***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: Diabetes management is firmly based within the primary care community . L and mark r and omized , controlled trials have demonstrated that even modest reductions in glycated hemoglobin ( HbA1c ) can yield improvements in economic and medical end-points . Diabetes is a chronic , progressive disease associated with loss of pancreatic β-cell function . Therefore , most patients will eventually require insulin therapies in order to achieve their individualized targeted HbA1c as their β-cell function and mass wanes . Although clinicians underst and the importance of early insulin initiation , there is little agreement as to when to introduce insulin as a therapeutic option . Once initiated , questions remain as to whether to allow the patients to self-titrate their dose or whether the dosing should be tightly regulated by the clinician . Physicians have many evidence -based basal insulin protocol s from which to choose , all of which have been shown to drive HbA1c levels to the American Diabetes Association target of ≤7 % . This article will discuss ways by which insulin therapies can be effectively introduced to patients within busy primary care practice s. Published evidence -based basal insulin protocol s will be evaluated for safety and efficacy OBJECTIVE Recent studies suggest that strict perioperative glycemic control improves clinical outcomes after cardiothoracic surgery . However , optimal methods and targets for controlling blood glucose ( BG ) levels in this setting have not been established . Currently published intensive insulin infusion protocol s ( IIPs ) have important practical limitations , which may affect their utility . In this article , the authors present their experience with a safe , effective , nurse-driven IIP , which was implemented simultaneously in 2 cardiothoracic intensive care units ( CTICUs ) . DESIGN Prospect i ve cohort study . SETTING Tertiary referral hospital and community teaching hospital . PARTICIPANTS CTICU patients . INTERVENTIONS A st and ardized , intensive IIP was used for all patients admitted to both CTICUs .  Hourly BG levels , relevant baseline variables , and clinical interventions were collected prospect ively from the active hospital chart and CTICU nursing records . MEASUREMENTS AND MAIN RESULTS The IIP was used 137 times in 118 patients . The median time required to reach target BG levels ( 100 - 139 mg/dL ) was 5 hours . Once BG levels decreased below 140 mg/dL , 58 % of 2,242 subsequent hourly BG values fell within the narrow target range , 73 % within a " clinical ly desirable " range of 80 to 139 mg/dL , and 94 % within a " clinical ly acceptable " range of 80 to 199 mg/dL. Only 5 ( 0.2 % ) BG values were less than 60 mg/dL , with no associated adverse clinical events . CONCLUSIONS The IIP safely and effectively improved glycemic control in 2 CTICUs , with minimal hypoglycemia . Based on prior studies showing the benefits of strict glycemic control , the implementation of this IIP should help to reduce morbidity and mortality in CTICU patients AIM Perioperative tight blood glucose ( BG ) control using insulin therapy  after major surgery is a difficult , time-consuming task that also raises some concerns over the risk of severe hypoglycaemia . The aim of the present prospect i ve study was to evaluate the efficacy and safety of an insulin therapy protocol in use at our institution . METHODS A total of 230 consecutive patients ( mean+/-SD age : 67+/-11 years ; diabetic patients : n=62 ) undergoing cardiac surgery ( coronary artery bypass grafting : n=137 ; 20 % off-pump ) or intrathoracic aortic ( n=10 ) surgery were included . BG control was managed according to an insulin therapy protocol , described by Goldberg et al. ( 2004 ) [ 11 ] , in use for 6 months in our intensive care unit . Insulin infusion rate and frequency of BG monitoring were both adjusted according to : ( 1 ) the current BG value ; ( 2 ) the previous BG value ; and ( 3 ) the current insulin infusion rate . Efficacy was assessed by the percentage of time spent at the target BG level ( 100 - 139 mg/dL ) intraoperatively and during the first 2 postoperative days ( POD ) . RESULTS All patients received postoperative insulin therapy .  Patients spent 57.3 % and 69.7 % of time within the BG target range on POD 1 and 2 , respectively . The percentage of time was significantly higher in nondiabetics than in diabetics . Mean BG measurements per patient intraoperatively , on POD 1 and on POD 2 were 4+/-1 , 10+/-2 and 7+/-2 , respectively . No patient experienced any severe hypoglycaemic events ( BG<50mg/dL ) . CONCLUSION This study showed that a BG target of 100 - 139 mg/dL can be safely achieved with an insulin therapy protocol that can be routinely used in everyday clinical practice OBJECTIVE Continuous glucose monitoring ( CGM ) has been demonstrated to improve glycemic control in adults with type 1 diabetes but less so in children . We design ed a study to assess CGM benefit in young children aged 4 to 9 years with type 1 diabetes . RESEARCH DESIGN AND METHODS After a run-in phase , 146 children with type 1 diabetes ( mean age 7.5 ± 1.7 years , 64 % on pumps , median diabetes duration 3.5 years ) were r and omly assigned to CGM or to usual care . The primary outcome was reduction in HbA1c at 26 weeks by ≥0.5 % without the occurrence of severe hypoglycemia . RESULTS The primary outcome was achieved by 19 % in the CGM group and 28 % in the control group ( P = 0.17 ) . Mean change in HbA1c was −0.1 % in each group ( P = 0.79 ) . Severe hypoglycemia rates were similarly low in both groups . CGM wear decreased over time , with only 41 % averaging at least 6 days/week at 26 weeks . There was no correlation between CGM use and change in HbA1c ( rs = −0.09 , P = 0.44 ) . CGM  wear was well tolerated , and parental satisfaction with CGM was high . However , parental fear of hypoglycemia was not reduced . CONCLUSIONS CGM in 4- to 9-year-olds did not improve glycemic control despite a high degree of parental satisfaction with CGM . We postulate that this finding may be related in part to limited use of the CGM glucose data in day-to-day management and to an unremitting fear of hypoglycemia . Overcoming the barriers that prevent integration of these critical glucose data into day-to-day management remains a challenge OBJECTIVE The purpose of this study was to test the hypothesis that a liberal blood glucose strategy ( 121 - 180 mg/dL ) is not inferior to a strict blood glucose strategy ( 90 - 120 mg/dL ) for outcomes in patients after first-time isolated coronary artery bypass grafting and is superior for glucose control and target blood glucose management . METHODS A total of 189 patients undergoing coronary artery bypass grafting  were investigated in this prospect i ve r and omized study to compare 2 glucose control strategies on patient perioperative outcomes . Three methods of analyses ( intention to treat , completer , and per protocol ) were conducted . Observed power was robust ( > 80 % ) for significant results . RESULTS The groups were similar on preoperative hemoglobin A(1c ) and number of diabetic patients . The liberal group was found to be noninferior to the strict group for perioperative complications and superior on glucose control and target range management . The liberal group had significantly fewer patients with hypoglycemic events ( < 60 mg/dL ; P < .001 ) , but severe hypoglycemic events ( < 40 mg/dL ) were rare and no group differences were found ( P = .23 ) . These results were found with all 3 methods of analysis except for blood glucose variability , maximum blood glucose , and perioperative atrial fibrillation . CONCLUSIONS This study demonstrated that maintenance of blood glucose in a liberal range after coronary artery bypass grafting led to similar outcomes compared with a strict target range and was superior in glucose control and target range management . On the basis of the results of this study , a target blood glucose range of 121 to 180 mg/dL is recommended for patients after coronary artery bypass grafting as advocated by the Society of Thoracic Surgeons BACKGROUND : Critically ill cardiothoracic patients are prone to hyperglycemia and an increased risk of surgical site infections postoperatively . Aggressive insulin treatment is required to achieve tight glycemic control ( TGC ) and improve outcomes . OBJECTIVE : To examine and report on the performance of an insulin infusion protocol to maintain TGC , defined as a blood glucose level of 80–150 mg/dL , in critically ill cardiothoracic surgical patients . METHODS : A nurse-driven insulin infusion protocol was developed and initiated in postoperative cardiothoracic surgical intensive care patients with or without diabetes . In this before — after cohort study , 2 periods of measurement were performed : a 6–month baseline period prior to the initiation of the insulin infusion protocol  ( control group , n = 174 ) followed by a 6–month intervention period in which the protocol was used ( TGC group , n = 168 ) . RESULTS : Findings showed percent and time of blood glucose measurements within the TGC range ( control 47 % vs TGC 61 % ; p = 0.001 ) , AUC of glucose exposure > 150 mg/dL versus time for the first 24 hours of the insulin infusion ( control 28.4 vs TGC 14.8 ; p < 0.001 ) , median time to blood glucose < 150 mg/dL ( control 9.4 h vs TGC 2.1 h ; p < 0.001 ) , and percent blood glucose < 65 mg/dL as a marker for hypoglycemia ( control 9.8 % vs TGC 16.7 % ; NS ) . CONCLUSIONS : An insulin infusion protocol design ed to achieve a goal blood glucose range of 80–150 mg/dL efficiently and significantly improved TGC in critically ill postoperative cardiothoracic surgery patients without significantly increasing the incidence of hypoglycemia Most patients with type 2 diabetes mellitus develop cardiovascular disease ( CVD ) , with substantial loss of life expectancy . Nonfatal CVD contributes greatly to excess healthcare costs and decreased quality of life in patients with diabetes . The current epidemic of obesity has raised expectations that CVD associated with type 2 diabetes will become an even greater public health challenge . Despite the importance of this health problem , there is a lack of definitive data on the effects of the intensive control of glycemia and other CVD risk factors on CVD event rates in patients with type 2 diabetes . The Action to Control Cardiovascular Risk in Diabetes ( ACCORD ) trial is a r and omized , multicenter , double 2 x 2 factorial design study involving 10,251 middle-aged and older participants with type 2 diabetes who are at high risk for CVD events because of existing CVD or additional risk factors . ACCORD is testing the effects of 3 medical treatment strategies to reduce CVD morbidity and mortality . All participants are in the glycemia trial , which is testing the hypothesis that a therapeutic strategy that targets a glycosylated hemoglobin ( HbA1c ) level of < 6.0 % will reduce the rate of CVD events more than a strategy that targets an HbA1c level of 7.0%-7.9 % . The lipid trial includes 5,518 of the participants , who receive either fenofibrate or placebo in a double-masked fashion to test the hypothesis of whether , in the context of good glycemic control , a therapeutic strategy that uses a fibrate to increase high-density lipoprotein cholesterol and lower triglyceride levels together with a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor ( statin ) to lower low-density lipoprotein cholesterol will reduce the rate of CVD events compared with a strategy that uses a statin plus a placebo . The blood pressure trial includes the remaining 4,733 participants and tests the hypothesis that a therapeutic strategy that targets a systolic blood pressure of < 120 mm Hg in the context of good glycemic control will reduce the rate of CVD events compared with a strategy that targets a systolic blood pressure of < 140 mm Hg . The primary outcome measure for all 3 research questions is the first occurrence of a major CVD event , specifically nonfatal myocardial infa rct ion , nonfatal stroke , or cardiovascular death . Upon the expected completion of participant follow-up in 2009 , the ACCORD trial should document for the first time the benefits and risks of intensive glucose control , intensive blood pressure control , and the combination of fibrate and statin drugs in managing blood lipids in high-risk patients with type 2 diabetes BACKGROUND The impact of intensive insulin therapy on the clinical outcomes of hospitalized patients is highly controversial . We used a protocol based on dynamic insulin administration targeted to achieve moderately tight glycemic 
    Output:
    
The implementation of protocol s led to the achievement of blood glucose concentration targets more rapidly and the maintenance of a specified target blood glucose range for a longer time , without any increased frequency of hyperglycaemia .
The risk of hypoglycaemia was significantly reduced ( P < 0.00001 ) between studies .It can be concluded that the protocol -directed insulin infusion sliding scale is safe and improves blood glucose control when compared with the conventional practitioner-directed insulin infusion sliding scale .
This study supports the adoption of a protocol -directed insulin infusion sliding scale as a st and ard of care for post-cardiac surgery patients