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Odden M, Lee S, Steinman M, Rubinsky A, Jing B, Fung K, Graham L, Peralta C. Deprescribing Blood Pressure Treatment in VA Long-Term Care Residents. Innov Aging 2021. [PMCID: PMC8680287 DOI: 10.1093/geroni/igab046.1293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
There is growing interest in deprescribing of antihypertensive medications in response to adverse effects, or when a patient’s situation evolves such that the benefits are outweighed by the harms. We conducted a retrospective cohort study to evaluate the incidence and predictors of deprescribing of antihypertensive medication among VA long-term care residents ≥ 65 years admitted between 2006 and 2017. Data were extracted from the VA electronic health record, CMS Minimum Data Set, and Bar Code Medication Administration. Deprescribing was defined as a reduction in the number of antihypertensive medications, sustained for 2 weeks. Potentially triggering events for deprescribing included low blood pressure (<90/60 mmHg), acute renal impairment (creatinine increase of 50%), electrolyte imbalance (potassium below 3.5 mEq/L, sodium decrease by 5 mEq/L), and fall in the past 30 days. Among 22,826 VA nursing home residents on antihypertensive medication, 57% had describing event during their stay (median length of stay = 6 months). Deprescribing events were most common in the first 4 weeks after admission and the last 4 weeks of life. Among potentially triggering events, acute renal impairment was associated with greatest increase in the likelihood of deprescribing over the subsequent 4 weeks: among residents with this event, 32.7% were described compared to 7.3% in those without (risk difference = 25.5%, p<0.001). Falls were associated with the smallest increased risk of deprescribing (risk difference = 2.1%, p<0.001) of the events considered. Deprescribing of antihypertensive medications is common among VA nursing home residents, especially after a potential renal adverse event.
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Liu X, Lee S, Steinman M, Graham L, Li Y, Jing B, Odden M. Blood Pressure Control and Cardiovascular and Mortality Risk in VA Nursing Home Residents. Innov Aging 2021. [PMCID: PMC8680779 DOI: 10.1093/geroni/igab046.2320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Optimal blood pressure (BP) control in nursing home residents is controversial and this population has been excluded from trials. We evaluated the associations of BP level with cardiovascular (CV) events and all-cause mortality across antihypertensive medication categories in Veterans Affairs (VA) nursing home residents. Data for 18,589 residents aged 65 years and older was obtained from the VA Corporate Data Warehouse from October 2006 through September 2017. Baseline systolic BP (SBP) and diastolic BP (DBP) were divided into categories and analyses were stratified by antihypertensive therapy (0, 1, and ≥2 medications). Over a median follow-up of 1.8 years, CV events occurred in 3,519 (19%) residents and 15,897 (86%) residents died. In participants on no BP medications, high SBP (>150 mmHg) was associated with a greater risk of CV events (adjusted [cause-specific] hazard ratio, 1.39; 95% confidence interval, 0.94-2.06) compared with normal SBP (110-130mmHg). By contrast, in participants on ≥2 BP medications, the subgroup with low SBP (<110 mmHg) had a higher CV risk (1.38; 1.20-1.57). For DBP, in participants without BP medications, there were no differences in CV risk across DBP subgroups. Whereas among those on 1 or ≥2 medications, DBP <60 mmHg was associated with a higher CV risk (1.26; 1.03-1.55 and 1.35; 1.18-1.54, respectively) compared with normal DBP (70-80 mmHg). Participants with low SBP (<110 mmHg) and DBP (<70 mmHg) had an increased mortality risk regardless of the number of medications. These findings suggest a potential risk of low BP among nursing home residents on multiple antihypertensive medications.
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Anderson TS, Lee AK, Jing B, Lee S, Herzig SJ, Boscardin WJ, Fung K, Rizzo A, Steinman MA. Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System. JAMA Netw Open 2021; 4:e2128998. [PMID: 34673963 PMCID: PMC8531994 DOI: 10.1001/jamanetworkopen.2021.28998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
IMPORTANCE Transient elevations of blood glucose levels are common in hospitalized older adults with diabetes and may lead clinicians to discharge patients with more intensive diabetes medications than they were using before hospitalization. OBJECTIVE To investigate outcomes associated with intensification of outpatient diabetes medications at discharge. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed patients 65 years and older with diabetes not taking insulin who were hospitalized in the Veterans Health Administration Health System between January 1, 2011, and September 28, 2016, for common medical conditions. Data analysis was performed from January 1, 2020, to March 31, 2021. EXPOSURE Discharge with intensified diabetes medications, defined as filling a prescription at hospital discharge for a new or higher-dose medication than was being used before hospitalization. Propensity scores were used to construct a matched cohort of patients who did and did not receive diabetes medication intensifications. MAIN OUTCOMES AND MEASURES Coprimary outcomes of severe hypoglycemia and severe hyperglycemia were assessed at 30 and 365 days using competing risk regressions. Secondary outcomes included all-cause readmissions, mortality, change in hemoglobin A1c (HbA1c) level, and persistent use of intensified medications at 1 year after discharge. RESULTS The propensity-matched cohort included 5296 older adults with diabetes (mean [SD] age, 73.7 [7.7] years; 5212 [98.4%] male; and 867 [16.4%] Black, 47 [0.9%] Hispanic, 4138 [78.1%] White), equally split between those who did and did not receive diabetes medication intensifications at hospital discharge. Within 30 days, patients who received medication intensifications had a higher risk of severe hypoglycemia (hazard ratio [HR], 2.17; 95% CI, 1.10-4.28), no difference in risk of severe hyperglycemia (HR, 1.00; 95% CI, 0.33-3.08), and a lower risk of death (HR, 0.55; 95% CI, 0.33-0.92). At 1 year, no differences were found in the risk of severe hypoglycemia events, severe hyperglycemia events, or death and no difference in change in HbA1c level was found among those who did vs did not receive intensifications (mean postdischarge HbA1c, 7.72% vs 7.70%; difference-in-differences, 0.02%; 95% CI, -0.12% to 0.16%). At 1 year, 48.0% (591 of 1231) of new oral diabetes medications and 38.5% (548 of 1423) of new insulin prescriptions filled at discharge were no longer being filled. CONCLUSIONS AND RELEVANCE In this national cohort study, among older adults hospitalized for common medical conditions, discharge with intensified diabetes medications was associated with an increased short-term risk of severe hypoglycemia events but was not associated with reduced severe hyperglycemia events or improve HbA1c control. These findings indicate that short-term hospitalization may not be an effective time to intervene in long-term diabetes management.
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Odden MC, Lee SJ, Steinman MA, Rubinsky AD, Graham L, Jing B, Fung K, Marcum ZA, Peralta CA. Deprescribing Blood Pressure Treatment in Long-Term Care Residents. J Am Med Dir Assoc 2021; 22:2540-2546.e2. [PMID: 34364847 DOI: 10.1016/j.jamda.2021.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/06/2021] [Accepted: 07/10/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To evaluate the incidence of deprescribing of antihypertensive medication among older adults residing in Veterans Affairs (VA) nursing homes for long-term care and rates of deprescribing after potentially triggering events. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Long-term care residents aged 65 years and older admitted to a VA nursing home from 2006 to 2019 and using blood pressure medication at admission. METHODS Data were extracted from the VA electronic health record, and Centers for Medicare & Medicaid Services Minimum Data Set and Bar Code Medication Administration. Deprescribing was defined on a rolling basis as a reduction in the number or dose of antihypertensive medications, sustained for ≥2 weeks. We examined potentially triggering events for deprescribing, including low blood pressure (<90/60 mmHg), acute renal impairment (creatinine increase of 50%), electrolyte imbalance (potassium below 3.5 mEq/L, sodium decrease by 5 mEq/L), and falls. RESULTS Among 31,499 VA nursing home residents on antihypertensive medication, 70.4% had ≥1 deprescribing event (median length of stay = 6 months), and 48.7% had a net reduction in antihypertensive medications over their stay. Deprescribing events were most common in the first 4 weeks after admission and the last 4 weeks of life. Among potentially triggering events, a 50% increase in serum creatinine was associated with the greatest increase in the likelihood of deprescribing over the subsequent 4 weeks: residents with this event had a 41.7% chance of being deprescribed compared with 11.5% in those who did not (risk difference = 30.3%, P < .001). A fall in the past 30 days was associated with the smallest magnitude increased risk of deprescribing (risk difference = 3.8%, P < .001) of the events considered. CONCLUSIONS AND IMPLICATIONS Deprescribing of antihypertensive medications is common among VA nursing home residents, especially after a potential renal adverse event.
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Lee A, Jing B, Jeon SY, Boscardin J, Lee S. Predicting Life Expectancy Using Veterans Affairs Electronic Health Record Data. Innov Aging 2020. [PMCID: PMC7740909 DOI: 10.1093/geroni/igaa057.561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Electronic health records (EHRs) are a rich source of health data that could be used to create individualized life expectancy predictions to aid in clinical decision-making for long-term preventative treatments, such as cancer screening. Few previous studies have incorporated all possible predictors from the EHR. We aimed to screen and incorporate a large number of possible predictors from EHR data into a life expectancy (LE) prediction equation. Using the national Veteran’s Affairs (VA) EHR databases, we identified all patients aged 50+ with a primary care visit during 2005 and assessed demographics, diseases, medications, laboratory results, healthcare utilization, and vital signs during the one year prior to the visit. Mortality follow-up was complete through 2017. We used an 80% random sample for model development and a 20% random sample for model validation. We used a Gompertz survival model with backwards selection to identify approximately 100 variables for the final LE prediction equation. In 1,263,595 VA patients, the mean age was 68 years and the majority were male (94%) and white (87%). During 12 years of follow-up, 602,576 (47.7%) died. Of 930 predictors from the EHR, 99 were included in the LE prediction equation. Harrell’s C-statistic was 0.7705 (95%CI: 0.7693, 0.7718). The model estimated 10-year life expectancy with sensitivity of 81.6% (81.4%, 81.8%) and specificity of 68.8% (68.5%, 69.1%). In conclusion, we developed an LE prediction equation from hundreds of predictors in the VA EHR with good discrimination and calibration that may help clinicians weigh the potential benefit of long-term preventative treatments.
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Lam K, Gan S, Jing B, Nguyen B, Lee S. A Wasteful and Harmful Practice: Sliding Scale Insulin Use Among Nursing Home Veterans. Innov Aging 2020. [PMCID: PMC7740958 DOI: 10.1093/geroni/igaa057.665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The American Medical Directors Association and the American Diabetes Association discourage the use of sliding scale insulin (SSI) in nursing home residents with diabetes due to its association with hypoglycemia, hyperglycemia, nursing burden, and patient discomfort. However, prevalence of SSI use is unclear. We used Veterans Affairs (VA) data from October 2013 to September 2016 to determine the weekly prevalence of SSI among 22,847 veterans with diabetes admitted to VA nursing homes (NHs). Average age was 75.3 (SD 8.3) years, mean A1c was 7.3% (SD 1.6%) and 57% were admitted from hospital. We first identified residents receiving any short-acting insulin. We then classified short-acting insulin use into three mutually exclusive regimens: (1) fixed scheduled doses, (2) SSI, defined as a variable dose of short-acting insulin without a concurrent fixed dose or (3) bolus with correction (BWC), defined as a variable dose given concurrently with a fixed dose that day. During the first week of NH admission, 64.7% of residents with diabetes received no short-acting insulin, 7.4% received fixed scheduled doses, 6.3% received BWC and 21.4% were on SSI. At week 12, the prevalence of fixed dose and BWC regimens was unchanged from baseline (fixed dose = 8.4%; BWC = 7.0%). In contrast, the prevalence of SSI decreased weekly to 15.8% (p for linear trend < 0.0001). Although SSI prevalence decreased from week 1 to week 12, 51% of residents on short-acting insulin were still using SSI in their 12th week of their NH stay.
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Ya X, Qian W, Huiqing L, Haixiao W, Weiwei Z, Jing B, Lei C, Jianping Y, Shuping Y, Jiaya M, Dong W, Ruixia G. Role of carbon nanoparticle suspension in sentinel lymph node biopsy for early-stage cervical cancer: a prospective study. BJOG 2020; 128:890-898. [PMID: 32930483 DOI: 10.1111/1471-0528.16504] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To evaluate the clinical diagnostic validity of carbon nanoparticle suspension (CNS) in sentinel lymph node biopsy (SLNB) for assessing lymphatic spread of early-stage cervical cancer. DESIGN A prospective study. SETTING AND POPULATION 356 cases. METHODS We enrolled 356 stage Ia2-IIa2 cervical cancer patients to undergo SLNB using CNS, followed by systematic pelvic lymphadenectomy. All lymph node specimens were assessed using conventional histopathologic ± pathologic ultrastaging analyses. MAIN OUTCOME MEASURES Sentinel lymph node detection rate (DR), clinical diagnostic validity and various related factors were analysed. RESULTS CNS identified 1456 SLNs in 325 patients. The overall SLN DR was 91.29%. A significantly higher DR was found for patients with tumours <20 mm (97.75% versus 71.91%; P < 0.001). Two patients had false-negative results. SLNB with CNS had sensitivity of 96.65%, false-negative rate (FNR) of 4.35% and negative predictive value (NPV) of 99.29%. Importantly, sensitivity (100%), NPV (100%) and FNR (0%) were improved when testing the subgroup of patients with tumours <20 mm (267 cases). There were no observed differences in DR based on pathological type or grade, stage, depth of stromal invasion, surgical approach, menopausal status or prior treatment with chemotherapy (P > 0.05). CONCLUSIONS Sentinel lymph node biopsy with CNS results in favourable DR, sensitivity and NPV for women with early-stage cervical cancer with small tumour sizes. SLNB with CNS is safe, feasible and relatively effective for guiding precise surgical treatment of early-stage cervical cancer. TWEETABLE ABSTRACT Sentinel lymph node biopsy with carbon nanoparticle suspension is safe and feasible for early-stage cervical cancer.
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Tang VL, Jing B, Boscardin J, Ngo S, Silvestrini M, Finlayson E, Covinsky KE. Association of Functional, Cognitive, and Psychological Measures With 1-Year Mortality in Patients Undergoing Major Surgery. JAMA Surg 2020; 155:412-418. [PMID: 32159753 PMCID: PMC7066523 DOI: 10.1001/jamasurg.2020.0091] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/16/2020] [Indexed: 01/12/2023]
Abstract
Importance More older adults are undergoing major surgery despite the greater risk of postoperative mortality. Although measures, such as functional, cognitive, and psychological status, are known to be crucial components of health in older persons, they are not often used in assessing the risk of adverse postoperative outcomes in older adults. Objective To determine the association between measures of physical, cognitive, and psychological function and 1-year mortality in older adults after major surgery. Design, Setting, and Participants Retrospective analysis of a prospective cohort study of participants 66 years or older who were enrolled in the nationally representative Health and Retirement Study and underwent 1 of 3 types of major surgery. Exposures Major surgery, including abdominal aortic aneurysm repair, coronary artery bypass graft, and colectomy. Main Outcomes and Measures Our outcome was mortality within 1 year of major surgery. Our primary associated factors included functional, cognitive, and psychological factors: dependence in activities of daily living (ADL), dependence in instrumental ADL, inability to walk several blocks, cognitive status, and presence of depression. We adjusted for other demographic and clinical predictors. Results Of 1341 participants, the mean (SD) participant age was 76 (6) years, 737 (55%) were women, 99 (7%) underwent abdominal aortic aneurysm repair, 686 (51%) coronary artery bypass graft, and 556 (42%) colectomy; 223 (17%) died within 1 year of their operation. After adjusting for age, comorbidity burden, surgical type, sex, race/ethnicity, wealth, income, and education, the following measures were significantly associated with 1-year mortality: more than 1 ADL dependence (29% vs 13%; adjusted hazard ratio [aHR], 2.76; P = .001), more than 1 instrumental ADL dependence (21% vs 14%; aHR, 1.32; P = .05), the inability to walk several blocks (17% vs 11%; aHR, 1.64; P = .01), dementia (21% vs 12%; aHR, 1.91; P = .03), and depression (19% vs 12%; aHR, 1.72; P = .01). The risk of 1-year mortality increased within the increasing risk factors present (0 factors: 10.0%; 1 factor: 16.2%; 2 factors: 27.8%). Conclusions and Relevance In this older adult cohort, 223 participants (17%) who underwent major surgery died within 1 year and poor function, cognition, and psychological well-being were significantly associated with mortality. Measures in function, cognition, and psychological well-being need to be incorporated into the preoperative assessment to enhance surgical decision-making and patient counseling.
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Anderson TS, Lee S, Jing B, Fung K, Ngo S, Silvestrini M, Steinman MA. Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals. JAMA Netw Open 2020; 3:e201511. [PMID: 32207832 PMCID: PMC7093767 DOI: 10.1001/jamanetworkopen.2020.1511] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/24/2020] [Indexed: 01/08/2023] Open
Abstract
Importance Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home. Objective To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications. Design, Setting, and Participants This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013. Main Outcomes and Measures Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics. Results Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A1c (HbA1c) level less than 7.0%, and 1044 (6%) had an HbA1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA1c, while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels. Conclusions and Relevance In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA1c goal.
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Tang VL, Covinsky K, Finlayson E, Jing B, Boscardin J, Ngo S. GERIATRIC MEASURES AS PREDICTORS OF 1-YEAR MORTALITY IN MAJOR SURGERY PATIENTS. Innov Aging 2019. [PMCID: PMC6840257 DOI: 10.1093/geroni/igz038.1670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A growing proportion of older adults are undergoing major surgery despite the higher risk of post-operative mortality. Geriatric measures (i.e. physical, cognitive, and psychosocial function) are often not included in studies evaluating post-operative outcomes in older adults. Our goal was to determine the association of geriatric measures and 1-year mortality in older adults after major surgery. We analyzed longitudinal data from the Health and Retirement Study linked to Medicare claims (N=1364 participants), age ≥ 65 and who underwent abdominal aortic aneurysm [AAA] repair, coronary artery bypass graft [CABG], or colectomy. Our outcome was mortality within 1 year of the major operation. Predictors included the following geriatric measures: dependence in activities of daily living (ADL), dependence in independent activities of daily living (IADL), mobility ability, and dementia, and depression. We analyzed using multivariate cox proportional hazard models. Mean participant age was 76±6 years, 56% were women, 11% underwent a AAA repair, 50% CABG, 40% colectomy; 18% died within 1 year of their major operation. After adjusting for age, comorbidity burden, surgical type, gender, race, wealth, income, and education, the following measures were significantly associated with 1-year mortality: depression (adjusted HR (aHR): 1.53, p=0.03), dementia (aHR: 1.90, p=0.03), >1 ADL dependence (aHR: 2.35, p<0.01), >1 IADL dependence (aHR: 1.95, p<0.01), and inability to walk several blocks (aHR: 1.69, p<0.01). In this cohort, 18% of participants who underwent major surgery died within 1 year and function, cognition, and psychological well-being were significantly associated with mortality. These measures should be incorporated into pre-operative assessment.
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Anderson TS, Jing B, Auerbach A, Wray CM, Lee S, Boscardin WJ, Fung K, Ngo S, Silvestrini M, Steinman MA. Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge. JAMA Intern Med 2019; 179:1528-1536. [PMID: 31424475 PMCID: PMC6705136 DOI: 10.1001/jamainternmed.2019.3007] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE Transient elevations of blood pressure (BP) are common in hospitalized older adults and frequently lead practitioners to prescribe more intensive antihypertensive regimens at hospital discharge than the patients were using before hospitalization. OBJECTIVE To investigate the association between intensification of antihypertensive regimens at hospital discharge and clinical outcomes after discharge. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, patients 65 years and older with hypertension who were hospitalized in Veterans Health Administration national health system facilities from January 1, 2011, to December 31, 2013, for common noncardiac conditions were studied. Data analysis was performed from October 1, 2018, to March 10, 2019. EXPOSURES Discharge with antihypertensive intensification, defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive than was being used before hospitalization. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not receive antihypertensive intensifications at hospital discharge. MAIN OUTCOMES AND MEASURES The primary outcomes of hospital readmission, serious adverse events, and cardiovascular events were assessed by competing risk analysis. The secondary outcome was the change in systolic BP within 1 year of hospital discharge. RESULTS The propensity-matched cohort included 4056 hospitalized older adults with hypertension (mean [SD] age, 77 [8] years; 3961 men [97.7%]), equally split between those who did vs did not receive antihypertensive intensifications at hospital discharge. Groups were well matched on all baseline covariates (all standardized mean differences <0.1). Within 30 days, patients receiving intensifications had a higher risk of readmission (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; number needed to harm [NNH], 27; 95% CI, 16-76) and serious adverse events (HR, 1.41; 95% CI, 1.06-1.88; NNH, 63; 95% CI, 34-370). At 1 year, no differences were found in cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in systolic BP among those who did vs did not receive intensifications (mean BP, 134.7 vs 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, -2.4 to 3.7 mm Hg). CONCLUSIONS AND RELEVANCE Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.
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Anderson TS, Jing B, Wray CM, Ngo S, Xu E, Fung K, Steinman MA. Comparison of Pharmacy Database Methods for Determining Prevalent Chronic Medication Use. Med Care 2019; 57:836-842. [PMID: 31464843 PMCID: PMC6742560 DOI: 10.1097/mlr.0000000000001188] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pharmacy dispensing data are frequently used to identify prevalent medication use as a predictor or covariate in observational research studies. Although several methods have been proposed for using pharmacy dispensing data to identify prevalent medication use, little is known about their comparative performance. OBJECTIVES The authors sought to compare the performance of different methods for identifying prevalent outpatient medication use. RESEARCH DESIGN Outpatient pharmacy fill data were compared with medication reconciliation notes denoting prevalent outpatient medication use at the time of hospital admission for a random sample of 207 patients drawn from a national cohort of patients admitted to Veterans Affairs hospitals. Using reconciliation notes as the criterion standard, we determined the test characteristics of 12 pharmacy database algorithms for determining prevalent use of 11 classes of cardiovascular and diabetes medications. RESULTS The best-performing algorithms included a 180-day fixed look-back period approach (sensitivity, 93%; specificity, 97%; and positive predictive value, 89%) and a medication-on-hand approach with a grace period of 60 days (sensitivity, 91%; specificity, 97%; and positive predictive value, 91%). Algorithms that have been commonly used in previous studies, such as defining prevalent medications to include any medications filled in the prior year or only medications filled in the prior 30 days, performed less well. Algorithm performance was less accurate among patients recently receiving hospital or nursing facility care. CONCLUSION Pharmacy database algorithms that balance recentness of medication fills with grace periods performed better than more simplistic approaches and should be considered for future studies which examine prevalent chronic medication use.
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Anderson TS, Wray CM, Jing B, Fung K, Ngo S, Xu E, Shi Y, Steinman MA. Intensification of older adults' outpatient blood pressure treatment at hospital discharge: national retrospective cohort study. BMJ 2018; 362:k3503. [PMID: 30209052 PMCID: PMC6283373 DOI: 10.1136/bmj.k3503] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To assess how often older adults admitted to hospital for common non-cardiac conditions were discharged with intensified antihypertensive treatment, and to identify markers of appropriateness for these intensifications. DESIGN Retrospective cohort study. SETTING US Veterans Administration Health System. PARTICIPANTS Patients aged 65 years or over with hypertension admitted to hospital with non-cardiac conditions between 2011 and 2013. MAIN OUTCOME MEASURES Intensification of antihypertensive treatment, defined as receiving a new or higher dose antihypertensive agent at discharge compared with drugs used before admission. Hierarchical logistic regression analyses were used to control for characteristics of patients and hospitals. RESULTS Among 14 915 older adults (median age 76, interquartile range 69-84), 9636 (65%) had well controlled outpatient blood pressure before hospital admission. Overall, 2074 (14%) patients were discharged with intensified antihypertensive treatment, more than half of whom (1082) had well controlled blood pressure before admission. After adjustment for potential confounders, elevated inpatient blood pressure was strongly associated with being discharged on intensified antihypertensive regimens. Among patients with previously well controlled outpatient blood pressure, 8% (95% confidence interval 7% to 9%) of patients without elevated inpatient blood pressure, 24% (21% to 26%) of patients with moderately elevated inpatient blood pressure, and 40% (34% to 46%) of patients with severely elevated inpatient blood pressure were discharged with intensified antihypertensive regimens. No differences were seen in rates of intensification among patients least likely to benefit from tight blood pressure control (limited life expectancy, dementia, or metastatic malignancy), nor in those most likely to benefit (history of myocardial infarction, cerebrovascular disease, or renal disease). CONCLUSIONS One in seven older adults admitted to hospital for common non-cardiac conditions were discharged with intensified antihypertensive treatment. More than half of intensifications occurred in patients with previously well controlled outpatient blood pressure. More attention is needed to reduce potentially harmful overtreatment of blood pressure as older adults transition from hospital to home.
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Petrillo LA, Gan S, Jing B, Lang-Brown S, Boscardin WJ, Lee SJ. Hypoglycemia in Hospice Patients With Type 2 Diabetes in a National Sample of Nursing Homes. JAMA Intern Med 2018; 178:713-715. [PMID: 29279891 PMCID: PMC5885911 DOI: 10.1001/jamainternmed.2017.7744] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This retrospective cohort study examines whether patients with type 2 diabetes on hospice are assessed for dysglycemia, receive insulin or oral hypoglycemic medications, or experience hypoglycemia and hyperglycemia in the nursing home setting.
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Zhou Y, Ni X, Wen B, Duan L, Sun H, Yang M, Zou F, Lin Y, Liu Q, Zeng Y, Fu X, Pan K, Jing B, Wang P, Zeng D. Appropriate dose of Lactobacillus buchneri supplement improves intestinal microbiota and prevents diarrhoea in weaning Rex rabbits. Benef Microbes 2018; 9:401-416. [DOI: 10.3920/bm2017.0055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This study examined the effects on intestinal microbiota and diarrhoea of Lactobacillus buchneri supplementation to the diet of weaning Rex rabbits. To this end, rabbits were treated with L. buchneri at two different doses (LC: 104 cfu/g diet and HC: 105 cfu/g diet) for 4 weeks. PCR-DGGE was used to determine the diversity of the intestinal microbiota, while real-time PCR permitted the detection of individual bacterial species. ELISA and real-time PCR allowed the identification of numerous cytokines in the intestinal tissues. Zonula occludens-1, polymeric immunoglobulin receptor and immunoglobulin A genes were examined to evaluate intestinal barriers. Results showed that the biodiversity of the intestinal microbiota of weaning Rex rabbits improved in the whole tract of the treated groups. The abundance of most detected bacterial species was highly increased in the duodenum, jejunum and ileum after L. buchneri administration. The species abundance in the HC group was more increased than in the LC group when compared to the control. Although the abundance of Enterobacteriaceae exhibited a different pattern, Escherichia coli was inhibited in all treatment groups. Toll-like receptor (TLR)2 and TLR4 genes were down-regulated in all intestinal tissues as the microbiota changed. In the LC group, the secretion of the inflammatory cytokine tumour necrosis factor-α was reduced, the gene expression of the anti-inflammatory cytokine interleukin (IL)-4 was up-regulated and the expression of intestinal-barrier-related genes was enhanced. Conversely, IL-4 expression was increased and the expression of other tested genes did not change in the HC group. The beneficial effects of LC were greater than those of HC or the control in terms of improving the daily weight gain and survival rate of weaning Rex rabbits and reducing their diarrhoea rate. Therefore, 104 cfu/g L. buchneri treatment improved the microbiota of weaning Rex rabbits and prevented diarrhoea in these animals.
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Zeng Y, Zeng D, Zhang Y, Ni XQ, Wang J, Jian P, Zhou Y, Li Y, Yin ZQ, Pan KC, Jing B. Lactobacillus plantarumBS22 promotes gut microbial homeostasis in broiler chickens exposed to aflatoxin B1. J Anim Physiol Anim Nutr (Berl) 2017; 102:e449-e459. [DOI: 10.1111/jpn.12766] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/15/2017] [Indexed: 11/30/2022]
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Weng Y, Liu Y, Du H, Li L, Jing B, Zhang Q, Wang X, Wang Z, Sun Y. Glycosylation of DMP1 Is Essential for Chondrogenesis of Condylar Cartilage. J Dent Res 2017; 96:1535-1545. [PMID: 28759313 DOI: 10.1177/0022034517717485] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Imam TH, Fischer H, Jing B, Burchette R, Henry S, DeRose SF, Coleman KJ. Estimated GFR Before and After Bariatric Surgery in CKD. Am J Kidney Dis 2016; 69:380-388. [PMID: 27927587 DOI: 10.1053/j.ajkd.2016.09.020] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 09/12/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Several reviews have recently detailed the beneficial effects of weight loss surgery for kidney function. However, these studies have a number of limitations, including small sample size, few done in chronic kidney disease (CKD) stages 3 and 4, and many not including the main bariatric surgery procedures used in the United States today. STUDY DESIGN This was an observational retrospective cohort study comparing propensity score-matched bariatric surgery patients and nonsurgery control patients who were referred for, but did not have, surgery. Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy were also compared using propensity matching. SETTING & PARTICIPANTS Patients (714 surgery patients; 714 controls) were from a large integrated health care system, a mean of 58±8 (SD) years old, and mostly women (77%) and non-Hispanic whites (56%) and had diabetes mellitus (66%) and/or hypertension (91%). PREDICTOR Predictors at the time of surgery or referral to surgery were age, sex, race/ethnicity, weight, and presence of diabetes and/or hypertension. OUTCOMES The primary outcome for this study was change in estimated glomerular filtration rate (eGFR) from serum creatinine level over a median 3-year follow-up period. MEASUREMENTS Serum creatinine was used to calculate eGFR using the CKD-EPI (CKD Epidemiology Collaboration) creatinine equation. RESULTS Surgery patients had 9.84 (95% CI, 8.05-11.62) mL/min/1.73m2 greater eGFRs than controls at a median 3 years' follow-up and RYGB patients had 6.60 (95% CI, 3.42-9.78) mL/min/1.73m2 greater eGFRs than sleeve gastrectomy patients during the same period. LIMITATIONS This study is limited by its nonrandomized observational study design, estimation of GFR, and large changes in muscle mass, which may affect serum creatinine level independent of changes in kidney function. CONCLUSIONS Bariatric surgery, especially the RYGB procedure, results in significant improvements for up to 3 years in eGFRs for patients with CKD stages 3 and 4.
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Siebelmann S, Jing B, Cursiefen C, Steven P. [Non-Invasive Diagnosis of Ocular Graft-versus-Host Disease]. Klin Monbl Augenheilkd 2015; 232:652-7. [PMID: 25989034 DOI: 10.1055/s-0035-1545830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Ocular graft-vs-host disease (GvHD) is a major complication following allogenic blood stem cell transplantation (aBSCT) leading to a disturbance of the ocular surface integrity with a broad range of severity. Leading symptom is a pronounced autoinflammatory reaction in particular at the ocular surface with typical features of dry eye disease. Potential complications include visual loss, pain and damage to the ocular structures with, e. g. corneal ulcerations. Diagnosis and treatment of ocular GvHD are a challenge for attending ophthalmologists and require intensive interdisciplinary patient care in particular with haemato-oncologists. First and follow-up examinations consist of several diagnostic steps that include quantitative and qualitative analysis of tearfilm, visual acuity, ocular surface and retinal integrity, cataract development and subjective symptoms. Available tests are mostly evaluated for usage in dry eye diagnosis but are, however, mostly unspecific for diagnosing ocular GvHD reliably. Only combinations of several clinical tests together with the experience of specialised ophthalmologists may lead to the certain diagnosis and treatment decisions at state. This review illustrates the available established and innovative non-invasive diagnostic tests and evaluates their potential use for diagnosing ocular GvHD.
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Yiru W, Yu W, Jing B, Jie C, Lifeng L, Yu W. Endothelial differentiation promoted by hypoxia in human amniotic fluid-derived stem cells. BRITISH HEART JOURNAL 2011. [DOI: 10.1136/heartjnl-2011-300867.219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Lu F, Hu X, Jing B, Ma Y. [Analysis of nuclear DNA gene types of Leishmania isolates from hilly and plain foci of China]. ZHONGGUO JI SHENG CHONG XUE YU JI SHENG CHONG BING ZA ZHI = CHINESE JOURNAL OF PARASITOLOGY & PARASITIC DISEASES 2002; 16:432-5. [PMID: 12078288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
AIM To analyse the nuclear DNA (nDNA) polymorphism of Leishmania isolates from hilly and plain foci of China. METHODS nDNA were analysed by endonuclease digestion, Southern blotting and chromosomal localization. Probes were labeled with digoxigenin. RESULTS Using gp63 gene probe, similar hybridization bands were found to be existed between nDNAs of Leishmania donovani Jiangsu human isolate and L. d. Jeddah, also between nDNAs of L. d. Sichuan human isolate and L. infantum. Using beta-tubulin gene probe, there were two similar hybridization bands existed between nDNAs of L. d. Jiangsu human isolate and L. d. Jeddah, and three similar hybridization bands existed between nDNAs of L. d. Sichuan canine isolate and L. d. Gansu canine isolate, and two similar hybridization bands existed between nDNA of L. d. Sichuan canine isolate and L. d. Wenchuan human isolate. CONCLUSION Homology exists between L. d. Jiangsu human isolate and L. d. Jeddah from plain foci, between L. d. Sichuan human isolate from hilly foci and L. infantum, between L. d. Sichuan canine isolate and L. d. Gansu canine isolate from hilly foci. Homology as well as differences exist between L. d. Sichuan canine isolate and L. d. Wenchuan human isolate. Heterogeneity exists between isolates from hilly foci and plain foci.
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He S, Dai R, Lu B, Cao C, Bai H, Jing B. Medial axis reformation: a new visualization method for CT angiography. Acad Radiol 2001; 8:726-33. [PMID: 11508751 DOI: 10.1016/s1076-6332(03)80579-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
RATIONALE AND OBJECTIVES The authors performed this study to evaluate a new method (medial axis reformation [MAR]) for visualizing three-dimensional vascular data at electron-beam computed tomographic (CT) angiography. MATERIALS AND METHODS MAR was performed automatically with a personal computer-based workstation. After the region of interest was edited, voxels were divided into groups according to their path lengths. Centroids of groups were connected to form the medial axis. Then, the medial axis was refined with multiscale medial response. Bifurcations were also detected and refined. Finally, curved sections were generated through the branches and laid out onto a single image by using a splitting method. The authors performed MAR during electron-beam CT angiography of coronary arteries, common carotid arteries, and iliac arteries. RESULTS MAR displayed curved sections of branched vessels on one image, cut through the axis of vessels to show the vessel diameter objectively, and allowed the viewing direction to be altered arbitrarily. CONCLUSION Results of preliminary applications demonstrate that MAR is a valuable new visualization method for CT angiography.
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Lu B, Dai R, Jing B, Bai H, He S, Zhuang N, Wu Q, Zhu X. Evaluation of coronary artery bypass graft patency using three-dimensional reconstruction and flow study of electron beam tomography. Chin Med J (Engl) 2001; 114:466-72. [PMID: 11780405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
OBJECTIVE To establish and evaluate two protocols for the noninvasive visualization and assessment of coronary artery bypass graft (CABG) patency on electron beam tomography (EBT). METHODS Two hundred and fourteen consecutive patients who underwent coronary artery bypass graft surgery were scanned using both EBT angiography with 3-dimensional reconstruction and EBT flow study with time-density-curve analysis. RESULTS There were 589 CABGs evaluated in this study (10 grafts were excluded because of artifacts). Among them, 133 (98.5%) of 135 arterial grafts were patent, and 345 (77.7%) of 444 saphenous-vein grafts were patent. Within 5 years or between 5 and 10 years after operation, arterial graft patency exceeded venous graft patency (P < 0.001). Three-dimensional EBT angiography achieved higher sensitivity, specificity and accuracy (97.7%, 94.1% and 96.7%, respectively) than did EBT flow study (88.4%, 82.4% and 85.2%, respectively) for evaluating occlusion or patency of CABG. The intra-graft flow of patent arterial and venous grafts were 4.9 +/- 2.2 ml.min-1.g-1 and 6.9 +/- 2.8 ml.min-1.g-1, respectively (P < 0.001). CONCLUSION The combination of EBT three-dimensional reconstruction and flow study can be more effective in the assessment of CABG anatomy and quantification of patent CABG blood flow.
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Chen D, Qiao L, Jing B. [Effect of rhubarb on oxygen radicals leakage from mitochondria of intestinal mucosa in burned rats]. ZHONGGUO ZHONG XI YI JIE HE ZA ZHI ZHONGGUO ZHONGXIYI JIEHE ZAZHI = CHINESE JOURNAL OF INTEGRATED TRADITIONAL AND WESTERN MEDICINE 2000; 20:849-52. [PMID: 11938834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To investigate the effects of rhubarb on oxygen radicals leakage from the mitochondria of intestinal mucosa in burned rats. METHODS The activity of cytochrome oxidase and superoxide dismutase (SOD) in mitochondria isolated from intestinal mucosa of burn model of rats was used to evaluate the oxygen radicals leakage from the mitochondria. And the SOD and malondialdehyde (MDA) levels in plasma, liver, intestinal mucosa and its mitochondria were also determined. RESULTS After burn injury, the activity of cytochrome oxidase in intestinal mucosa decreased as the time elapses, rhubarb could improve it obviously. Furthermore, rhubarb could reduce the massive consumption of SOD and production of MDA obviously increased in plasma, liver, intestinal mucosa and its mitochondria after burning. CONCLUSION Rhubarb could enhance the activity of cytochrome oxidase and SOD in small intestine mucosal epithelia in burned rats, thus the oxygen radicals leakage from the mitochondria to be reduced.
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Lu B, Dai R, Bai H, He S, Jing B, Zhuang N, Gao R, Yang Y, Chen J, Budoff MJ. Evaluation of electron beam tomographic coronary arteriography with three-dimensional reconstruction in healthy subjects. Angiology 2000; 51:895-904. [PMID: 11103858 DOI: 10.1177/000331970005101102] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this study, the authors evaluated the performance characteristics of contrast-enhanced electron-beam tomography (EBT) with three-dimensional reconstruction in defining the coronary artery lumen in healthy subjects. Thirty patients with normal coronary angiograms by selective coronary arteriography (SCA) underwent contrast-enhanced EBT examination. Measured parameters included degree of luminal enhancement, intravascular contrast-to-noise ratio (CNR), and diameter and length of visualized lumen. Ventricular cavity, aortic blood pool, and coronary artery attenuation were found to be significantly different before and after intravenous injection of contrast material (p < 0.001). CNR decreased from proximal to distal segments within each vessel (p < 0.001), with a peak of 11.2 +/- 2.3 occurring in the proximal left anterior descending coronary artery (LAD) to a low of 4.8 +/- 2.0 in the distal left circumflex (LCX). Luminal diameters visualized by EBT had no significant difference with that of SCA (p > 0.05). Therefore, EBT angiography with three-dimensional reconstruction allows for noninvasive coronary arteriography revealing long segments of the major coronary arteries in normal subjects.
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