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      Oral Hypoglycemics: Increased Postoperative Mortality in Coronary Risk Patients

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          Abstract

          Background: Diabetes mellitus (DM), particularly if insulin-dependent, is a predictor of increased perioperative risk, whereas stringent metabolic control with insulin is beneficial in the critically ill. Methods: The impact of oral hypoglycemics (OH) vs. insulin on outcome was determined as a secondary retrospective analysis of a cohort study in patients with coronary artery disease (CAD) and DM undergoing major non-cardiac surgery. Primary end-point was 2-year all-cause mortality; secondary endpoints were perioperative myocardial ischemia and 2-year cardiac mortality. Results: Of 173 patients, DM was diagnosed in 42 (24%) based on pre-existing treatment with OH (15%) or insulin (9%). During follow-up, 40/173 (23%) patients died. All-cause mortality was similar in the non-diabetic (20%) and insulin groups (19%) but significantly higher in the OH group (42%; p = 0.025). Cardiac mortality tended to be higher in the OH group compared with the insulin and non-diabetic groups (27 vs. 19% and 11%, respectively; p = 0.066). Multivariate analysis revealed renal failure (odds ratio [OR] = 4.9, 95% confidence interval [CI] = 1.8–13.0), treatment with OH (OR = 3.3, 95% CI = 1.2–9.0), peripheral vascular surgery (OR = 2.7, 95% CI = 1.2–6.0), and prior diuretic therapy (OR = 2.6, 95% CI = 1.1–5.7) being independently associated with 2-year all-cause death. No difference existed in postoperative ischemia among the different groups. Conclusions: Long-term mortality after major non-cardiac surgery is elevated in patients with CAD and diabetes mellitus only if they are treated with OH, but not if they are treated with insulin. Further evaluation of the impact of perioperative anti-diabetic treatment on morbidity and mortality in CAD is warranted.

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          Most cited references 8

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          Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose versus glycemic control.

          Maintenance of normoglycemia with insulin reduces mortality and morbidity of critically ill patients. Here we report the factors determining insulin requirements and the impact of insulin dose vs. blood glucose control on the observed outcome benefits. A prospective, randomized, controlled trial. A 56-bed predominantly surgical intensive care unit in a tertiary teaching hospital. A total of 1,548 patients were randomly assigned to either strict normalization of blood glucose (80-110 mg/dL) with insulin infusion or the conventional approach, in which insulin is only given to maintain blood glucose levels at 180-200 mg/dL. It was feasible and safe to achieve and maintain blood glucose levels at 20 IU/hr). Between day 7 and 12, insulin requirements decreased by 40% on stable caloric intake. Brief, clinically harmless hypoglycemia occurred in 5.2% of intensive insulin-treated patients on median day 6 (2-14) vs. 0.8% of conventionally treated patients on day 11 (2-10). The outcome benefits of intensive insulin therapy were equally present regardless of whether patients received enteral feeding. Multivariate logistic regression analysis indicated that the lowered blood glucose level rather than the insulin dose was related to reduced mortality (p <.0001), critical illness polyneuropathy (p <.0001), bacteremia (p =.02), and inflammation (p =.0006) but not to prevention of acute renal failure, for which the insulin dose was an independent determinant (p =.03). As compared with normoglycemia, an intermediate blood glucose level (110-150 mg/dL) was associated with worse outcome. Normoglycemia was safely reached within 24 hrs and maintained during intensive care by using insulin titration guidelines. Metabolic control, as reflected by normoglycemia, rather than the infused insulin dose, was related to the beneficial effects of intensive insulin therapy.
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            Oral Antihyperglycemic Therapy for Type 2 Diabetes

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              Helicobacter pylori eradication in long-term users of non-steroidal anti-inflammatory drugs

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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2007
                May 2007
                29 January 2007
                : 107
                : 4
                : 296-301
                Affiliations
                Departments of Cardiology, Anesthesia, and Endocrinology, Diabetes and Clinical Nutrition, University Hospital, Basel, Switzerland
                Article
                99065 Cardiology 2007;107:296–301
                10.1159/000099065
                17264509
                © 2007 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 1, Tables: 3, References: 28, Pages: 6
                Categories
                Original Research

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