Comparison of morbidity and mortality in diabetics versus nondiabetics having isolated coronary bypass versus coronary bypass plus valve operations versus isolated valve operations

The impact of diabetes mellitus (DM) on the outcome of patients requiring cardiac surgery has been investigated in previous decades. However, the profile of cardiac surgical practice is changing in addition to changes in patients' risk profile, making the results inconclusive. In this study we sought to investigate the impact of DM on operative mortality and morbidity in patients undergoing cardiac surgery and adjust for patient and disease characteristics. In total 10,709 patients (9,229 nondiabetics and 1,480 diabetics) were admitted to the study; 5,557 patients (1,012 diabetics) underwent an isolated coronary operation, 1,775 patients (278 diabetics) underwent coronary plus valve operations, and 3,337 patients (209 diabetics) underwent valve operations. To control for differences in patient and disease characteristics, a propensity score (for DM) was performed. DM increased crude morbidity and this difference was maintained after risk adjustment for propensity score; conversely, the crude operative mortality risk was higher in diabetics but not significantly after adjustment for propensity score. Thereafter, DM remained independently associated to operative mortality risk in the valve population only (odds ratio 2.53, 95% confidence interval 1.45 to 4.4, p = 0.001). In conclusion, DM has a significant impact on operative mortality of patients undergoing heart valve surgery. Although diabetic patients undergoing coronary operations are not at increased risk of operative mortality, morbidity is significantly affected in the overall population.     

不停跳冠状动脉旁路移植术对糖尿病患者术后早期结果的影响

目的探讨糖尿病对冠状动脉旁路移植术的手术病死率和并发症发生率的影响作用.方法回顾分析1995年10月-2004年1月958例择期行冠状动脉旁路移植术的患者,其中191例并发糖尿病.糖尿病和无糖尿病患者按是否应用体外循环进一步分为四组,对四组患者术前、术后资料进行对比分析.结果糖尿病组应用体外循环患者手术病死率为5.6%,糖尿病组不停跳冠状动脉旁路移植术患者为2.1%.结论糖尿病是影响冠状动脉旁路移植术预后的危险因素,不停跳冠状动脉旁路移植术能显著减少糖尿病患者的手术病死率和并发症发生率.     

Preexisting Diabetes and Risks of Morbidity and Mortality After Gastrectomy for Gastric Cancer: A Nationwide Database Study

The purpose of this study was to determine the risk of surgical mortality and morbidity in patients with diabetes mellitus (DM) undergoing a gastrectomy for gastric cancer (GC).Using the Taiwan National Health Insurance Research Database, we identified 6284 patients who underwent gastrectomy for GC from 1999 to 2010. In addition, we created a non-DM control cohort consisting of 6268 patients who received gastrectomy during the same period.Compared with the non-DM cohort, the DM cohort exhibited a higher prevalence of preoperative coexisting medical conditions, namely hypertension, hyperlipidemia, coronary artery disease, chronic kidney disease, chronic pulmonary disease, stroke, and cirrhosis. The odds ratio (OR) of 30-day postoperative mortality after gastrectomy in the DM cohort was 1.04 (95% confidence interval 0.78–1.40) after we adjusted for covariates. The DM cohort did not exhibit a significantly higher risk of 30-day postoperative morbidities. Further analysis revealed that only patients with a history of a DM-related coma exhibited a higher risk of 30-day postoperative mortality (adjusted OR 2.46, 95% confidence interval 1.10 − 5.54). Moreover, the risk of 90-day postoperative mortality was significantly higher in patients with DM-related eye involvement, coma, peripheral circulatory disease, and renal manifestations, in comparison with the non-DM cohort.The risk of 90-day mortality after gastrectomy for GC is higher in patients with DM-related manifestations than those without DM.     

Clinical outcomes and left ventricular function in diabetic patients with acute myocardial infarction treated by primary coronary angioplasty

The objective of the present study was to compare left ventricular (LV) function and clinical outcomes in diabetics versus nondiabetics with acute myocardial infarction (AMI) treated by primary coronary angioplasty. A total of 327 consecutive AMI subjects were reperfused by primary coronary angioplasty within 12 hours from onset. Diabetes mellitus (DM) was present in 104 of the 327 patients. LV function was serially determined by left ventriculograms taken in the acute and chronic phases (6 months after onset). (I) The early ST-segment resolution rate was lower in DM patients compared with non-DM patients (59% versus 83%, P < 0.0001). (II) During a 6-month follow-up, the percentages of target vessel revascularization (TVR), coronary aorta bypass grafting (CABG), and cardiac death were higher in the DM patients compared with the non-DM patients (TVR: 29% versus 19%; P < 0.05, CABG: 10% versus 5% ; P < 0.05, cardiac death: 12% versus 4%; P = 0.01). (III) The differences in left ventricular ejection fraction (LVEF) between two stages (delta-LVEF) were significantly lower in the DM patients than the non-DM patients (1 +/- 9% versus 7 +/- 10%, P < 0.0001). (IV) Multivariate analysis identified DM as an independent predictor of cardiac death (Odds ratio 5.5, 95% CI, 1.3-23.7, P < 0.05) and as a sole independent predictor of LVEF deterioration (Odds ratio 5.8, 95% CI, 2.8-11.8, P < 0.001). In patients with AMI treated using primary coronary angioplasty, DM is closely related to left-ventricular systolic dysfunction and a poor patient outcome, including mortality.     

Effect of revascularization on coronary chronic total occlusion in patients undergoing coronary artery bypass grafting

BackgroundBypass grafting for chronic total occlusions (CTOs) remains surgically challenging and controversial. Therefore, we evaluated the incidence and clinical outcomes of revascularization on CTOs undergoing coronary artery bypass grafting (CABG).MethodsAmong 828 patients who underwent isolated CABG from January 2010 to December 2018, 245 patients (29.6%) diagnosed with at least one CTO were included and retrospectively reviewed. Primary endpoints were 30-day and overall mortality. Secondary endpoint was the composite outcome of major adverse cardiac and cerebrovascular events (MACCE).ResultsWith a mean follow-up of 56.6±6.5 months in 245 patients with CTOs, 51 patients (20.8%) received incomplete revascularization (ICR) for CTO lesions. Risk factor analysis showed that ICR was associated with increased 30-day [odds ratio 8.62; 95% confidence interval (CI): 1.64–50; P=0.011] and overall mortality (hazard ratio (HR) 2.13; 95% CI: 1.07–4.21; P=0.03). ICR also increased the risk of MACCE (HR 1.98; 95% CI: 1.12–3.54; P=0.01). Freedom from overall mortality was 92.8%, 90.4%, and 86.8% in the complete revascularization group, and 86.3%, 80.0%, and 72.7% in the ICR group, at 1, 3, and 5 years, respectively (P=0.004).ConclusionsIn patients with CTOs undergoing CABG, the rate of ICR was 20.8%, and it significantly increased the risk of mortality and MACCE. Further studies in a large cohort are needed.     

Morbidity and mortality following coronary artery bypass graft surgery in patients with cirrhosis: a population‐based study

Background: The risk of cardiac surgery in patients with cirrhosis is poorly defined. Our objective was to describe outcomes of coronary artery bypass graft (CABG) surgery in cirrhotic patients from a population‐based perspective. Methods: We analysed the 1998–2004 Nationwide In‐patient Sample to identify patients hospitalized for CABG surgery. The effect of cirrhosis on mortality, complications, length of stay (LOS) and charges was evaluated using logistic regression models. Results: Between 1998 and 2004, there were 403 094 CABG admissions; 711 patients (0.2%) had cirrhosis. The average annual number of surgeries increased 4.2% [95% confidence interval (CI) 0.7–7.8] in cirrhotic patients, but decreased 5.5% (3.4–7.5) in non‐cirrhotic patients. Patients with cirrhosis had an increased risk of mortality [17 vs. 3%; adjusted odds ratio (OR) 6.67; 95% CI 5.31–8.31], complications [43 vs. 28%; OR 1.99 (95% CI 1.72–2.30)] and greater LOS and charges (P<0.0001). Predictors of mortality included age over 60 (OR 2.21; 95% CI 1.31–3.73), female gender (OR 1.92; 95% CI 1.08–3.41), ascites (OR 3.80; 95% CI 1.95–7.39) and congestive heart failure (OR 1.75; 95% CI 1.08–2.84). Hospital volume and off‐pump CABG did not affect mortality. Conclusions: Patients with cirrhosis have an increased risk of morbidity and mortality following CABG surgery. Additional studies are necessary to refine risk stratification in this high‐risk patient population.     

Prevalence, predictors, and outcomes of conservative medical management in non-ST-segment elevation acute coronary syndromes in Gulf RACE-2

We assessed the prevalence, predictors, and in-hospital and long-term outcomes of conservative medical management for patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) compared with percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG). This prospective study conducted from October 2008 to June 2009 in 65 hospitals from 6 Arabian Gulf countries included 30-day and 1-year mortality follow-up for 3661 patients. Compared with conservative management group (2859 patients; 78.1%), the PCI group (638; 17.4%) had significantly better unadjusted and adjusted in-hospital (odds ratio [OR]: 0.40, 95% confidence interval [CI]: 0.17-0.97), 30-day (OR: 0.44, 95% CI: 0.24-0.76) and 1-year (OR: 0.58, 95% CI: 0.40-0.87) mortality rates. Comparison with the CABG group (164; 4.5%) yielded similar results with inclusion of patients scheduled for CABG after hospital discharge. Independent predictors of conservative medical management were mainly country of residence and history of prior CABG.     

Comparison of three-year clinical outcomes after sirolimus-eluting stent implantation among insulin-treated diabetic, non-insulin-treated diabetic, and non-diabetic patients from j-Cypher registry

The purpose of the present study was to evaluate the 3-year clinical outcomes after percutaneous coronary intervention with sirolimus-eluting stents in patients with insulin-treated diabetes mellitus (DM-insulin) and those with non-insulin-treated DM (DM-non-insulin) compared to patients without DM. Of 10,778 consecutive patients treated exclusively with sirolimus-eluting stents in the j-Cypher registry, we identified 996 patients with DM-insulin, 3,404 with DM-non-insulin, and 6,378 without DM. Compared to the non-DM group, the adjusted risk of a serious cardiovascular event (composite of all-cause death, myocardial infarction, and stroke) was significantly greater in the DM-insulin group (hazard ratio 1.12, 95% confidence interval [CI] 1.03 to 1.23; p = 0.01), but not in the DM-non-insulin group (hazard ratio 1.02, 95% CI 0.96 to 1.09; p = 0.47). The adjusted risk of target lesion revascularization was significantly greater in both the DM-insulin group (odds ratio 1.52, 95% CI 1.19 to 1.92; p = 0.0006) and the DM-non-insulin group (odds ratio 1.24, 95% CI 1.05 to 1.45; p = 0.009). In conclusion, a diabetes-associated excess risk of target lesion revascularization was found, regardless of insulin use in this large, real-world study of Japanese patients with sirolimus-eluting stent implantation. However, regarding serious cardiovascular events, an excess risk was seen only in the DM-insulin group. The risk of serious cardiovascular events was similar between the DM-non-insulin and non-DM groups.     

The impact of diabetes mellitus on major amputation among patients with chronic limb threatening ischemia undergoing elective endovascular therapy- a nationwide propensity score adjusted analysis

AimTo investigate the risk of major amputation after elective endovascular therapy in patients with chronic limb threatening ischemia (CLTI) comparing patients with and without diabetes mellitus (DM).MethodsIn this nationwide cohort study, all patients registered in the Swedish Vascular Register after elective endovascular therapy for CLTI caused by infra-inguinal arterial disease from 2010 to 2014 were included. Among 4578 individuals, 2251 had DM and were registered in the National Diabetes Register between 2009 and 2014. A propensity score adjusted Cox regression analysis was conducted to compare outcomes between groups. Median follow-up was 4.0 and 3.6 years for patients with DM and without DM, respectively.ResultsThe incidence rates of major amputation and acute myocardial infarction (AMI) were 43% (95% CI 1.23–1.67) and 37% (95% CI 1.13–1.67) higher, respectively, among patients with DM compared to patients without DM. There was no difference in mortality (HR 1.04, 95% CI 0.95–1.14).ConclusionsPatients with DM had a higher risk of major amputation and AMI compared to those without DM after elective endovascular therapy for CLTI. Prevention of DM with CLTI is of utmost importance to reduce the risk of adverse limb and cardiovascular outcomes.     

Preoperative Hypernatremia Predicts Increased Perioperative Morbidity and Mortality

Background

The prognostic implications of preoperative hypernatremia are unknown. We sought to determine whether preoperative hypernatremia is a predictor of 30-day perioperative morbidity and mortality.

Methods

We conducted a cohort study using the American College of Surgeons-National Surgical Quality Improvement Program and identified 908,869 adult patients undergoing major surgery from approximately 300 hospitals from the years 2005 to 2010. We followed the patients for 30-day perioperative outcomes, which included death, major coronary events, wound infections, pneumonia, and venous thromboembolism. Multivariable logistic regression was used to estimate the odds of 30-day perioperative outcomes.

Results

The 20,029 patients (2.2%) with preoperative hypernatremia (>144 mmol/L) were compared with the 888,840 patients with a normal baseline sodium (135-144 mmol/L). Hypernatremia was associated with a higher odds for 30-day mortality (5.2% vs 1.3%; adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.33-1.56), and this finding was consistent in all subgroups. The odds increased according to the severity of hypernatremia (P < .001 for pairwise comparison for mild [145-148 mmol/L] vs severe [>148 mmol/L] categories). Furthermore, hypernatremia was associated with a greater odds for perioperative major coronary events (1.6% vs 0.7%; aOR, 1.16; 95% CI, 1.03-1.32), pneumonia (3.4% vs 1.5%; aOR, 1.23; 95% CI, 1.13-1.34), and venous thromboembolism (1.8% vs 0.9%; OR, 1.28; 95% CI, 1.14-1.42).

Conclusion

Preoperative hypernatremia is associated with increased perioperative 30-day morbidity and mortality.     

Influence of peripheral vascular occlusive disease on the morbidity and mortality of coronary artery bypass grafting

The impact of peripheral vascular occlusive disease (PVD) on outcome for patients who have undergone coronary artery bypass grafting (CABG) was assessed by comparing preoperative and intraoperative patient characteristics and outcome in 2 groups of patients who underwent CABG (patients with PVD, n=96; patients without PVD, n=593). Patients with PVD were significantly older (69+/-8.4 vs 63+/-8.7; p<0.0001), and had a higher incidence of diabetes mellitus (48% vs 32%; p<0.01), hypertension (62% vs 46%; p<0.01), preoperative cerebral infarction (26% vs 12%; p<0.001) and chronic renal dysfunction (11% vs 4.4%; p<0.01) than those without PVD. Postoperative morbidity and mortality were assessed, after those risk factors were adjusted, using multivariate logistic regression analysis. The perioperative myocardial infarction (PMI) rate and in-hospital mortality rate were significantly higher in patients with PVD than in patients without PVD (9.4% vs 3.0%; p=0.0108, 17% vs 2.7%; p=0.0003, respectively). The odds ratio of PMI and in-hospital mortality were 3.4 (95% confidence intervals (CI): 1.3-8.6) and 4.3 (95% CI: 2.0-9.5), respectively. Although the excess mortality rate was mainly the result of cardiac problems, such as low output syndrome or arrhythmia, in most of the cases, PVD, which may frequently prevent the use of the intraaortic balloon pump, also seemed to have a strong relation to postoperative morbidity and mortality.     

The impact of ethnicity on outcomes following coronary artery bypass graft surgery in the Veterans Health Administration

OBJECTIVES: We evaluated the effect of African American (AA) and Hispanic American (HA) ethnicity on mortality and complications following coronary artery bypass graft (CABG) surgery in the Veterans Health Administration (VHA). BACKGROUND: Few studies have examined the impact of ethnicity on outcomes following cardiovascular procedures. METHODS: This study included all 29,333 Caucasian, 2,570 AA, and 1,525 HA patients who underwent CABG surgery at any one of the 43 VHA cardiac surgery centers from January 1995 through March 2001. We evaluated the relationship between ethnicity (AA vs. Caucasian and HA vs. Caucasian) and 30-day mortality, 6-month mortality, and 30-day complications, adjusting for a wide array of demographic, cardiac, and noncardiac variables. RESULTS: After adjustment for baseline characteristics, AA and Caucasian patients had similar 30-day (AA/Caucasian odds ratio [OR] 1.07; 95% confidence interval [CI] 0.84 to 1.35; p = 0.59) and 6-month mortality risk (AA/Caucasian OR 1.10; 95% CI 0.91 to 1.34; p = 0.31). However, among patients with low surgical risk, AA ethnicity was associated with higher mortality (OR 1.52, CI 1.10 to 2.11, p = 0.01), and AA patients were more likely to experience complications following surgery (OR 1.28; 95% CI 1.14 to 1.45; p < 0.01). In contrast, HA patients had lower 30-day (HA/Caucasian OR 0.70; 95% CI 0.49 to 0.98; p = 0.04) and 6-month mortality risk (HA/Caucasian OR 0.66; 95% CI 0.50 to 0.88; p < 0.01) than Caucasian patients. CONCLUSIONS: Ethnicity does not appear to be a strong risk factor for adverse outcomes following CABG surgery in the VHA. Future studies are needed to determine why AA patients have more complications, but ethnicity should not affect the decision to offer the operation.     

Diabetes and outcomes of coronary artery bypass graft surgery in patients with severe left ventricular dysfunction: results from The CABG Patch Trial database. The CABG Patch Trial Investigators and Coordinators

OBJECTIVES: We examined the relationship between diabetes mellitus and outcomes after coronary artery bypass graft (CABG) surgery in patients with severe left ventricular (LV) dysfunction. BACKGROUND: Although diabetes is associated with poor outcomes after CABG surgery among unselected patients, the relationship between diabetes and mortality after CABG surgery among patients with LV dysfunction is less certain. METHODS: Using data from The CABG Patch Trial, a study of implantable cardiac defibrillator therapy, we analyzed 900 patients with ejection fraction <0.36 who underwent CABG surgery from 1990 to 1996. RESULTS: Diabetics comprised 38% of the patients, and 48% of diabetics were prescribed insulin. Diabetes was associated with hypertension, peripheral vascular disease, history of stroke, clinical heart failure and rales on physical exam. Diabetics were at higher risk for postoperative superficial sternal wound infection and renal failure. With an average follow-up time of 32 +/-16 months, actuarial all-cause mortality 48 months after CABG surgery was 26% in diabetics and 24% in nondiabetics (p = 0.66, log-rank test). Diabetes was not associated with long-term mortality in Cox multiple regression analyses. Actuarial re-hospitalization rates 48 months after CABG surgery were 85% in diabetics and 69% in nondiabetics (p = 0.0001, log-rank test). Diabetics had a 44% higher risk of re-hospitalization for any cause (p = 0.0001) and a 24% higher risk of re-admission for cardiac causes (p < 0.05). Unexpectedly, fewer arrhythmic events were found in diabetics. CONCLUSIONS: Diabetes was not a predictor of mortality after CABG surgery among patients with LV dysfunction despite associated comorbidities. However, diabetes was associated with increased postoperative complications and re-hospitalization.     

Effect of body mass index on early outcomes in patients undergoing coronary artery bypass surgery

OBJECTIVES: This study sought to quantify the effect of body mass index (BMI) on early clinical outcomes following coronary artery bypass grafting (CABG). BACKGROUND: Obesity is considered a risk factor for postoperative morbidity and mortality after cardiac surgery, although existing evidence is contradictory. METHODS: A concurrent cohort study of consecutive patients undergoing CABG from April 1996 to September 2001 was carried out. Main outcomes were early death; perioperative myocardial infarction; infective, respiratory, renal, and neurological complications; transfusion; duration of ventilation, intensive care unit, and hospital stay. Multivariable analyses compared the risk of outcomes between five different BMI groups after adjusting for case-mix. RESULTS: Out of 4,372 patients, 3.0% were underweight (BMI <20 kg/m(2)), 26.7% had a normal weight (BMI >or=20 and <25 kg/m(2)), 49.7% were overweight (BMI >or=25 and <30 kg/m(2)), 17.1% obese (BMI >or=30 and <35 kg/m(2)) and 3.6% severely obese (BMI >or=35 kg/m(2)). Compared with the normal weight group, the overweight and obese groups included more women, diabetics, and hypertensives, but fewer patients with severe ischemic heart disease and poor ventricular function. Underweight patients were more likely than normal weight patients to die in hospital (odds ratio [OR] = 4.0, 95% CI 1.4 to 11.1), have a renal complication (OR = 1.9, 95% confidence interval [CI] 1.0 to 3.7), or stay in hospital longer (>7 days) (OR = 1.7, 95% CI 1.1 to 2.5). Overweight, obese, and severely obese patients were not at higher risk of adverse outcomes than normal weight patients, and were less likely than normal weight patients to require transfusion (ORs from 0.42 to 0.86). CONCLUSIONS: Underweight patients undergoing CABG have a higher risk of death or complications than normal weight patients. Obesity does not affect the risk of perioperative death and other adverse outcomes compared to normal weight, yet obese patients appear less likely to be selected for surgery than normal weight patients.     

Outcomes of diabetics receiving bare‐metal stents versus drug‐eluting stents

Objectives : We sought to determine if differences existed in in‐hospital outcomes, long‐term rates of target vessel revascularization (TVR), and/or long‐term mortality trends between patients with diabetes mellitus undergoing percutaneous coronary intervention (PCI) with either a drug‐eluting stent(s) (DES) or a bare metal stent(s) (BMS). Background : Short‐ and long‐term clinical outcomes of patients with diabetes mellitus undergoing PCI with DES versus BMS remain inconsistent between randomized‐controlled trials (RCTs) and observational studies. Methods : Data were collected prospectively on diabetics undergoing PCI with either DES or BMS from January 2000 to June 2008. Demographic information, medical histories, in‐hospital outcomes, and long‐term TVR and mortality trends were obtained for all patients. Results : A total of 1,319 patients were included in the study. Diabetics receiving DES had a significant reduction in index admission MACE compared to diabetics receiving BMS. Using multivariable adjustment, after a mean follow‐up of 2.5 years (maximum 5 years), diabetics who received DES had a 38% decreased risk of TVR compared to diabetics with BMS [HR 0.62 (95% CI: 0.43–0.90)]; diabetics with DES had an insignificant adjusted improvement in long‐term survival compared to diabetics with BMS [HR 0.72 (95% CI: 0.52–1.00)]. These long‐term survival and TVR rates were confirmed using propensity scoring. Conclusions : The use of DES when compared with BMS among diabetics undergoing PCI is associated with significant improvement in long‐term TVR, with an insignificant similar trend in all‐cause mortality. The long‐term results of this observational study are consistent with prior RCTs after adjusting for confounding variables. © 2010 Wiley‐Liss, Inc.     

The outcome of cardiac surgery in dialysis-dependent patients

BACKGROUND: Patients on dialysis for end-stage renal failure (ESRF) are undergoing cardiac surgery with increasing frequency. Furthermore, ESRF is known to be an important risk factor for complications of cardiac operations performed with cardiopulmonary bypass. AIMS: To evaluate the outcome of dialysis-dependent patients undergoing cardiac surgery at one institution. METHODS: A retrospective analysis was performed on consecutive patients with ESRF dependent upon maintenance haemodialysis or peritoneal dialysis who underwent cardiac surgery from January 1998 to August 2002. RESULTS: Thirty-eight patients on dialysis underwent cardiac surgery during this time period (1.5% of total cases). The most common cause for ESRF was diabetic nephropathy (n = 12). Operations performed included isolated coronary artery bypass grafting (CABG, n = 22), CABG and valve surgery (n = 8), and valve surgery alone (n = 6). When allowing for age, sex, surgeon and operative category, the odds ratio for mortality risk of dialysis patients, compared with all others, was 4.9 (95% confidence interval (CI): 1.7-13.9, p = 0.003), and for morbidity risk, was 2.8 (95% CI: 1.4-5.4, p = 0.003). CONCLUSIONS: Patients on dialysis have an increased morbidity and mortality following cardiac surgery, however we believe ESRF should not be regarded as an absolute contraindication to cardiac surgery or cardiopulmonary bypass.     

Uncontrolled diabetes mellitus increases risk of infection in patients with advanced cirrhosis

BackgroundDiabetes mellitus (DM) is common in patients with cirrhosis and is associated with increased risk of infection.AimTo analyze the impact of uncontrolled DM on infection and mortality among inpatients with advanced cirrhosis.MethodsThis study utilized the Nationwide Inpatient Sample from 1998 to 2014. We defined advanced cirrhosis using a validated ICD-9-CM algorithm requiring a diagnosis of cirrhosis and clinically significant portal hypertension or decompensation. The primary outcome was bacterial infection. Secondary outcomes included inpatient mortality stratified by elderly age (age≥70). Multivariable logistic regression analyzed outcomes.Results906,559 (29.2%) patients had DM and 109,694 (12.1%) were uncontrolled. Patients who had uncontrolled DM were younger, had less ascites, but more encephalopathy. Bacterial infection prevalence was more common in uncontrolled DM (34.2% vs. 28.4%, OR 1.33, 95% CI 1.29–1.37, p<0.001). Although uncontrolled DM was not associated with mortality, when stratified by age, elderly patients with uncontrolled DM had a significantly higher risk of inpatient mortality (OR 1.62, 95% CI 1.46–1.81).ConclusionsUncontrolled DM is associated with increased risk of infection, and when combined with elderly age is associated with increased risk of inpatient mortality. Glycemic control is a modifiable target to improve morbidity and mortality in patients with advanced cirrhosis.     

Metabolic syndrome increases operative mortality in patients undergoing coronary artery bypass grafting surgery.

OBJECTIVES: The aim of this study was to determine the impact of the metabolic syndrome (MS) on operative mortality after a coronary artery bypass grafting surgery (CABG). BACKGROUND: Diabetes and obesity are highly prevalent among patients undergoing CABG. However, it remains unclear whether these factors have a significant impact on operative mortality after this procedure. We hypothesized that the metabolic abnormalities associated with MS could negatively influence the operative outcome of CABG surgery. METHODS: We retrospectively analyzed the data of 5,304 consecutive patients who underwent an isolated CABG procedure between 2000 and 2004. Of these 5,304 patients, 2,411 (46%) patients met the National Cholesterol Education Program-Adult Treatment Panel III criteria for MS. The primary end point was operative mortality. RESULTS: The operative mortality after CABG surgery was 2.4% in patients with MS and 0.9% in patients without MS (p < 0.0001). The MS was a strong independent predictor of operative mortality (relative risk 3.04 [95% confidence interval (CI) 1.73 to 5.32], p = 0.0001). After adjusting for other risk factors, the risk of mortality was increased 2.69-fold (95% CI 1.43 to 5.06; p = 0.002) in patients with MS and diabetes and 2.36-fold (95% CI 1.26 to 4.41; p = 0.007) in patients with MS and no diabetes, whereas it was not significantly increased in the patients with diabetes and no MS. CONCLUSIONS: This is the first study to report that MS is a highly prevalent and powerful risk factor for operative mortality in patients undergoing a CABG surgery. Thus, interventions that could contribute to reduce the prevalence of MS in patients with coronary artery disease or that could acutely modify the metabolic perturbations of MS at the time of CABG might substantially improve survival in these patients.     

Impact of Diabetes Mellitus on Outcomes of Percutaneous Coronary Intervention in Chronic Total Occlusions: A Systematic Review and Meta-Analysis

BackgroundPatients with diabetes mellitus (DM) have a high prevalence of coronary chronic total occlusions (CTOs). We conducted a systematic review and meta-analysis to characterize outcomes after CTO percutaneous coronary intervention (PCI) in patients without or with DM.MethodsPubMed, EMBASE, Cochrane, and Google Scholar were queried for studies comparing non-DM vs. DM patients undergoing attempted CTO PCI. The primary outcome was all-cause mortality at longest follow-up (at least 6 months). Secondary outcomes were major adverse cardiovascular events (MACE) which is a composite endpoint including myocardial infarction, cardiac or all-cause mortality and any revascularization in patients after CTO PCI, target vessel revascularization (TVR), myocardial infarction (MI), Japanese chronic total occlusion (J-CTO) score and prevalence of multivessel (MV) CTO disease. We used a random effects model to calculate odds ratios (ORs) and 95% confidence intervals (CIs).ResultsSixteen studies, including 2 randomized control trials and 14 observational studies, met inclusion criteria. At longest follow-up, all-cause mortality (OR 0.54 [95% CI 0.37–0.80], p < 0.0001) and MACE (OR 0.82 [95% CI 0.72–0.93], p < 0.00001) were significantly lower in non-DM CTO patients. MV CTO disease was less prevalent in patients without DM (OR 0.80 [95% CI 0.69–0.93], p = 0.004). However, there were no differences in MI, TVR and J-CTO score.ConclusionsNon-diabetics undergoing CTO PCI have lower all-cause mortality and MACE than diabetics. Future research may determine if DM control improves diabetics' CTO PCI outcomes.     

Diabetes poses a higher risk of hepatocellular carcinoma and mortality in patients with chronic hepatitis B: A population‐based cohort study

Diabetes mellitus may be a risk factor of HCC development in chronic hepatitis B infected patients and affect the all‐cause mortality. This study aimed to examine whether DM was associated with the development of HCC with CHB and affected the all‐cause mortality. A total of 2966 CHB patients newly diagnosed with DM in 2000 were retrieved from the Longitudinal Cohort of Diabetes Patients database and used propensity scores matching based on age, sex‐gender, alcohol‐related liver disease and baseline liver cirrhosis to compare with the non‐DM patients from the Taiwanese National Health Insurance Research Database. The CHB patients with DM compared to the non‐DM had significantly increased (3.3%) risk for HCC development and significantly increased (2.8%) risk of HCC‐related mortality. Interestingly, the all‐cause mortality was significantly higher in the DM cohort (16.9%) compared to the non‐DM cohort (8.2%). In a multivariable transition‐specific Cox model to investigate the adjusted hazard ratio of CHB patients with DM or non‐DM during the transitions from start to HCC was 1.35; 95% CI (1.16‐1.57) and from HCC to death was 1.31; 95% CI (1.06‐1.62). All‐cause mortality between CHB patients with DM or non‐DM during the transitions from start to death was 2.32; 95% CI (1.84‐2.92). Taken together, DM is an independent risk factor associated with increasing disease development of HCC, HCC‐related mortality and all‐cause mortality in CHB patients. This study may provide a clinical strategy for strict DM control in order to reduce the risk of disease development in CHB patients.