Disparities by Race in Pregnancy Care and Clinical Outcomes in Women With Multiple Sclerosis: A Diverse Multicenter Cohort

BACKGROUND AND OBJECTIVES: Racial disparities exist in both neurologic and obstetric populations, underscoring the importance of evaluating pregnancy outcomes in diverse women with multiple sclerosis (MS). The objective of this multicenter retrospective study was to compare pregnancy care and outcomes between Black and Hispanic (underrepresented) and White women with MS. METHODS: Demographic and clinical data were extracted from medical records of 9 US MS centers for women with MS/clinically isolated syndrome who delivered live births between 2010 and 2021. Sites identified at last 15 consecutive Black/Hispanic women and a matching number of White women. Socioeconomic factors, pregnancy, and MS care/outcomes were compared between groups (underrepresented and White and then Black and Hispanic) using Wilcoxon rank sum (U statistic and effect size r reported), χ2, t tests and logistic regressions as appropriate to data type. Multiple imputation by chained equation was used to account for missing data. RESULTS: Overall, 294 pregnancies resulting in live births were analyzed ( 81 Black, 67 Hispanic, and 146 White mothers). Relative to underrepresented women, White women lived in areas of higher median (interquartile range [IQR]) Child Opportunity Index (79 [45.8] vs 22 [45.8], U = 3,824, r = 0.56, p < 0.0001) and were more often employed (84.9% vs 75%, odds ratio [OR] 2.57, CI 1.46-4.50, p = 0.0008) and privately insured (93.8% vs 56.8%, OR 11.6, CI 5.5-24.5, p < 0.0001) and more received a 14-week ultrasound (98.6% vs 93.9%, OR 4.66, CI 0.99-21.96, p = 0.027). Mode of delivery was significantly different between the three groups (X2(10,294) = 20.38, p = 0.03); notably, Black women had the highest rates of emergency cesarean deliveries, and Hispanic women highest rates of uncomplicated vaginal deliveries. Babies born to underrepresented women had lower median (IQR) birthweights than babies born to White women (3,198 g [435.3 g] vs 3,275 g [412.5 g], U = 9,255, r = 0.12, p = 0.04) and shorter median (IQR) breastfeeding duration (4.5 [3.3] vs 6.0 [4.2] months, U = 8,184, r = 0.21, p = 0.003). While underrepresented women were younger than White women (mean [SD] 30.9 [4.8] vs 33.8 [4.0], t = 1.97, CI 1.96-3.98, p < 0.0001), their median (Q1-Q3, IQR) Expanded Disability Status Scale was higher (1.5 [1-2.5, 1.5] vs 1 [0-1.5, 1.5], U = 7,260, r = 0.29, p < 0.0001) before pregnancy. Finally, medical records were missing more key data for Black women (19.7% missing vs 8.9% missing, OR 2.54, CI 1.25-5.06, p = 0.008). DISCUSSION: In this geographically diverse multicenter cohort, underrepresented women entered pregnancy with higher disability and fewer health care resources. Pregnancy represents a pivotal window where structural factors affect maternal and fetal health and neurologic trajectories; it is a critical period to optimize care and health outcomes.

Effect of prone positioning and high flow nasal oxygen on oxygenation and overall outcome in spontaneously breathing awake patient with severe COVID-19 induced acute hypoxemic respiratory failure: A prospective observational study.

Background: Previous studies suggest that prone positioning can increase PaO2/FiO2 and reduce mortality in moderate to severe acute respiratory distress syndrome. Effect of prone positioning and high flow nasal oxygen has been studied individually in COVID-19 patients but their combined effect on patient's outcome is yet to be reported. Methods: In this study 120 severe COVID-19 positive patients were included and placed in awake prone positioning with high flow nasal oxygen. The efficacy in improving oxygenation with prone positioning and high flow nasal oxygen were evaluated by blood gas analysis. The primary outcome was a proportion of patients requiring non-invasive ventilation or invasive ventilation. The secondary outcomes were a comparison of arterial blood gas parameters and biochemical inflammatory parameters pre proning, end of first proning and end of last prone position in these patients. Results: We found only 35 patients (34.3%) required the need for non-invasive or invasive mechanical ventilation support whereas 67 patients (65.7%) were managed successfully on high flow nasal oxygen along with awake prone positioning (p = 0.001). We found there were statistically significant improvements in arterial blood gas parameters and biochemical inflammatory markers after the end of last prone positioning with high flow nasal oxygen. Conclusions: Early application of prone positioning in combination with high flow nasal oxygen may help in avoiding mechanical ventilation by improving oxygenation and biochemical inflammatory markers.

Fiber-optic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units.

BACKGROUND: Percutaneous dilatational tracheostomy (PCDT) using fiber-optic bronchoscope (FOB) is a widely practiced technique, but its availability and cost remain a concern in nations with limited resources. Mini-surgical technique of PCDT incorporating minimal blunt dissection has shown improved results even without the use of FOB. The study is primarily intended to compare these two techniques and establish a safer cost-effective alternative to FOB-guided PCDTs. PATIENTS AND METHODS: This randomized comparative study [registered (CTRI/2018/04/013191)] was conducted on 120 mechanically ventilated patients. In 60 patients, mini-surgical PCDT (group-M) was performed with 2 cm longitudinal skin incision and blunt dissection till pretracheal fascia without FOB guidance using Portex-Ultraperc™ sets. In remaining 60 patients, PCDT was performed under FOB vision with similar skin incision (without blunt dissection) using Portex-Ultraperc™ sets (group-F). Two techniques were compared with regard to procedural time and percentage of complications occurred during or after the procedure. RESULTS: Procedure time [group-M: 6.30 ± 1.28 minutes; group-F: 14.43 ± 1.84 minutes (p <0.001)] and mean blood loss [group-M: 5.33 ± 1.69 mL; group-F: 6.87 ± 3.11 mL (p = 0.001)] was significantly less in group-M. Higher incidence of desaturation [group-M: 16.7%; group-F: 35% (p = 0.022)] was noted in group-F, whereas arrhythmias [group-M: 21.7%; group-F: 6.7% (p = 0.018)] were higher in group-M. There was no statistical difference in incidence of pneumothorax and subcutaneous emphysema. There was no incidence of posterior tracheal wall perforation in any of the patients. CONCLUSION: Mini-surgical technique is a faster alternative of FOB-guided PCDT with comparable incidence of complications. It can safely be used in intensive care units (ICUs) where FOB is not available. CLINICAL TRIAL REGISTRATION NUMBER: CTRI/2018/05/014307. NAME OF REGISTRY: Clinical Trials Registry of India (CTRI), URL-http://ctri.nic.in. HOW TO CITE THIS ARTICLE: Kumar A, Kohli A, Kachru N, Bhadoria P, Wadhawan S, Kumar D. Fiber-optic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units. Indian J Crit Care Med 2021;25(11):1269-1274.

Comparative evaluation of dexmedetomidine and fentanyl in total intravenous anesthesia for laparoscopic cholecystectomy: A randomised controlled study.

BACKGROUND AND AIMS: Laparoscopic cholecystectomy is one of the commonly performed ambulatory surgeries. The selection of anesthetic agents for ambulatory surgeries should be done bearing in mind the need for early discharge. Opioids form an integral component of total intravenous anesthesia (TIVA) but their associated side effects may result in an increased hospital stay. Hence, we planned a study to compare the opioid (fentanyl) and non-opioid (dexmedetomidine) based technique of TIVA for laparoscopic surgery. MATERIAL AND METHODS: Ninety ASA I and II patients between 18-60 years of either sex posted for laparoscopic cholecystectomy were randomly allocated into two groups namely group D (Dexmedetomidine) and group F (Fentanyl). Patients received propofol infusion along with group specific drug infusion, after which an appropriate size proseal laryngeal mask airway was placed. The patients were assessed for discharge time from post-anesthesia care unit (PACU), on table recovery time, time to first rescue analgesia, hemodynamic parameters, incidence of postoperative nausea and vomiting (PONV) and any other complication. RESULTS: Demographic profile of both the groups was comparable. Group D had longer on table recovery time (13.00 ± 2.34 min vs 6.29 ± 2.46 min; P < 0.001) and time to discharge from PACU (6.80 ± 3.96 min vs 2.36 ± 1.67 min; P < 0.001) compared to group F. Group F had better hemodynamic stability compared to group D. In group D, 77% patients required rescue analgesia in first one hour post surgery, unlike 22% in group F. No patient in group D had PONV. CONCLUSION: Opioid based technique (Fentanyl) of TIVA is superior over non-opioid based (dexmedetomidine) technique with faster recovery, early discharge, decreased postoperative pain scores and better hemodynamic stability. PONV is observed with opioids which can be treated successfully with antiemetics.

Event-Based Near-Eye Gaze Tracking Beyond 10,000 Hz.

The cameras in modern gaze-tracking systems suffer from fundamental bandwidth and power limitations, constraining data acquisition speed to 300 Hz realistically. This obstructs the use of mobile eye trackers to perform, e.g., low latency predictive rendering, or to study quick and subtle eye motions like microsaccades using head-mounted devices in the wild. Here, we propose a hybrid frame-event-based near-eye gaze tracking system offering update rates beyond 10,000 Hz with an accuracy that matches that of high-end desktop-mounted commercial trackers when evaluated in the same conditions. Our system, previewed in Figure 1, builds on emerging event cameras that simultaneously acquire regularly sampled frames and adaptively sampled events. We develop an online 2D pupil fitting method that updates a parametric model every one or few events. Moreover, we propose a polynomial regressor for estimating the point of gaze from the parametric pupil model in real time. Using the first event-based gaze dataset, we demonstrate that our system achieves accuracies of 0.45°-1.75° for fields of view from 45° to 98°. With this technology, we hope to enable a new generation of ultra-low-latency gaze-contingent rendering and display techniques for virtual and augmented reality.

Comeback of ketamine: resurfacing facts and dispelling myths.

Initially known as CI-581, ketamine was first synthesized in 1962 as a replacement from phencyclidine. It has since been used as an anesthetic and analgesic. In addition, it has bronchodilating, sedative, and amnestic properties, preserving airway reflexes and sympathetic nervous system tone. Since the discovery of ketamine, it has been a major topic of discussion due to controversies regarding its usage in particular sets of patients. In the past 50 years, despite its potential benefits, it is not commonly used because of concerns of "emergence phenomenon," its use as a substance of abuse, and its systemic side effects. Since 2012, three World Health Organization reviews on ketamine have addressed its international control. Researchers have been studying this wonder drug for a decade worldwide. Many myths of ketamine regarding emergence phenomenon and its use in traumatic brain injury and open eye injury have been disproved in recent times. It is becoming popular in pre-hospital settings, critical care, emergency medicine, low-dose acute pain services, and adjuvant in regional anesthesia techniques. This review highlights the current consensus on the various applications of ketamine in the literature.

Correlation of Patient Profiles and Biomarkers with Outcomes in Covid-19 Icu Patients: A Retrospective Analysis.

Background: COVID-19 is a novel disease with a highly variable and unpredictable clinical course. Various clinicodemographic factors and numerous biomarkers have been identified in studies from the West and marked as possible predictors of severe illness and mortality which may be used to triage patients for early aggressive care. This triaging becomes even more significant in resource-limited critical care settings of the Indian subcontinent. Methods: This retrospective observational study recruited 99 cases of COVID-19 admitted to intensive care from 1 May to 1 August 2020. Demographic, clinical and baseline laboratory data were collected and analysed for association with clinical outcomes, including survival and need for mechanical ventilatory support. Results: Male gender (p=0.044) and diabetes mellitus (p=0.042) were associated with increased mortality. Binomial logistic regression analysis revealed Interleukin-6 (IL6) (p=0.024), D-dimer (p=0.025) and CRP (p<0.001) as significant predictors of need of ventilatory support and IL6 (p=0.036), CRP (p=0.041), D-dimer (p=0.006) and PaO2FiO2 ratio (p=0.019) as significant predictors of mortality. CRP >40 mg/L predicted mortality with sensitivity of 93.3% and specificity of 88.9% (AUC 0.933) and IL6> 32.5 pg/ml with a sensitivity of 82.2% and specificity of 70.4% (AUC 0.821). Conclusion: Our results suggest that a baseline CRP >40 mg/L, IL6 >32.5 pg/ml or D-dimer >810 ng/ml are early accurate predictors of severe illness and adverse outcomes and may be used to triage patients for early intensive care.

Acute Cerebrovascular Events With COVID-19 Infection.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) has been associated with an increased incidence of thrombotic events, including stroke. However, characteristics and outcomes of COVID-19 patients with stroke are not well known. METHODS: We conducted a retrospective observational study of risk factors, stroke characteristics, and short-term outcomes in a large health system in New York City. We included consecutively admitted patients with acute cerebrovascular events from March 1, 2020 through April 30, 2020. Data were stratified by COVID-19 status, and demographic variables, medical comorbidities, stroke characteristics, imaging results, and in-hospital outcomes were examined. Among COVID-19-positive patients, we also summarized laboratory test results. RESULTS: Of 277 patients with stroke, 105 (38.0%) were COVID-19-positive. Compared with COVID-19-negative patients, COVID-19-positive patients were more likely to have a cryptogenic (51.8% versus 22.3%, P<0.0001) stroke cause and were more likely to suffer ischemic stroke in the temporal (P=0.02), parietal (P=0.002), occipital (P=0.002), and cerebellar (P=0.028) regions. In COVID-19-positive patients, mean coagulation markers were slightly elevated (prothrombin time 15.4±3.6 seconds, partial thromboplastin time 38.6±24.5 seconds, and international normalized ratio 1.4±1.3). Outcomes were worse among COVID-19-positive patients, including longer length of stay (P<0.0001), greater percentage requiring intensive care unit care (P=0.017), and greater rate of neurological worsening during admission (P<0.0001); additionally, more COVID-19-positive patients suffered in-hospital death (33% versus 12.9%, P<0.0001). CONCLUSIONS: Baseline characteristics in patients with stroke were similar comparing those with and without COVID-19. However, COVID-19-positive patients were more likely to experience stroke in a lobar location, more commonly had a cryptogenic cause, and had worse outcomes.

Single-point versus double-point injection technique of ultrasound-guided supraclavicular block: A randomized controlled study.

BACKGROUND AND AIMS: This study aims to compare the single-point injection and double-point injection technique of ultrasound-guided supraclavicular block with regard to the success rate, time taken to perform the procedure, onset and duration of sensory and motor block, and complications. MATERIAL AND METHODS: A total of 60 American Society of Anesthesiologists physical status I and II patients between 20 and 50 years of age, with body mass index ≤30 kg/m2 posted for forearm surgeries, with anticipated surgical duration more than 1 h were randomly divided into two groups: group S (single-point injection) and group D (double-point injection technique). After locating the brachial plexus with ultrasound, needle was inserted from lateral to medial direction to reach the plexus. In group D, 20 ml of inj. bupivacaine 0.5% was deposited as 10 ml each in superior (in the cluster) and inferior pocket (corner pocket) between the plexus and subclavian artery with the help of hydrodissection while in group S the total 20 ml was deposited in the superior (in the cluster) pocket. The onset of sensory and motor block was assessed using pin prick method and modified Bromage scale. Adequacy of block was ensured by assessing the ulnar, radial, and median nerve distribution. Procedural time was defined from the point of scanning the plexus till the drug was injected completely. Total sensory, motor duration, and complications if any were noted. RESULTS: Group D had higher success rate compared to group S (96.7 vs. 83.3%; P < 0.0001). The total procedural time was significantly more in group D compared to group S (14.6 ± 2.7 vs. 10.1 ± 1.7 min; P < 0.0001). The onset of sensory and motor block was faster and the duration of sensory and motor block was significantly longer in group D. CONCLUSION: The adequacy of block, sensory, and motor duration was significantly high in newer double-point injection technique. However, it requires longer procedural time compared to single-point injection technique.

I-Gel as an intubation conduit: Comparison of three different types of endotracheal tubes.

BACKGROUND AND AIMS: I-Gel®, a novel SAD has been introduced as a ventilating device but has widely gained popularity as conduit for intubation. Unlike intubating laryngeal mask airway (ILMA), I-Gel® does not have an endotracheal tube specially designed for it. Hence the aim of this study was to compare the rate of successful intubation via I-Gel® using three different types of endotracheal tubes. METHODS: We randomised 75 American Society of Anesthesiologists (ASA) physical status I and II patients, between the age group 18-60 years of either sex undergoing elective surgery under general anaesthesia into three groups on the basis of endotracheal tube (ETT), used for intubation via I-Gel®: Group P (Polyvinyl chloride ETT), Group I (Intubating laryngeal mask airway ETT), Group F (flexometallic ETT). After following the standard induction protocol, appropriate size I Gel® was inserted in all patients. Thereafter group specific ETT was inserted via I-Gel®. We recorded and compared the time taken for successful intubation, the success rate, number of attempts taken, manoeuvres used, and complications among three different types of ETT. Quantitative variables were compared using Kruskal Wallis test and the qualitative variables were compared using Chi-square test. RESULTS: The time taken for successful intubation was least in group P (10.51 ± 3.82 seconds). Group P also had the highest first attempt (68%) and overall rate of successful intubation (88%). CONCLUSION: PVC ETT had highest first attempt success rate and required minimum time for endotracheal intubation via I-Gel® when compared to ILMA ETT and Flexible ETT.

Entropy vs standard clinical monitoring using total intravenous anesthesia during transvaginal oocyte retrieval in patients for in vitro fertilization.

STUDY OBJECTIVE: Day care surgery is an important arena for monitors of anesthetic depth where minimizing drug use is essential for rapid turnover. Underdosage, on the other hand, carries the risks of intraoperative awareness and pain. Transvaginal oocyte retrieval (TVOR), often performed under total intravenous anesthesia using propofol and fentanyl in Indian patients, is a procedure of special interest because, in addition to the above concerns, toxic effects of propofol on oocytes have been described. We have studied the role of entropy monitor, a depth of anesthesia monitor, in optomising drug titration and facilitating distinction between analgesic and hypnotic components of anesthesia. DESIGN: Prospective randomized controlled study. SETTING: Operating theater and postoperative recovery area. PATIENTS: One hundred twenty American Society of Anesthesiologists class I and II female patients coming to the IVF centre for TVOR under total intravenous anesthesia using propofol and fentanyl. They were randomly allocated into 2 groups: Group EM (drugs titrated as per entropy values: state entropy and response entropy) and group CM (drugs titrated as per standard clinical monitoring). INTERVENTION: None. MEASUREMENTS: Total propofol consumption (TP), total fentanyl consumption (TF), on-table recovery time (T1), time to discharge (T2), intraoperative awareness (A). MAIN RESULTS: Patients in group EM demonstrated 6.7% lesser consumption of propofol (P= .01), 10.9% more consumption of fentanyl (P= .007) and 1 minute faster recovery on-table (P= .009) as compared to group CM. In the PACU, only 10% patients of group EM required supplemental analgesia as opposed to 28.3% in CM group (P= .01). Time to discharge was similar in both groups and no intraoperative awareness was noted. CONCLUSION: Entropy monitor is a useful tool allowing distinction between analgesic and hypnotic components of general anesthesia in patients undergoing TVOR and facilitating drug titration accordingly. Its impact on intraoperative awareness needs to be further evaluated.

Relation between central corneal thickness and intraocular pressure in Punjabi population.

OBJECTIVE: The motive of this study was to determine the variation of central corneal thickness (CCT) in the Punjabi population and to examine its relationship with intraocular pressure (IOP) using a non-contact tonometer. The study and results emphasize the effects of age, sex and refraction on this relationship, which is important for the diagnosis and prevention of glaucoma in adequate time. METHODS: The study design was a cross-sectional, population-based survey. The participants were 279 females and 253 males of Punjab Province, India, in the age group of 21-70 years. The CCT was measured using an ultrasonic pachymeter, and the IOP was measured using an air-puff tonometer in all subjects. RESULTS: The mean values of CCT and IOP were observed to vary imprecisely with age. The measurement of both parameters was also affected by sex and refraction. The linear regression analysis suggests that the mean value of CCT grows progressively with increasing value of mean IOP. A significant positive correlation was identified between CCT and IOP in the age group of 21-70 years. The authors inferred that this correlation value varies prominently with age for both sexes, which needs to be investigated further. CONCLUSIONS: The authors suggest that CCT is a noteworthy source of variation in IOP measurements for males as well as females belonging to different age groups, when assessing IOP as a risk for glaucoma in the Punjabi population.

Anaesthesia for in vitro fertilisation.

SUMMARY: In vitro fertilization is an upcoming speciality. Anaesthesia during assisted reproductive technique is generally required during oocyte retrieval, which forms one of the fundamental steps during the entire procedure. Till date variety of techniques like conscious sedation, general anaesthesia and regional anaesthesia has been tried with none being superior to the other. However irrespective of the technique the key point of anaesthesia for in vitro fertilization is to provide the anaesthetic exposure for least duration so as to avoid its detrimental effects on the embryo cleavage and fertilization.

Importance of hepatitis C coinfection in the development of QT prolongation in HIV-infected patients.

BACKGROUND: Case reports and unblinded studies suggest that human immunodeficiency virus (HIV) disease is associated with QT prolongation and torsade de pointes ventricular tachycardia. Hepatitis C coinfection is common in patients with HIV disease, and cirrhosis is also associated with QT prolongation. We therefore undertook a systematic analysis of the role of liver injury, nutritional state, and coinfection with hepatitis C in the etiology of QT prolongation in HIV disease. METHODS: We performed a blinded, controlled retrospective cohort study of 1648 patients over a 3-year period at a university-affiliated municipal hospital. All electrocardiograms were included if patients with HIV disease had measurements of CD4 count and viral load within 3 months and serum electrolytes within 30 days (n = 816). Control subjects were chosen randomly from the general medicine service (n = 832). QT interval was measured in lead II and corrected for heart rate by Bazett's formula (QTc). RESULTS: QTc was slightly but significantly longer in patients with HIV disease than in controls (443 +/- 37 vs 436 +/- 36 milliseconds, P < .001). Patients with hepatitis C had more pronounced QTc prolongation (452 +/- 41 vs 437 +/- 35 milliseconds, P < .001). CD4 count, HIV viral load, and HIV medications had no effect on QTc. When patients with hepatitis C were excluded from the analysis, there was no statistical difference between patients with HIV disease and controls (438 +/- 34 vs 436 +/- 36 milliseconds, P = .336). Multiple linear regression revealed that both HIV and hepatitis C infection predicted QTc prolongation, as did age, female sex, history of hypertension, use of opiates, low serum K+ and albumin, and high AST. Hepatitis C coinfection nearly doubled the risk of QTc of 470 milliseconds or greater in patients with HIV disease (29.6% vs 15.8%, P < .001). CONCLUSIONS: Human immunodeficiency virus and hepatitis C infections both independently prolong QTc. Coinfection with hepatitis C greatly increases the likelihood of clinically significant QTc prolongation in patients with HIV disease.

Diabetes and stress hyperglycemia associated with myocardial infarctions at an urban municipal hospital: prevalence and effect on mortality.

Municipal hospitals in large cities provide care for patients from immigrant and mixed ethnic communities that are at high risk for diabetes. Both diabetes and stress hyperglycemia increase the risk of adverse outcome after myocardial infarctions, and the impact of stress hyperglycemia on the outcome of myocardial infarctions in this particular setting has not been previously studied. We therefore undertook a retrospective cohort study to determine the prevalence of diabetes and stress hyperglycemia in patients presenting to a university-affiliated Bronx municipal hospital with myocardial infarction, and the relationship of these conditions to the extent of coronary disease and mortality. We obtained data on 106 consecutive patients from July 1998 to April 1999 with a diagnosis-related group diagnosis of either myocardial infarction or acute coronary syndrome, in which myocardial infarction was confirmed by serum enzymes or characteristic electrocardiographic changes. Patients were followed until March 30, 2001. Measurements of clinical parameters and results of catheterization were obtained for all patients. Death rates were determined by laboratory database, direct patient contact, or data from National Death Index. Eighty percent of the cohort had either a diagnosis of diabetes (n = 45, 42% of cohort) or evidence of stress hyperglycemia (defined as serum glucose greater than 126 mg/dL at the time of admission without prior diagnosis of diabetes, n = 40, 38%). In-hospital mortality for patients with diabetes, stress hyperglycemia, or normal glucose was 20%, 15%, and 14%, respectively. Eighty-three percent of the cohort received beta blockers, and 61% of hospital survivors had catheterization. Left main or triple vessel disease was common in both patients with diabetes (52%) and patients with stress hyperglycemia (32%). Mortality at follow up (maximum follow up 3 years; mean follow up 19.6 months) was much higher in patients with either diabetes (42%) or stress hyperglycemia (52%) than normal subjects (24%). Kaplan-Meier analysis of the difference in mortality between patients with high glucose on admission and normal subjects was borderline significant (P = 0.06). Multivariate regression demonstrated that age (P = 0.020), increase in admission serum creatinine (P = 0.001), and reduction in either ejection fraction (P = 0.016) or admission systolic blood pressure (P = 0.005) were significant predictors of mortality. Glycemic status and sex were not independently associated with death after controlling for these other factors. These results show that the prevalence of both diabetes and stress hyperglycemia on presentation with myocardial infarction is strikingly high in this immigrant, mixed ethnic, urban population. Patients with diabetes and stress hyperglycemia had advanced disease on presentation and much higher mortality at 2 to 3 years than those with normal blood glucose. The mortality difference is the result of older age and more advanced disease rather than hyperglycemia per se.