Background In contrast with the setting of acute myocardial infarction, there are limited data regarding the impact of diabetes mellitus on clinical outcomes in contemporary cohorts of patients with chronic coronary syndromes. We aimed to investigate the prevalence and prognostic impact of diabetes according to geographical regions and ethnicity. Methods and results CLARIFY is an observational registry of patients with chronic coronary syndromes, enrolled across 45 countries in Europe, Asia, America, Middle East, Australia, and Africa in 2009–2010, and followed up yearly for 5 years. Chronic coronary syndromes were defined by ≥1 of the following criteria: prior myocardial infarction, evidence of coronary stenosis >50%, proven symptomatic myocardial ischaemia, or prior revascularization procedure. Among 32 694 patients, 9502 (29%) had diabetes, with a regional prevalence ranging from below 20% in Northern Europe to ∼60% in the Gulf countries. In a multivariable-adjusted Cox proportional hazards model, diabetes was associated with increased risks for the primary outcome (cardiovascular death, myocardial infarction, or stroke) with an adjusted hazard ratio of 1.28 (95% confidence interval 1.18, 1.39) and for all secondary outcomes (all-cause and cardiovascular mortality, myocardial infarction, stroke, heart failure, and coronary revascularization). Differences on outcomes according to geography and ethnicity were modest. Conclusion In patients with chronic coronary syndromes, diabetes is independently associated with mortality and cardiovascular events, including heart failure, which is not accounted by demographics, prior medical history, left ventricular ejection fraction, or use of secondary prevention medication. This is observed across multiple geographic regions and ethnicities, despite marked disparities in the prevalence of diabetes. ClinicalTrials identifier ISRCTN43070564

An 11-year-old male presented to the pediatric emergency department with a one-day history of periumbilical pain with nausea, anorexia, and scant vomiting. On examination, he had moderate tenderness in the right upper quadrant with moderate guarding and rebound tenderness. Imaging showed concern for early acute appendicitis. The patient was admitted and underwent laparoscopic appendectomy. Despite the appendectomy, the patient continued to have fevers and abdominal pain. Four days after the initial presentation, the patient decompensated and was diagnosed with multisystem inflammatory syndrome. This case is interesting because the patient never met diagnostic criteria for multisystem inflammatory syndrome in children (MIS-C) prior to his decompensation. If a patient's symptoms continue or worsen despite seemingly appropriate management, the patient must be reassessed for other causes of pathology. Surgeons must have a high index of suspicion for MIS-C in patients with recent COVID-19 diagnoses, and this case demonstrates that MIS-C can present in phases and not all at once.

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