Hypoglycemia-associated mortality is not drug-associated but linked to comorbidities

ObjectiveAlthough tight glucose control is used widely in hospitalized patients, there is concern that medication-induced hypoglycemia may worsen patient outcomes. We sought to determine if the mortality risk associated with hypoglycemia in hospitalized noncritically ill patients is linked to glucose-lowering medications (drug-associated hypoglycemia) or merely an association mediated by comorbidities (spontaneous hypoglycemia).MethodsA retrospective cohort of patients admitted to the general wards of an academic center during 2007 was studied. The in-hospital mortality risk of a hypoglycemic group (at least 1 blood glucose ≤ 70 mg/dL) was compared with that of a normoglycemic group using survival analysis. Stratification by subgroups of patients with spontaneous and drug-associated hypoglycemia was performed.ResultsAmong 31,970 patients, 3349 (10.5%) had at least 1 episode of hypoglycemia. Patients with hypoglycemia were older, had more comorbidities, and received more antidiabetic agents. Hypoglycemia was associated with increased in-hospital mortality (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.33-2.09; P < .001). However, this greater risk was limited to patients with spontaneous hypoglycemia (HR, 2.62; 95% CI, 1.97-3.47; P < .001) and not to patients with drug-associated hypoglycemia (HR, 1.06; 95% CI, 0.74-1.52; P = .749). After adjustment for patient comorbidities, the association between spontaneous hypoglycemia and mortality was eliminated (HR, 1.11; 95% CI, 0.76-1.64; P = .582).ConclusionDrug-associated hypoglycemia was not associated with increased mortality risk in patients admitted to the general wards. The association between spontaneous hypoglycemia and mortality was eliminated after adjustment for comorbidities, suggesting that hypoglycemia may be a marker of disease burden rather than a direct cause of death.     

Initial management of septic patients with hyperglycemia in the noncritical care inpatient setting

BackgroundPrevious research on the management of hyperglycemia in patients with sepsis has focused primarily on those with established organ failure in the critical care setting. The impact of hyperglycemia and glycemic control in patients with infection before developing severe sepsis or shock remains undefined.MethodsThis observational, prospective, cohort study investigated the relationship between initial 72-hour time-weighted mean glucose concentrations and in-hospital mortality, intensive care unit transfer, and hospital length of stay in a cohort of patients with an acute infection who were admitted from the emergency department to a non-intensive care unit hospital ward. We used multivariate regression models adjusted for age, diabetes, and disease severity.ResultsA total of 1849 patients were included, of whom 29% had diabetes. In the 1310 nondiabetic patients, we observed hyperglycemia using time-weighted glucose concentrations: 121 to 150 mg/dL (n = 204, 16%), 151 to 180 mg/dL (n = 32, 2.4%), and greater than 180 mg/dL (n = 21, 1.6%). Insulin treatment was infrequent in nondiabetic patients, with 9%, 13%, and 29% of nondiabetic patients in these ranges receiving insulin, respectively. As patient glucose values increased, in-hospital mortality increased in nondiabetic patients, with odds ratios (ORs) of 4.4 (95% confidence interval [CI], 1.8-11), 10.0 (95% CI, 2.5-40), and 9.3 (95% CI, 1.9-44.0). Conversely, hyperglycemia did not confer an increased risk of adverse outcomes in diabetic patients. Likewise, increased risk for unplanned intensive care unit admission from the floor demonstrated ORs of 2.2 (95% CI, 1.1-4.3), 2.0 (95% CI, 0.45-8.9), and 6.3 (95% CI, 1.9-20.6) in nondiabetic patients, whereas no increased risk was found in diabetic patients.ConclusionsIn this cohort of acutely infected patients without established severe sepsis or shock, higher glucose concentrations within the first 72 hours in the nondiabetic population were associated with worse hospital outcomes and were less likely to be treated with insulin compared with diabetic patients.     

Benefits from intracoronary as compared to intravenous abciximab administration for STEMI patients undergoing primary angioplasty: a meta-analysis of 8 randomized trials

BackgroundAdjunctive abciximab administration has been demonstrated to reduce mortality and reinfarction in patients with ST-elevation myocardial infarction (STEMI) referred to invasive management. Standard abciximab regimen consists of an intravenous (IV) bolus followed by a 12-h IV infusion. Experimental studies and small clinical trials suggest the superiority of intracoronary (IC) injection of abciximab over IV route. Therefore, the aim of the current study was to perform a meta-analysis of randomized trials (RCTs) to assess the clinical efficacy and safety of IC vs IV abciximab administration in STEMI patients undergoing primary angioplasty.MethodsWe obtained results from all RCTs enrolling STEMI patients undergoing primary percutaneous coronary intervention (PCI). The primary endpoint was mortality, while recurrent myocardial infarction, postprocedural epicardial (TIMI 3) and myocardial (MBG 2–3) perfusion were identified as secondary endpoints. The safety endpoint was the risk of major bleeding complications.ResultsA total of 8 randomized trials were finally included in the meta-analysis, enrolling a total of 3259 patients. As compared to IV route, IC abciximab was associated with a significant improvement in myocardial perfusion (OR [95% CI] = 1.76 [1.28–2.42], p < 0.001), without significant benefits in terms of mortality (OR [95% CI] = 0.85 [0.59–1.23], p = 0.39), reinfarction (OR [95% CI] = 0.79 [0.46–1.33], p = 0.37), or major bleeding complications (OR [95% CI] = 1.19 [0.76–1.87], p = 0.44). However, we observed a significant relationship between patient's risk profile and mortality benefits from IC abciximab administration (p = 0.011).ConclusionsThe present updated meta-analysis showed that IC administration of abciximab is associated with significant benefits in myocardial perfusion, but not in clinical outcome at short-term follow-up as compared to IV abciximab administration, without any excess of major bleedings in STEMI patients undergoing primary PCI. However, a significant relationship was observed between patient's risk profile and mortality benefits from IC abciximab administration. Therefore, waiting for long-term follow-up results and additional randomized trials, IC abciximab administration cannot be routinely recommended, but may be considered in high-risk patients.     

CYP2C19*2/ABCB1-C3435T polymorphism and risk of cardiovascular events in coronary artery disease patients on clopidogrel: Is clinical testing helpful?

BackgroundStudies evaluating CYP2C19*2 and ABCB1-C3435T polymorphisms have shown conflicting results. We performed this meta-analysis to evaluate role of clinical testing for these polymorphisms in CAD patients on clopidogrel.Methods19,601 patients from 14 trials were analyzed. The endpoints were major adverse cardiovascular events (MACE), cardiovascular (CV) death, stent thrombosis (ST), myocardial infarction (MI), stroke and major bleeding. Combined relative risks (RR) with 95% confidence intervals (CI) were computed for each outcome by using standard methods of meta-analysis and test parameters were computed.ResultsCYP2C19*2 polymorphism was associated with higher risk of MACE [RR: 1.28, CI: 1.06–1.54; p = 0.009], CV death [RR: 3.21, CI: 1.65–6.23; p = 0.001], MI [RR: 1.36, CI: 1.12–1.65; p = 0.002], ST [RR: 2.41, CI: 1.69–3.41; p < 0.001]. No difference was seen in major bleeding events [RR: 1.02, CI: 0.86–1.20; p = 0.83]. Subgroup analysis showed similar results for elective PCI [RR: 1.34, CI: 1.01–1.76; p = 0.03], and PCI with DES [RR: 1.53, CI: 1.029–1.269; p = 0.03]. CYP2C19*2 polymorphism has very low sensitivity (28–58%), specificity (71–73%), positive predictive value (3–10%) but good negative predictive value (92–99%). ABCB1-C3435T polymorphism analysis revealed similar MACE [RR: 1.13, CI: 0.99–1.29; p = 0.06], ST [RR: 0.88, CI: 0.52–1.47; p = 0.63] and major bleeding [RR: 1.04, CI: 0.87–1.25; p = 0.62] in both groups.ConclusionIn CAD patients on clopidogrel therapy, CYP2C19*2 polymorphism is associated with significantly increased adverse cardiovascular events. However, due to the low positive predictive value, routine genetic testing cannot be recommended at present.     

The metabolic syndrome in early pregnancy and risk of gestational diabetes mellitus

AimThe objective of the present study was to determine whether or not maternal metabolic syndrome in early pregnancy in women without previous diabetes is associated with the development of gestational diabetes mellitus (GDM).MethodsA total of 508 women from the Rhea study—involving a pregnant cohort in Crete, Greece (2007–2009)—with singleton pregnancies were included in the present analysis. Maternal fasting serum samples were collected and blood pressure measured before gestational week 15. The metabolic syndrome in early pregnancy was defined according to NHLBI/AHA criteria. Pregnant women were screened for GDM between weeks 24 and 28 of gestation, as defined by Carpenter and Coustan criteria. Multivariable log-binomial regression models were used to estimate the effect of the metabolic syndrome in early pregnancy on the risk of GDM, after adjusting for confounding factors.ResultsWomen with the metabolic syndrome were at high risk of GDM (RR = 3.17; 95% CI: 1.06–9.50). Among the components of the metabolic syndrome, the most significant risk factors were impaired fasting glucose (RR = 4.92; 95% CI: 1.41–17.23) and pre-pregnancy obesity (RR = 2.65; 95% CI: 1.23–5.70). A 10-mmHg rise in systolic and diastolic blood pressure increased the relative risk of GDM by 49% (RR = 1.49; 95% CI: 1.10–2.02) and 34% (RR = 1.34; 95% CI: 1.04–1.73), respectively, whereas a 1-unit increase in pre-pregnancy BMI increased the relative risk of GDM by 6% (RR = 1.06; 95% CI: 1.01–1.12).ConclusionThese findings suggest that women with the metabolic syndrome in early pregnancy have a greater risk of developing GDM.     

Prognostic value of hyperglycemia on-admission in diabetic versus non-diabetic patients presenting with ST-elevation myocardial infarction in Tunisia

BackgroundHyperglycemia on-admission is a powerful predictor of adverse events in patients presenting for ST-elevation myocardial infarction (STEMI).AimIn this study, we sought to determine the prognostic value of hyperglycemia on-admission in Tunisian patients presenting with STEMI according to their diabetic status.MethodsPatients presenting to our center between January 1998 and September 2014 were enrolled. Hyperglycemia was defined as a glucose level ≥11 mmol/L. In-hospital prognosis was studied in diabetic and non-diabetic patients. The predictive value for mortality of glycemia level on-admission was assessed by mean of the area under receiver operating characteristic (ROC) curve calculation.ResultsA total of 1289 patients were included. Mean age was 60.39 ± 12.8 years and 977 (77.3%) patients were male. Prevalence of diabetes mellitus was 70.2% and 15.2% in patients presenting with and without hyperglycemia, respectively (p < 0.001). In univariate analysis, hyperglycemia was associated to in-hospital death in diabetic (OR: 8.85, 95% CI: 2.11–37.12, p < 0.001) and non-diabetic patients (OR: 2.57, 95% CI: 1.39–4.74, p = 0.002). In multivariate analysis, hyperglycemia was independently predictive of in-hospital death in diabetic patients (OR: 9.6, 95% CI: 2.18–42.22, p = 0.003) but not in non-diabetic patients (OR: 1.93, 95% CI: 0.97–3.86, p = 0.06). Area under ROC curve of glycemia as a predictor of in-hospital death was 0.792 in diabetic and 0.676 in non-diabetic patients.ConclusionIn patients presenting with STEMI, hyperglycemia was associated to hospital death in diabetic and non-diabetic patients in univariate analysis. In multivariate analysis, hyperglycemia was independently associated to in-hospital death in diabetic but not in non-diabetic patients.     

Factors associated with in-hospital mortality in patients with acute aortic syndrome involving the ascending aorta

BackgroundAortic intramural hematoma (IMH), a variant form of classic dissection (AD), is an increasingly recognized and potentially fatal entity of acute aortic syndrome (AAS). We sought to assess the real impact of increased recognition of IMH on mortality of AAS involving the ascending aorta.MethodsWe evaluated 186 consecutive patients with AAS involving the ascending aorta (57.0 ± 13.5 years, 95 females) admitted between January 1993 and March 2003.ResultsFinal diagnosis was AD in 135 patients and IMH in 51 (27%). Patients with AD were younger (54.0 ± 13 vs. 65.6 ± 10.7 years, p < 0.05) and surgery was more frequently performed (82% vs. 31%, p < 0.001). Overall in-hospital mortality was 16% (30/186); both total mortality (19% vs. 8%, p = 0.059) and mortality without surgery (71% vs. 9%, p < 0.001) was higher in AD. Logistic regression identified the following presenting variables as predictors of mortality: AD (OR 53.0; 95% CI, 6.6–425.4; p < 0.001), confusion/coma (OR 20.1; 95% CI, 3.8–107.8; p < 0.001), tamponade (OR 5.3; 95% CI, 1.2–24.3; p = 0.031), heart failure (OR 8.1; 95% CI, 1.1–61.0; p = 0.043), and medical treatment only (OR 17.6; 95% CI, 4.6–67.6, p < 0.001). Tamponade was more prevalent in IMH (25% vs. 11%, p = 0.038), and was a predictor of higher mortality in both groups.ConclusionIMH comprises of significant proportion of AAS involving the ascending aorta and is an independent variable associated with lower mortality despite lower frequency of surgery. Treatment option including optimal timing of surgery can be individualized based on underlying disease entity of AAS and some clinical features at the initial presentation.     

Vitamin D and gestational diabetes: a systematic review and meta-analysis

BackgroundConflicting results currently exists on the association between vitamin D and glucose metabolism. The role of maternal vitamin D status in gestational diabetes mellitus (GDM) is not clear. This meta-analysis aimed to examine this role in women with GDM compared with normal glucose tolerance (NGT).MethodsWe performed a systematic review and meta-analysis by searching MEDLINE database, the Cochrane library and Uptodate® Online for English-language literature up to September 2011. Summary odds ratios were calculated using a random-effects model meta-analysis.ResultsSeven observational studies were eligible for the meta-analysis, including 2146 participants of whom 433 were diagnosed with GDM. Four studies reported a high incidence of vitamin D deficiency in pregnant women (> 50%). Overall vitamin D deficiency (serum 25-hydroxyvitamin D (25OHD) < 50 nmol/l) in pregnancy was significantly related to the incidence of GDM with an odds ratio of 1.61 (95% CI 1.19–2.17; p = 0.002). Serum 25OHD was significant lower in participants with GDM than in those with NGT (? 5.33 nmol/l (95% CI ? 9.73 to ? 0.93; p = 0.018).ConclusionsThis meta-analysis indicates a significant inverse relation of serum 25OHD and the incidence of GDM. However, it remains unclear whether this association is causal due to the observational study design of the studies. Clinical trials are needed to examine whether vitamin D supplementation will improve glycemic control in women with GDM.     

Adenosine improves post-procedural coronary flow but not clinical outcomes in patients with acute coronary syndrome: a meta-analysis of randomized trials

AimsAdjunctive therapy with adenosine has been shown to improve coronary flow in patients with acute coronary syndromes (ACS); it is unclear, however, whether adenosine can effectively reduce adverse clinical events. The aim of our study was to perform a meta-analysis of all randomized controlled trials (RCTs) investigating angiographic and clinical outcomes in ACS patients undergoing PCI or thrombolysis and receiving adjunctive adenosine therapy vs. placebo.MethodsMedline/CENTRAL/EMBASE and Google Scholar database were scanned. The meta-analysis included ten RCTs (N = 3821). All-cause mortality was chosen as primary endpoint. Secondary endpoints were re-infarction (MI), heart failure (HF) symptoms (NYHA class III/IV), no-reflow (defined as TIMI 0 flow) and >50% ST-resolution.ResultsAdenosine compared to placebo was associated with a significant reduction of post-procedural no-reflow (OR [95% CI] = 0.25 [0.08–0.73], p = 0.01); however, at a median follow-up of 6 months, prior treatment with adenosine did not confer significant benefits in terms of reduction of mortality (OR_Fixed [95% CI] = 0.87 [0.69–1.09], p = 0.23), as well as re-MI (p = 0.80), HF symptoms (p = 0.44) and ST-resolution (p = 0.09). Separate analyses conducted in the subgroups of ST-elevation MI patients treated with either PCI or thrombolysis confirmed the findings found in the overall population.ConclusionsThis meta-analysis shows that adenosine adjunctive therapy does not improve survival nor reduce the rates of re-MI and HF symptoms in patients with ACS treated with PCI or thrombolysis. The beneficial effect on post-procedural coronary flow was not associated with consistent advantages on clinical outcomes.     

The addition of pioglitazone in type 2 diabetics poorly controlled on insulin therapy: A meta-analysis

AimTo quantify the effect of a pioglitazone on glycemic control and lipid parameters, as well as the risk of adverse events when incorporated into the treatment regimen of patients with type 2 diabetes inadequately controlled on insulin.MethodsThe electronic databases PubMed, Embase and The Cochrance Library were searched systematically to identify randomized controlled trials (RCTs) of pioglitazone therapy in patients with type 2 diabetes mellitus (DM) inadequately controlled after treatment with insulin. Data on change of haemoglobin A1C (HbA1c), fasting plasma glucose (FPG), lipid parameters and risk of hypoglycemic, edema events were extracted from each study and pooled according to fixed effect model or random effect model in meta-analyses.ResultsFour RCTs including 1767 patients were included. The pooled estimate of change in HbA1c from baseline was 1.22% (95% CI 1.01–1.44, p < 0.001 vs. baseline) and of change in FPG from baseline was 1.63 mmol/l (95% CI 0.75–2.50, p < 0.001 vs. baseline). Pioglitazone significantly increased high-density lipoprotein cholesterol (HDL-c) level (0.2 mmol/L, 95%CI: 0.13–0.28) and low-density lipoprotein cholesterol (LDL-c) level (0.10 mol/L, 95%CI: 0.09–0.17), and lowered triglyceride (TG) level (0.05 mmol/L, 95%CI: 0.01–0.09). The odds of experiencing a hypoglycemic event in pioglitazone-treated arms was significantly higher than comparator treatments (RR = 1.57, 95% CI 1.12–2.20, p < 0.001). The case was the same with edema (RR = 2.42, 95% CI 1.67–3.50, p < 0.001).ConclusionsOur study implied that in patients with type 2 DM whose control is inadequate on insulin therapy, the additional pioglitazone could significantly improve glucose metabolism and might have a positive effect on important components of the lipid profile, which may have important implications in reducing the risk of cardiovascular disease, a major long-term complication in type 2 diabetes mellitus. Besides, the adverse events (AEs) were well tolerated.     

Lower fasting blood glucose, glucose variability and nocturnal hypoglycaemia with glargine vs NPH basal insulin in subjects with Type 1 diabetes

Background and aimsTo compare switching from NPH insulin (NPH) to insulin glargine (glargine) with continuing NPH for changes in fasting blood glucose (FBG) in patients with Type 1 diabetes on basal–bolus therapy with insulin lispro as bolus insulin. Secondary objectives included self-monitoring blood glucose, mean daily blood glucose (MDBG) and mean amplitude glucose excursion (MAGE) values alongside changes in HbA_1c and safety profiles.Methods and resultsThis was a 30-week, parallel, open-label, multicentre study. Seven-point profiles were used to calculate MDBG and MAGE. Hypoglycaemia and adverse events were recorded by participants. FBG improved significantly with both glargine (baseline–endpoint change: −28.0 mg/dL; 95% CI: −37.3, −18.7 mg/dL; p < 0.001) and NPH (−9.8 mg/dL; 95% CI: −19.1, −0.5 mg/dL; p = 0.0374). The improvement was significantly greater with glargine than NPH (mean difference: −18.2 mg/dL; 95% CI: −31.3, −5.2 mg/dL; p = 0.0064). MDBG (−10.1 mg/dL; 95% CI: −18.1, −2.1 mg/dL; p = 0.0126) and MAGE (−20.0 mg/dL; 95% CI: −34.5, −5.9 mg/dL; p = 0.0056) decreased significantly with glargine, but not NPH although endpoint values were no different with the two insulins. Baseline to endpoint change in HbA_1c was similar (−0.56 vs −0.56%) with no differences at endpoint. Overall hypoglycaemia was no different, but glargine reduced nocturnal hypoglycaemia (“serious episodes” with BG < 42 mg/dl, p = 0.006) whereas NPH did not (p = 0.123), although endpoint values were no different.ConclusionSwitching from NPH to glargine is well tolerated and results into lower FBG, and lower glucose variability while reducing nocturnal hypoglycaemia. These data provide a rationale for more aggressive titration to target with glargine in Type 1 diabetes.     

Evaluation of transient hyperglycemia in non-diabetic patients with febrile neutropenia

BackgroundWe aimed to examine the effect of transient hyperglycemia in non-diabetic patients with febrile neutropenia.MethodsA total of 86 patients with febrile neutropenia were evaluated between June 2006 and December 2009. After measuring random blood glucose level at admission, cases with stress hyperglycemia were included in the study. Stress hyperglycemia was defined as documented random blood glucose level of 140 mg/dl and above without known diabetes mellitus, impaired glucose tolerance and impaired fasting glucose. A Multinational Association for Supportive Care in Cancer (MASCC) scoring system was used for the prediction of low and high risk patients according to medical complications at the onset of the febrile episode.ResultsThere were more patients with stress hyperglycemia than the patients with normoglycemia in the high risk group (p = 0.001). The growth of gram negative bacteria and fungi was higher in patients with stress hyperglycemia than with normoglycemia (p = 0.001). The patients receiving antifungal therapy had a higher rate of stress hyperglycemia than the patients without receiving antifungal therapy (p = 0.009). The patients with stress hyperglycemia had higher mortality rates than the patients with normoglycemia (p = 0.007). According to the MASCC risk-index, stress hyperglycemia increased 3.35 fold in the high risk patients compared to the low risk patients (p = 0.046) and 4.14 fold in the patients treated with antibacterial and antifungal agents compared to the patients treated with only antibacterial agents (p = 0.038).ConclusionPatients with stress hyperglycemia had more adverse clinical outcomes than patients with normoglycemia. We think further studies are needed to evaluate the relationship between stress hyperglycemia and febrile neutropenia.     

Predictive value of admission blood glucose level on short-term mortality in acute cerebral ischemia

BackgroundAdmission hyperglycemia increases the risk of death in patients with acute stroke. However, the most appropriate cut-off of glucose level indicating an increased risk of short-term mortality remains unknown.Purpose and methodsWe aimed at establishing the optimum cut-offs of several variables (including admission blood glucose levels) predicting case-fatality (72 hours, 7 days) and unfavorable outcome [modified Rankin Scale (mRS) score 5–6 at 7 days] in consecutive first-ever acute ischemic stroke. Receiver operating characteristic (ROC) curves were constructed.ResultsEight hundred eleven consecutive patients were included [median age of 77 (69–83) years; 418 (52%) male; 239 (30%) diabetics; median admission National Institutes of Health Stroke Scale (NIHSS) 7 (4–12), 32 (4%) dead within 72 hours; 64 (8%) dead within day 7; 155 (19%) with unfavorable outcome]. Median admission glucose levels were 113 (97–155) mg/dL. Diabetics had significantly higher median glucose levels than non-diabetics [163 (133–214) vs. 107 (92–123) mg/dL, p < 0.001]. According to ROC analysis, the only significant predictive value of glycemia was ≥ 143 mg/dL for 72-hour fatality (sensitivity 88% and specificity 70%) especially in non-diabetics (sensitivity 88% and sensitivity 62%). This cut-off point was an independent predictor for 72-hour fatality (overall: OR = 4.0, CI = 1.6–9.9, p = 0.003; non-diabetics: OR = 4.9, CI = 1.7–14.5, p = 0.004). The cut-offs of fasting total cholesterol levels and admission leukocytes had poor predictive values for each outcome, while those of admission NIHSS had good discrimination in predicting short-term outcome measures.ConclusionsAdmission hyperglycemia (≥ 143 mg/dL) is a strong and an independent predictor for 72-hour fatality, especially in patients with no prior history of diabetes mellitus.     

Taxa de filtração glomerular: que fórmula deverá ser usada em doentes com enfarte agudo do miocárdio?

IntroductionThere is disagreement regarding the best method for assessing renal dysfunction in patients with myocardial infarction (MI). This study aims to compare two commonly used formulas for measuring glomerular filtration rate (GFR) (Cockcroft-Gault [CG] and modification of diet in renal disease [MDRD]) in terms of predicting extent of coronary artery disease (CAD) and short- and long-term cardiovascular risk.MethodsWe studied 452 patients admitted to a cardiac intensive care unit (ICU) with MI (age 69.01 ± 13.64 years; 61.7% male, 38.5% diabetic) and followed for two years. CG and MDRD GFR estimates were compared in terms of prediction of CAD extent, in-hospital mortality risk and cardiovascular risk during follow-up.ResultsGFR <60 ml/min/1.73 m² using the MDRD formula was associated with a tendency for more extensive CAD (2.70 affected segments vs. 2.20, p = 0.052) and higher two-year mortality risk (p < 0.001, OR 3.84, 95% CI 2.04-7.22) and risk for reinfarction (p < 0.001, OR 4.09, 95% CI 2.00-8.39), decompensated heart failure (DHF) (p < 0.001, OR 3.95, 95% CI 2.04-7.66) and combined cardiovascular endpoints (p = 0.001, OR 2.47, 95% CI 1.47-4.17). Using the CG formula, GFR < 60 ml/min/1.73 m² only predicted higher risk for DHF (p = 0.016, OR 4.5, 95% CI 1.11-16.57), despite a tendency for more overall combined cardiovascular endpoints (p = 0.09, OR 2.84). Both formulas predicted in-hospital mortality.Discussion/ConclusionsThis study confirmed the value of GFR in predicting various cardiovascular endpoints in patients with MI. Compared to the CG formula, the MDRD formula was significantly more accurate in predicting the severity of CAD and two-year CV risk in patients admitted to the ICU with MI.     

Quality of diabetes care predicts the development of cardiovascular events: results of the QuED study

Background and aimIn the context of the QuED Study we assessed whether a quality of care summary score was able to predict the development of cardiovascular (CV) events in patients with type 2 diabetes.Methods and resultsThe score was calculated using process and intermediate outcome indicators (HbA_1c, blood pressure, low-density lipoprotein cholesterol, microalbuminuria) and ranged from 0 to 40. Overall, 3235 patients were enrolled, of whom 492 developed a CV event after a median follow-up of 5 years. The incidence rate (per 1000 person-years) of CV events was 62.4 in patients with a score ≤10, 54.8 in those with a score between 15 and 20, and 39.8 in those with a score >20. In adjusted multilevel regression models, the risk to develop a CV event was 89% greater in patients with a score of ≤10 (rate ratio [RR] = 1.89; 95% confidence interval [CI] 1.43–2.50) and 43% higher in those with a score between 10 and 20 (RR = 1.43; 95% CI 1.14–1.79), as compared to those with a score >20. A difference between centers of 5 points in the mean quality score was associated with a difference of 16% in CV event risk (RR = 0.84; 95% CI 0.72–0.98).ConclusionOur study documented for the first time a close relationship between a score of quality of diabetes care and long-term outcomes.     

Long-term follow-up of participants in a health promotion program for treated hypertensives (ADAPT)

Background and aimsImprovements in a lifestyle modification program for hypertensives were maintained 1 year later. Longer follow-up in such studies is limited; we therefore re-assessed participants after an additional 2 years in which there was no contact with program facilitators.Methods and resultsParticipants randomised to usual care (N = 118) or a 4-month lifestyle program (N = 123) were previously assessed after 4 months and 1 year. After a further 2 years, diet, alcohol intake, physical activity, weight, waist girth, ambulatory blood pressure (BP), blood lipids, glucose and insulin were measured (usual care N = 64; program N = 76). Statistically significant net changes, relative to usual care, included blood cholesterol (−0.2 mmol/L, 95% CI 0.1–0.4); physical activity (53 min/week, 95% CI 15–91); dietary saturated fat (−1.9% energy, 95% CI −0.1 to −3.8); fish (3.2 serves/month, 95% CI 0.7–5.7); vegetables (9.1 serves/month, 95% CI 3.2–15.1); and sweet foods (−6.2 serves/month, 95% CI −1.1 to −11.3). Between-group changes in weight (−0.7 kg, 95% CI −1.8–0.4), BP (systolic 1.4 mmHg, 95% CI −0.7–3.5)/diastolic 1.0 mmHg, 95% CI −0.3–2.4) and Framingham risk (usual care: men 12.1%, women 3.7%; program: men 12.2%; women 3.5%) did not differ significantly.ConclusionContinued reinforcement with long-term follow-up is needed in lifestyle modification programs.     

Retrospective comparative analysis of metabolic control and early complications in familial and sporadic type 1 diabetes patients

BackgroundGenetic susceptibility and lifestyle are associated with glycemic control and diabetic complications in type 1 diabetes (T1D).ObjectivesTo investigate metabolic control and occurrence of acute and microvascular complications among familial and sporadic T1D patients.Patients and MethodsRetrieved from our institutional registry of new T1D cases for the years 1979–2008 were 226 familial patients belonging to 121 families (58 parent–offspring, 63 sib-pairs) and 226 sporadic cases matched for age, gender, and year of diagnosis. Extracted from medical files were clinical course and therapeutic regimen.ResultsMean age at diagnosis of diabetes of the cohort was 10.8 ± 5.7 years. Throughout follow-up (11.1 ± 8.7 years) mean HbA1c values were significantly higher in familial than in sporadic cases (8.18% ± 1.15% vs. 7.85% ± 1.15%, p = 0.005). Diabetic ketoacidosis (DKA) rates were higher in familial than sporadic cases (2.8 vs. 1.9 events per 100 patient-years; incidence rate ratio (IRR) = 1.5, 95% CI [1.03, 2.22, p = 0.03]). Severe hypoglycemia events per 100 patient-years were comparable in familial and sporadic groups (3.7 vs. 4.0 events); sib-pairs had higher rates than parent–offspring (4.8 vs. 2.4 events; (IRR) = 2, 95% CI [1.03, 3.25, p = 0.03]). The percentage of patients with microvascular complications was similar in the familial (21.7%) and sporadic (26.7%) groups. In both familial and sporadic cases the most significant predictor for metabolic control and microvascular complications was diabetes duration; a higher mean HbA1c level was the predictor for DKA events.ConclusionsThe worse metabolic control and increased rate of DKA in familial T1D patients as compared to those in the sporadic T1D patients warrant intensified surveillance in this population.     

Endoscopic retrograde cholangiopancreatography versus surgery for choledocholithiasis – A meta-analysis

Introduction and ObjectivesThere is no consensus on the best treatment option for choledocholithiasis. Therefore, the aim of this study was to compare endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct surgery (CBDS) for the treatment of choledocholithiasis.Materials and methodsWe performed a systematic review of randomized controlled trials (RCTs) comparing ERCP and CBDS in the treatment of choledocholithiasis. MEDLINE and EMBASE were the used databases. RCTs assessing mortality, bile duct clearance failure, complications, or length of hospital stay were considered eligible. Meta-analysis was performed using random effects model, through the Mantel–Haenszel method for binary outcomes and through the inverse variance method for continuous outcomes. The quality of the evidence was evaluated according to the Grading of Recommendations Assessment, Development and Evaluation Working Group. The study protocol was registered at the PROSPERO platform (CRD42017073196).ResultsNineteen RCTs (2466 patients) were included in the meta-analysis. There was no evidence of significant difference between interventions regarding mortality (risk ratio – RR = 1.31, 95% confidence interval – 95% CI = 0.60–2.85, p = 0.49), bile duct clearance failure (RR = 1.17, 95% CI = 0.86–1.59, p = 0.31), complications (RR = 0.99, 95% CI = 0.82–1.20, p = 0.94) and length of hospital stay (weighted mean difference – MD = 1.06, 95% CI = −0.62–2.73, p = 0.22). Sensitivity analyses failed to demonstrate significant changes in results compared to the main analyses. The quality of the evidence was considered to be low.ConclusionThere was no evidence of significant difference between ERCP and CBDS for the treatment of choledocholithiasis.     

Serum osmolarity as an outcome predictor in hospital emergency medical admissions

BackgroundTo determine whether the serum osmolarity, calculated at the time of an emergency medical presentation, alone or combined with other predictors, could identify patients at low and high risks of an inpatient death by day 30.MethodsA retrospective analysis of all emergency medical patients admitted to St. James's Hospital (SJH), Dublin between the 1st of January 2002 and the 31st of December 2009, using the hospital in-patient enquiry (HIPE) system, linked to the patient administration system, and laboratory datasets. Hospital inpatient mortality (30 days) was obtained from a database of deaths over the same period. Multivariate logistic regression was used to derive the best predictive model, with goodness of fit and Area Under the Receiver Operator Curves (AUROC) assessing the predictive accuracy.ResultsUnivariate analysis identified two quantiles of < 10% and > 75% of the osmolarity distribution as being at an increased mortality risk. Their respective mortality rates were 13.7% and 15.7% respectively, with unadjusted odds rate that were 1.66 (1.47, 1.88): p < 0.0001 and 3.14 (2.87, 3.43): p < 0.0001. After adjustment for other outcome predictors, a significant association with increased mortality remained, with OR = 1.82 (1.61, 2.06), p < 0.0001. Although the calculated osmolarity alone was not sufficiently predictive with AUROC = 0.74 (95% CI: 0.73, 0.76), when combined with other predictors, the AUROC increased to 0.86 (95% CI: 0.84, 0.88).ConclusionAdmission osmolarity, a simple calculation, is associated with the risk of mortality in acutely ill medical patients; deviations outside the normal range are relevant. A useful clinical predictive algorithm requires the incorporation of additional predictors.