiwan, R.O.C.

Background: Estimated glomerular filtration rate (eGFR) is used for diagnosis of chronic kidney disease (CKD). The eGFR models based on serum creatinine or cystatin C are used more in clinical practice. Albuminuria and neck circumference are associated with CKD and may have correlations with eGFR.

Aim: We explored the correlations and modelling formulates among various indicators such as serum creatinine, cystatin C, albuminuria, and neck circumference for eGFR.

Design: Cross-sectional study.

Methods: We reviewed the records of patients with high cardiovascular risk from 2010 to 2011 in Taiwan. 24-hour urine creatinine clearance was used as the standard. We utilized a decision tree to select for variables and adopted a stepwise regression method to generate five models. Model 1 was based on only serum creatinine and was adjusted for age and gender. Model 2 added serum cystatin C, models 3 and 4 added albuminuria and neck circumference, respectively. Model 5 simultaneously added both albuminuria and neck circumference.

Results: Total 177 patients were recruited in this study. In model 1, the bias was 2.01 and its precision was 14.04. In model 2, the bias was reduced to 1.86 with a precision of 13.48. The bias of model 3 was 1.49 with a precision of 12.89, and the bias for model 4 was 1.74 with a precision of 12.97. In model 5, the bias could be lower to 1.40 with a precision of 12.53.

Conclusions: In this study, the predicting ability of eGFR was improved after the addition of serum cystatin C compared to serum creatinine alone. The bias was more significantly reduced by the calculation of albuminuria. Furthermore, the model generated by combined albuminuria and neck circumference could provide the best eGFR predictions among these five eGFR models. Neck circumference can be investigated potentially in the further studies.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0185693PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5796684PMC
March 2018

Comparison of cardiovascular outcomes and all-cause mortality in patients with chronic hepatitis B and C: A 13-year nationwide population-based study in Asia.

Atherosclerosis 2018 02 12;269:178-184. Epub 2018 Jan 12.

Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Chiayi, Taiwan.

Background And Aims: Viral hepatitis infection has been linked to increased atherosclerosis. We therefore investigated cardiovascular outcomes in patients with hepatitis B virus (HBV) and hepatitis C virus (HCV) infection.

Methods: Electronic medical records during 2000-2012 were retrieved from the Taiwan National Health Insurance Research Database. Exclusion criteria were age <18, history of coexisting HBV and HCV infection, acute coronary syndrome, coronary intervention, venous thromboembolism, peripheral artery disease, stroke, major or gastrointestinal bleeding, malignancy, and a follow-up period <180 days. Patients with HBV and HCV infection were propensity-matched then compared for outcomes. Primary outcomes were cardiovascular events at the 1-year follow-up, 3-year follow-up, 5-year follow-up, and at the end of follow-up.

Results: 41,554 patients with diagnosis of HBV or HCV were retrieved from 2000 to 2012. After exclusion criteria, 31,943 patients were eligible for analysis and propensity score matched. The study population consisted of 6030 patients with HBV infection and 6030 patients with HCV infection. Risk of composite arterial events (acute coronary syndrome, peripheral artery disease, and acute ischemic stroke) was significantly higher in patients with HCV infection compared with patients with HBV infection (p = 0.012 at 5-year follow-up and p = 0.003 at the end of follow-up). All-cause mortality was significantly higher in patients with HCV infection compared with patients with HBV infection (p < 0.001 at 3-year follow-up, 5-year follow-up, and at the end of follow-up).

Conclusions: In patients with chronic viral hepatitis, subjects with HCV infection had a significantly higher risk of composite arterial events and all-cause mortality compared with those with HBV infection.
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http://dx.doi.org/10.1016/j.atherosclerosis.2018.01.007DOI Listing
February 2018

Clinical outcomes of peripartum cardiomyopathy: a 15-year nationwide population-based study in Asia.

Medicine (Baltimore) 2017 Oct;96(43):e8374

Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City Department of Cardiology, Chang Gung Memorial Hospital, Keelung Divison of Cardiology, Weill Cornell Medical Center, New York, NY Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City Department of Rehabilitation, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City Department of Infectious Diseases, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City Department of Nephrology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City College of Medicine, Chang Gung University, Taoyuan City, Taiwan.

Peripartum cardiomyopathy (PPCM) is the development of heart failure during late pregnancy to months postpartum with potential fatal outcome. However, the disease is not well-studied in Asia.We aimed to investigate the epidemiology and clinical outcomes of PPCM in Taiwan.Electronic medical records were retrieved from Taiwan National Health Insurance Research Database from 1997 to 2011. Patients with PPCM were separated into 3 groups based on the timing of diagnosis. Early: PPCM diagnosed first to ninth month of pregnancy. Traditional: PPCM diagnosed last month of pregnancy till fifth month post-delivery. Late: PPCM diagnosed sixth to twelfth month post-delivery. Primary outcomes defined as cardiac death, all-cause mortality, and major adverse cardiovascular events (MACE) within 1 year.A total of 3,506,081 deliveries during 1997 to 2011 were retrieved and 925 patients with PPCM were identified. Overall incidence of PPCM was 1:3,790 during the 15 years. Early, Traditional, and Late group each had 88, 742, and 95 patients. Cardiac death occurred in 31 patients, all-cause mortality in 72 patients, and MACE in 65 patients. Late group had 2- to 3-fold event rates in cardiac death, all-cause mortality, and MACE compared with Early and Traditional groups. Cumulative incidence showed significant differences for cardiac death (P = .0011), all-cause mortality (P = .0031), and MACE (P = .0014) among 3 groups. Multivariate Cox model showed Late group had significantly worse outcomes after adjusted for clinical variables compared with 2 other groups.Our study is the largest national cohort among Asian countries that showed timing of diagnosis of PPCM had different outcomes. Late diagnosis portended significantly increased morbidity and mortality, even after adjusted for clinical variables.
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http://dx.doi.org/10.1097/MD.0000000000008374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5671863PMC
October 2017