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Zhang Y, Cai S, Xiong X, Zhou L, Shi J, Chen D. Intraoperative Glucose and Kidney Injury After On-Pump Cardiac Surgery: A Retrospective Cohort Study. J Surg Res 2024; 300:439-447. [PMID: 38865746 DOI: 10.1016/j.jss.2024.04.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/26/2024] [Accepted: 04/20/2024] [Indexed: 06/14/2024]
Abstract
INTRODUCTION Acute kidney injury (AKI) is a common complication after on-pump cardiac surgery, and previous studies have suggested that blood glucose is associated with postoperative AKI. However, limited evidence is available regarding intraoperative glycemic thresholds in cardiac surgery. The aim of this study was to explore the association between peak intraoperative blood glucose and postoperative AKI, and determine the cut-off values for intraoperative glucose concentration associated with an increased risk of AKI. METHODS The study was retrospective and single-centered. Adult patients in West China Hospital of Sichuan University who underwent on-pump cardiac surgery (n = 3375) were included. The primary outcome was the incidence of AKI. Multivariable logistic analysis using restricted cubic spline was performed to explore the association between intraoperative blood glucose and postoperative AKI. RESULTS The incidence of AKI in the study population was 18.0% (607 of 3375). Patients who developed AKI had a significantly higher peak intraoperative glucose during the surgery compared to those without AKI. After adjustment for confounders, the incidence of AKI increased with peak intraoperative blood glucose (adjusted odds ratio, 1.08, 95% confidence interval 1.03, 1.12). Furthermore, it was demonstrated that the possibility of AKI was relatively flat till 127.8 mg/dL (7.1 mmol/L) glucose levels which started to rapidly increase afterward. CONCLUSIONS Increased intraoperative blood glucose was associated with an increased risk of AKI. Among patients undergoing on-pump cardiac surgery, avoiding a high glucose peak (i.e., below 127.8 mg/dL [7.1 mmol/L]) may reduce the risk of postoperative AKI.
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Affiliation(s)
- Yuyang Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Shuang Cai
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Xinglong Xiong
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Leng Zhou
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Jing Shi
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Dongxu Chen
- Department of Anesthesiology, West China Second Hospital of Sichuan University, Chengdu, China; Sichuan University West China Second University Hospital Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China.
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Xiong X, Chen D, Cai S, Qiu L, Shi J. Association of intraoperative hyperglycemia with postoperative composite infection after cardiac surgery with cardiopulmonary bypass: A retrospective cohort study. Front Cardiovasc Med 2023; 9:1060283. [PMID: 36712254 PMCID: PMC9880037 DOI: 10.3389/fcvm.2022.1060283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/29/2022] [Indexed: 01/14/2023] Open
Abstract
Background The association between intraoperative hyperglycemia (IH) and postoperative infections in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) is inadequately studied. Methods A total of 3,428 patients who underwent cardiac surgery with CPB at our institution between June 1, 2019 and July 30, 2021 were enrolled to evaluate the association of IH (blood glucose ≥ 180 mg/dL) with postoperative infection in patients. The new onset of any type of infection and the optimal cutoff values of intraoperative glucose to predict in-hospital infection were determined. Results The composite outcome occurred in 497 of 3,428 (14.50%) patients. IH was associated with an increased risk of postoperative composite infection [adjusted odds ratio: 1.39, (95% confidence interval), 1.06-1.82, P = 0.016]. Restricted cubic splines were applied to flexibly model and visualize the association of intraoperative peak glucose with infection, and a J-shaped association was revealed. Besides, it was demonstrated that the possibility of infection was relatively flat till 150 mg/dL glucose levels which started to rapidly increase afterward. Conclusion We summarize that IH is associated with an elevated risk of postoperative new-onset composite infections and perioperative blood glucose management should be more stringent, i.e., lesser than 150 mg/dL in patients undergoing cardiac surgery.
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Affiliation(s)
- Xinglong Xiong
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Dongxu Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Shuang Cai
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Li Qiu
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jing Shi
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China,*Correspondence: Jing Shi,
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Djouani A, Smith A, Choi J, Lall K, Ambekar S. Cardiac surgery in the morbidly obese. J Card Surg 2022; 37:2060-2071. [PMID: 35470870 DOI: 10.1111/jocs.16537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/28/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Obesity rates globally continue to rise and in turn the body mass index (BMI) of patients undergoing cardiac surgery is set to mirror this. Patients who are Class III obese (BMI ≥ 40) pose significant challenges to the surgical teams responsible for their care and are also at high risk of complications from surgery and even death. To improve outcomes in this population, interventions carried out in the preoperative, operative, and postoperative periods have shown promise. Despite this, there are no defined best practice national guidelines for perioperative management of obese patients undergoing cardiac surgery. AIM This review is aimed at clinicians and researchers in the field of cardiac surgery and aims to form a basis for the future development of clinical guidelines for the management of obese cardiac surgery patients. METHODS The PubMed database was utilized to identify relevant literature and strategies employed at various stages of the surgical journey were analyzed. CONCLUSIONS Data presented identified the benefits of preoperative respiratory muscle training, off-pump coronary artery bypass grafting where possible, and early extubation. Further randomized controlled trials are required to identify optimal operative and perioperative management strategies before the introduction of such guidance into clinical practice.
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Affiliation(s)
- Adam Djouani
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Alexander Smith
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Jeesoo Choi
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Kulvinder Lall
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Shirish Ambekar
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
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Buelter J, Smith JB, Carel ZA, Kinsey D, Kruse RL, Vogel TR, Bath J. Preoperative HbA1c and Outcomes Following Lower Extremity Vascular Procedures. Ann Vasc Surg 2021; 83:298-304. [PMID: 34942340 DOI: 10.1016/j.avsg.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/02/2021] [Accepted: 12/04/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Limited data exist evaluating pre-operative hemoglobin A1c (HbA1c) in patients undergoing vascular procedures for peripheral arterial disease (PAD). This study evaluated the relationship of preoperative HbA1c on outcomes after open and endovascular lower extremity (LE) vascular procedures for PAD. METHODS We selected patients with PAD admitted for elective LE procedures between September 2008 and December 2015 from the Cerner Health Facts® database using ICD-9-CM diagnosis and procedure codes. Bivariable analysis and multivariable logistic models examined the association of patient characteristics, procedure type, and preoperative HbA1c (normal < 6.5%, high ≥ 6.5%) with postsurgical outcomes that included infection, renal failure, respiratory or cardiac complications, length of stay (LOS), in-hospital mortality, and readmission. RESULTS Of 4,087 patients who underwent a LE vascular procedure for PAD, 2,462 (60.2%) had a preoperative HbA1c recorded. The cohort was mostly male (60%), white (73%), and underwent endovascular intervention (77%). Patients with high HbA1c levels were more likely of black race (p < .02) and had significantly higher comorbidities (p < .0001). Elevated HbA1c was associated with diabetes (p < .0001) and cellulitis (p = .05) on unadjusted analysis. Multivariable logistic regression (adjusting for patient, hospital, comorbidity and procedural characteristics) revealed that elevated HbA1c was significantly associated with 30-day readmission (OR = 1.06, 95% CI = 1.00-1.12), but was not associated with the other outcomes. An independent diagnosis of diabetes was not predictive of complications or readmission. CONCLUSIONS Historic glucose control, as evidenced by a high preoperative HbA1c level, is not associated with adverse outcome, other than readmission, in patients undergoing LE procedures for PAD. Given the known association of high perioperative glucose levels with poor outcome following vascular procedures, this is suggestive of a more important effect of perioperative, as opposed to chronic, glucose control upon outcome. Thus, we suggest focusing efforts on creating standardized goal-directed guidelines for glucose control in the perioperative period for LE vascular procedures to potentially mitigate complications.
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Affiliation(s)
| | - Jamie B Smith
- Department of Family and Community Medicine, University of Missouri, Columbia, MO
| | | | - Danielle Kinsey
- Department of General Surgery, University of Missouri, Kansas City, MO
| | - Robin L Kruse
- Department of Family and Community Medicine, University of Missouri, Columbia, MO
| | - Todd R Vogel
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Jonathan Bath
- Division of Vascular Surgery, University of Missouri, Columbia, MO.
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Lemanska A, Byford RC, Cruickshank C, Dearnaley DP, Ferreira F, Griffin C, Hall E, Hinton W, de Lusignan S, Sherlock J, Faithfull S. Linkage of the CHHiP randomised controlled trial with primary care data: a study investigating ways of supplementing cancer trials and improving evidence-based practice. BMC Med Res Methodol 2020; 20:198. [PMID: 32711460 PMCID: PMC7382082 DOI: 10.1186/s12874-020-01078-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/08/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) are the gold standard for evidence-based practice. However, RCTs can have limitations. For example, translation of findings into practice can be limited by design features, such as inclusion criteria, not accurately reflecting clinical populations. In addition, it is expensive to recruit and follow-up participants in RCTs. Linkage with routinely collected data could offer a cost-effective way to enhance the conduct and generalisability of RCTs. The aim of this study is to investigate how primary care data can support RCTs. METHODS Secondary analysis following linkage of two datasets: 1) multicentre CHHiP radiotherapy trial (ISRCTN97182923) and 2) primary care database from the Royal College of General Practitioners Research and Surveillance Centre. Comorbidities and medications recorded in CHHiP at baseline, and radiotherapy-related toxicity recorded in CHHiP over time were compared with primary care records. The association of comorbidities and medications with toxicity was analysed with mixed-effects logistic regression. RESULTS Primary care records were extracted for 106 out of 2811 CHHiP participants recruited from sites in England (median age 70, range 44 to 82). Complementary information included longitudinal body mass index, blood pressure and cholesterol, as well as baseline smoking and alcohol usage but was limited by the considerable missing data. In the linked sample, 9 (8%) participants were recorded in CHHiP as having a history of diabetes and 38 (36%) hypertension, whereas primary care records indicated incidence prior to trial entry of 11 (10%) and 40 (38%) respectively. Concomitant medications were not collected in CHHiP but available in primary care records. This indicated that 44 (41.5%) men took aspirin, 65 (61.3%) statins, 14 (13.2%) metformin and 46 (43.4%) phosphodiesterase-5-inhibitors at some point before or after trial entry. CONCLUSIONS We provide a set of recommendations on linkage and supplementation of trials. Data recorded in primary care are a rich resource and linkage could provide near real-time information to supplement trials and an efficient and cost-effective mechanism for long-term follow-up. In addition, standardised primary care data extracts could form part of RCT recruitment and conduct. However, this is at present limited by the variable quality and fragmentation of primary care data.
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Affiliation(s)
- Agnieszka Lemanska
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH UK
- Data Science, National Physical Laboratory, Teddington, UK
| | - Rachel C. Byford
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Cruickshank
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - David P. Dearnaley
- The Institute of Cancer Research and Royal Marsden NHS Trust, London, UK
| | - Filipa Ferreira
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Griffin
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - William Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), London, UK
- School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Julian Sherlock
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sara Faithfull
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH UK
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Sjödin L, Enocson A, Rotzius P, Lapidus LJ. Increased mortality among patients with diabetes following first-ever transfemoral amputation. Diabetes Res Clin Pract 2018; 143:225-231. [PMID: 30009936 DOI: 10.1016/j.diabres.2018.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 05/15/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
Abstract
AIMS Transfemoral amputation (TFA) is associated with a high postoperative mortality though it is unclear whether diabetes is associated with an increased mortality or not. The aim was to examine mortality at 1 week and 1 year after first-ever TFA with special reference to diabetes. METHODS We included 162 first-ever TFAs from 1996 to 2012. Mortality data were collected with the use of the Swedish personal identification number. RESULTS The median age was 85 years. Diabetes mellitus were present in 19% (n = 30) of the patients and 67% (n = 109) had cardiovascular disease. Mortality was significantly higher for patients with diabetes compared to patients without diabetes at 1 week (30% vs. 8%, p = 0.001) and at 1 year (80% vs. 57%, p = 0.02). This difference was significant in multivariable analysis. CONCLUSIONS We conclude that postoperative mortality was high. The high mortality rate emphasizes the need for early and adequate evaluation of every patient́s overall condition and whether amputation is beneficial or not. Although further studies are needed to analyze the specific causes of early death in amputees and we suggest close monitoring of blood-sugar in patients with diabetes and early treatment of infections and cardiac events in all patients.
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Affiliation(s)
- Lina Sjödin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, and Unit of Orthopaedics, Södersjukhuset, SE-118 83 Stockholm, Sweden.
| | - Anders Enocson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, and Unit of Orthopaedics, Södersjukhuset, SE-118 83 Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Pierre Rotzius
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, and Unit of Orthopaedics, Södersjukhuset, SE-118 83 Stockholm, Sweden
| | - Lasse J Lapidus
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, and Unit of Orthopaedics, Södersjukhuset, SE-118 83 Stockholm, Sweden
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Abstract
High-value CCC is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology. The high-performing CCC system and culture should aim to learn quickly and continuously improve. CCC demands a proactive, interactive, precise, an expert team, and continuity.
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Ramakrishna H, Gutsche JT, Patel PA, Evans AS, Weiner M, Morozowich ST, Gordon EK, Riha H, Bracker J, Ghadimi K, Murphy S, Spitz W, MacKay E, Cios TJ, Malhotra AK, Baron E, Shaefi S, Fassl J, Weiss SJ, Silvay G, Augoustides JGT. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2016. J Cardiothorac Vasc Anesth 2016; 31:1-13. [PMID: 28041810 DOI: 10.1053/j.jvca.2016.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Indexed: 12/11/2022]
Affiliation(s)
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adam S Evans
- Department of Anesthesiology, Cleveland Clinic Florida, Weston, FL
| | - Menachem Weiner
- Anesthesiology and Critical Care, Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | | | - Emily K Gordon
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Hynek Riha
- Cardiothoracic Anesthesiology and Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Joseph Bracker
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kamrouz Ghadimi
- Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care, Duke University, Durham, NC
| | - Sunberri Murphy
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Warren Spitz
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Emily MacKay
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Elvera Baron
- Anesthesiology and Critical Care, Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | - Shahzad Shaefi
- Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Harvard Medical School, Boston, MA
| | - Jens Fassl
- Cardiovascular and Thoracic Section, Department of Anesthesia and Intensive Care Medicine, University of Basel, Basel, Switzerland
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - George Silvay
- Anesthesiology and Critical Care, Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | - John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Pezzella AT, Holmes SD, Pritchard G, Speir AM, Ad N. Impact of perioperative glycemic control strategy on patient survival after coronary bypass surgery. Ann Thorac Surg 2014; 98:1281-5. [PMID: 25134860 DOI: 10.1016/j.athoracsur.2014.05.067] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 05/14/2014] [Accepted: 05/22/2014] [Indexed: 01/04/2023]
Abstract
BACKGROUND Glycemic control in the perioperative period decreases mortality and morbidity, but data are scarce with regard to the effects of glucose control approaches on survival. We assessed long-term survival in patients treated with 2 strategies of glucose control after first-time isolated coronary artery bypass graft. METHODS In a previously published trial, patients were prospectively randomized to strict (90-120 mg/dL) or liberal (121-180 mg/dL) glucose control protocols. The aim of this study was to assess long-term data on survival and health-related quality of life based on the original prospective randomized study population. RESULTS No differences were found in cumulative survival between the strict (95.5%) and liberal (93.5%) target range groups (log-rank = 0.32, p = 0.57) over a mean follow-up of 40.0 ± 4.4 months. Physical health-related quality of life significantly improved in all patients from baseline to 6 months after surgery (F = 17.73, p < 0.001), and there were no differences in improvement of health-related quality of life between the 2 target range groups (F = 0.15, p = 0.70). CONCLUSIONS These results support our previous findings and indicate that a liberal glycemic control strategy after coronary artery bypass leads to survival rates and improvements in health-related quality of life that are similar to those achieved with a strict target range. In addition, the liberal strategy is superior in glucose control and target range management.
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Affiliation(s)
- A Thomas Pezzella
- Cardiac Surgery Research, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia
| | - Sari D Holmes
- Cardiac Surgery Research, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia
| | - Graciela Pritchard
- Cardiac Surgery Research, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia
| | - Alan M Speir
- Cardiac Surgery Research, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia
| | - Niv Ad
- Cardiac Surgery Research, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia.
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Sundt TM. With the best of intentions. Eur J Cardiothorac Surg 2014; 47:739-40. [PMID: 24996407 DOI: 10.1093/ejcts/ezu263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Edward D. Churchill Professor of Surgery, Harvard Medical School, Boston, MA, USA
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