Both sc and epicardial adipose tissue is a source of proinflammatory cytokines in cardiac surgery patients and may contribute to the development of postoperative insulin resistance.

OBJECTIVE -To evaluate a fully automated algorithm for the establishment of tight glycemic control in critically ill patients and to compare the results with different routine glucose management protocols of three intensive care units (ICUs) across Europe (Graz, Prague, and London).RESEARCH DESIGN AND METHODS -Sixty patients undergoing cardiac surgery (age 67 Ϯ 9 years, BMI 27.7 Ϯ 4.9 kg/m 2 , 17 women) with postsurgery blood glucose levels Ͼ120 mg/dl (6.7 mmol/l) were investigated in three different ICUs (20 per center). Patients were randomized to either blood glucose management (target range 80 -110 mg/dl [4.4 -6.1 mmol/l]) by the fully automated model predictive control (MPC) algorithm (n ϭ 30, 10 per center) or implemented routine glucose management protocols (n ϭ 30, 10 per center). In all patients, arterial glucose was measured hourly to describe the glucose profile until the end of the ICU stay but for a maximum period of 48 h. CONCLUSIONS -The data suggest that the MPC algorithm is safe and effective in controlling glycemia in critically ill postsurgery patients. RESULTS Diabetes Care 29:271-276, 2006E pidemiological studies have revealed a significant relationship between impaired glycemic control and poor outcome in patients with acute cardiovascular events (1-3), postoperative wound infections (4,5), and trauma (6). Patients with diabetes are affected, but patients with stress hyperglycemia with no previous diagnosis of diabetes also have a poor prognosis (1,2,7,8). Critical illness and trauma induce counterregulatory hormone release and alterations in carbohydrate metabolism such as enhanced hepatic gluconeogenesis, insulin resistance, and relative insulin deficiency (9,10).A growing body of evidence indicates that treatment of hyperglycemia improves clinical outcome (11). In a prospective randomized trial in Leuven, postoperative patients were treated with an intensive insulin protocol (12). Strict glycemic control (80 -110 mg/dl) resulted in a reduction of in-hospital mortality and a decrease in organ system dysfunction compared with moderate hyperglycemia (180 -200 mg/dl). In another study performed on a mixed medical-surgical population, the implementation of an intensive glucose management protocol led to decreased mortality, morbidity, and length of intensive care unit (ICU) stay of critically ill adult patients (13).Based on this clinical evidence, efforts have to be made to maintain strict glycemic control in critically ill patients. To achieve this goal, the implementation of complex intensive insulin infusion protocols based on frequent bedside glucose monitoring is required. Numerous guidelines have been developed and tested to implement tight glycemic control in ICUs (13-18). However, most of these guidelines still require user interventions or intuitive decisions of ICU staff.The development of a closed-loop control system that automatically regulates the dose of insulin based on glucose measurements could permit tight glycemic control without increasing the work-

Type 2 diabetes mellitus (T2DM) resolution in morbidly obese patients following metabolic surgery suggests the efficacy of T2DM surgery in non-morbidly obese patients (body mass index [BMI] <35 kg/m(2)). This literature review examined research articles in English over the last 30 years (1979-2009) that addressed surgical resolution of T2DM in patients with a mean BMI <35. Weighted and simple means (95% CI) were calculated to analyze study outcomes. Sixteen studies met inclusion criteria; 343 patients underwent one of eight procedures with 6-216 months follow-up. Patients lost a clinically meaningful, not excessive, amount of weight (from BMI 29.4 to 24.2; -5.1), moving from the overweight into the normal weight category. There were 85.3% patients who were off T2DM medications with fasting plasma glucose approaching normal (105.2 mg/dL, -93.3), and normal glycated hemoglobin, 6% (-2.7). In subgroup comparison, BMI reduction and T2DM resolution were greatest following malabsorptive/restrictive procedures, and in the preoperatively mildly obese (30.0-35.0) vs overweight (25.0-25.9) BMI ranges. Complications were few with low operative mortality (0.29%). Novel and/or known mechanisms of T2DM resolution may be engaged by surgery at a BMI threshold

Compared with RMP, the eMPC algorithm was more effective and comparably safe in maintaining euglycemia in cardiac surgery patients.

Obese patients with and without T2DM have increased mRNA expression of chemotactic and proinflammatory factors in SCAT and expression of corresponding receptors in PM. Two weeks of VLCD significantly improved this profile in T2DM patients.