Diabetes and coronary artery bypass surgery. An examination of perioperative glycemic control and outcomes

WSTĘP. Celem pracy była ocena dokładności kontroli glikemii w okresie okołooperacyjnym u chorych na cukrzycę poddanych zabiegowi pomostowania aortalno-wieńcowego (CABG, coronary artery bypass grafting) oraz analiza związku między kontrolą glikemii a wewnątrzszpitalną chorobowością i śmiertelnością. MATERIAŁ I METODY. Było to badanie retrospektywne obejmujące kolejnych chorych na cukrzycę, u których wykonano CABG między kwietniem 2000 roku a marcem 2001 roku. Objęto nim pacjentów, którzy przeżyli co najmniej 24 godziny po zabiegu. WYNIKI. Spośród 291 analizowanych chorych w chwili przyjęcia do szpitala u 95% występowała cukrzyca typu 2, zaś u 40% retinopatia, nefropatia lub neuropatia. Podczas pobytu w szpitalu (średnio 7 dni) 78 pacjentów (27%) doznało udaru mózgu niepowodującego zgonu, zawału serca, zakażenia lub zmarło (wszystkie te sytuacje zaliczano do "zdarzeń niepożądanych"). Kontrola glikemii była niedostateczna (średnia glikemia w 1. dniu po zabiegu wynosiła 11,4 mmol/l [11,2–11,6 mmol/l]) i istotnie wiązała się z wystąpieniem zdarzeń niepożądanych po CABG (p = 0,03). U osób, u których stężenie glukozy we krwi w 1. dniu po zabiegu było najwyższe, stwierdzono największe ryzyko wystąpienia zdarzeń niepożądanych (iloraz szans = 2,5 [1,1–5,3]). Nawet po skorygowaniu wyników pod względem innych objawów klinicznych i czynników wynikających z zabiegu glikemia w 1. dniu po operacji nadal istotnie wiązała się z ryzykiem wystąpienia zdarzeń niepożądanych. Wzrost glikemii o każdy 1 mmol/l powyżej 6,1 mmol/l zwiększał ryzyko o 17%. WNIOSKI. Okołooperacyjna kontrola glikemii w badanej grupie chorych na cukrzycę, u których wykonano CABG w szpitalu o 3. stopniu referencji, była niedostateczna. Zdaniem autorów wyeliminowanie tego czynnika jest konieczne, ponieważ hiperglikemia w 1. dniu po zabiegu w niniejszym badaniu wiązała się z występowaniem zdarzeń niepożądanych.INTRODUCTION. To determine the adequacy of perioperative glycemic control in diabetic patients undergoing coronary artery bypass grafting (CABG) and to explore the association between glycemic control and in-hospital morbidity/mortality. MATERIAL AND METHODS. Retrospective cohort study of consecutive patients with diabetes undergoing CABG between April 2000 and March 2001 who survived at least 24 h postoperatively. RESULTS. Of the 291 patients in this study, 95% had type 2 diabetes and 40% had retinopathy, nephropathy, or neuropathy at baseline. During hospitalization (median 7 days), 78 (27%) of these patients suffered a nonfatal stroke or myocardial infarction, septic complication, or died ("adverse outcomes"). Glycemic control was suboptimal (average glucose on first postoperative day was 11.4 [11.2–11.6] mmol/l) and was significantly associated with adverse outcomes post-CABG (P = 0.03). Patients whose average glucose level was in the highest quartile on postoperative day 1 had higher risk of adverse outcomes after the first postoperative day than those with glucose in the lowest quartile (odds ratio 2.5 [1.1-5.3]). Even after adjustment for other clinical and operative factors, average blood glucose level on the first postoperative day remained significantly associated with subsequent adverse outcomes: for each 1-mmol/l increase above 6.1 mmol/l, risk increased by 17%. CONCLUSIONS. Perioperative glycemic control in our cohort of diabetic patients undergoing CABG in a tertiary care facility was suboptimal. We believe closure of this care gap is imperative, because hyperglycemia in the first postoperative day was associated with subsequent adverse outcomes in our study patients

Iraq War mortality estimates: A systematic review

<p>Abstract</p> <p>Background</p> <p>In March 2003, the United States invaded Iraq. The subsequent number, rates, and causes of mortality in Iraq resulting from the war remain unclear, despite intense international attention. Understanding mortality estimates from modern warfare, where the majority of casualties are civilian, is of critical importance for public health and protection afforded under international humanitarian law. We aimed to review the studies, reports and counts on Iraqi deaths since the start of the war and assessed their methodological quality and results.</p> <p>Methods</p> <p>We performed a systematic search of 15 electronic databases from inception to January 2008. In addition, we conducted a non-structured search of 3 other databases, reviewed study reference lists and contacted subject matter experts. We included studies that provided estimates of Iraqi deaths based on primary research over a reported period of time since the invasion. We excluded studies that summarized mortality estimates and combined non-fatal injuries and also studies of specific sub-populations, e.g. under-5 mortality. We calculated crude and cause-specific mortality rates attributable to violence and average deaths per day for each study, where not already provided.</p> <p>Results</p> <p>Thirteen studies met the eligibility criteria. The studies used a wide range of methodologies, varying from sentinel-data collection to population-based surveys. Studies assessed as the highest quality, those using population-based methods, yielded the highest estimates. Average deaths per day ranged from 48 to 759. The cause-specific mortality rates attributable to violence ranged from 0.64 to 10.25 per 1,000 per year.</p> <p>Conclusion</p> <p>Our review indicates that, despite varying estimates, the mortality burden of the war and its sequelae on Iraq is large. The use of established epidemiological methods is rare. This review illustrates the pressing need to promote sound epidemiologic approaches to determining mortality estimates and to establish guidelines for policy-makers, the media and the public on how to interpret these estimates.</p

The Association Between Prior Use of Aspirin and/or Warfarin and the In-hospital Management and Outcomes in Patients Presenting With Acute Coronary Syndromes: Insights From the Global Registry of Acute Coronary Events (GRACE)

BACKGROUND: The role of acetylsalicylic acid (ASA [aspirin]) and warfarin in secondary prevention after acute coronary syndromes (ACS) is well established. However, there are sparse data comparing the presentation and outcomes of patients who present with ACS while on ASA and/or warfarin therapy and those on neither. METHODS: Using data from the Canadian Global Registry of Acute Coronary Events (GRACE), we stratified 14,090 ACS patients into 4 groups according to prior use of antithrombotic therapies and compared in-hospital management and outcomes. RESULTS: Among 14,090 ACS patients, 7411 (52.6%) were not on prior ASA or warfarin therapy, 5724 (40.6%) were on ASA only, 593 (4.2%) were on warfarin only, and 362 (2.6%) were on both ASA and warfarin. ACS patients taking ASA and/or warfarin were older with more comorbidities than the patients on neither drug. Patients receiving prior warfarin only or ASA and warfarin were less likely to receive guideline-recommended therapies. Patients who were taking prior warfarin only had higher unadjusted rates of death, death and/or reinfarction (re-MI), congestive heart failure (CHF), and major bleeding as compared with patients on no prior therapy. Furthermore, patients who were taking ASA and warfarin had higher unadjusted rates of death and/or re-MI and CHF than patients on prior ASA only. CONCLUSIONS: ACS patients on prior warfarin are a high-risk population, yet they receive less guideline-recommended therapies and have higher unadjusted adverse event rates during their index hospitalization. With the increasing use of oral anticoagulants, clinical trials are needed to guide the optimal management of these ACS patients. Inc. All rights reserved