***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 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: CONTEXT Corticosteroid therapy induces potentially detrimental hyperglycemia in septic shock . In addition , the benefit of adding fludrocortisone in this setting is unclear . OBJECTIVES To test the efficacy of intensive insulin therapy in patients whose septic shock was treated with hydrocortisone  and to assess , as a secondary objective , the benefit of fludrocortisone . DESIGN , SETTING , AND PATIENTS A multicenter , 2 x 2 factorial , r and omized trial , involving 509 adults with septic shock who presented with multiple organ dysfunction , as defined by a Sequential Organ Failure Assessment score of 8 or more , and who had received hydrocortisone treatment was conducted from January 2006 to January 2009 in 11 intensive care units in France . INTERVENTIONS Patients were r and omly assigned to 1 of 4 groups : continuous intravenous insulin infusion with hydrocortisone alone , continuous intravenous insulin infusion with hydrocortisone plus fludrocortisone , conventional insulin therapy with hydrocortisone alone , or conventional insulin therapy with intravenous hydrocortisone plus fludrocortisone . Hydrocortisone was administered in a 50-mg bolus every 6 hours , and fludrocortisone was administered orally in 50-microg tablets once a day , each for 7 days . MAIN OUTCOME MEASURE In-hospital mortality . RESULTS Of the 255 patients treated with intensive insulin , 117 ( 45.9 % ) , and 109 of 254 ( 42.9 % ) treated with conventional insulin therapy died ( relative risk [ RR ] , 1.07 ; 95 % confidence interval [ CI ] , 0.88 - 1.30 ; P = .50 ) . Patients treated with intensive insulin experienced significantly more episodes of severe hypoglycemia ( < 40 mg/dL ) than those in the conventional-treatment group , with a difference in mean number of episodes per patient of 0.15 ( 95 % CI , 0.02 - 0.28 ; P = .003 ) . At hospital discharge , 105 of 245 patients treated with fludrocortisone ( 42.9 % ) died and 121 of 264 ( 45.8 % ) in the control group died ( RR , 0.94 ; 95 % CI , 0.77 - 1.14 ; P = .50 ) . CONCLUSIONS Compared with conventional insulin therapy , intensive insulin therapy did not improve in-hospital mortality among patients who were treated with hydrocortisone for septic shock . The addition of oral fludrocortisone did not result in a statistically significant improvement in in-hospital mortality . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00320099 Introduction Hyperglycemia , hypoglycemia , and increased glycemic variability have each beenindependently associated with increased risk of mortality in critically ill patients . The role of diabetic status on modulating the relation of these threedomains of glycemic control with mortality remains uncertain . The purpose of thisinvestigation was to determine how diabetic status affects the relation ofhyperglycemia , hypoglycemia , and increased glycemic variability with the risk ofmortality in critically ill patients . Methods This is a retrospective analysis of prospect ively collected data involving 44,964 patients admitted to 23 intensive care units ( ICUs ) from nine countries , betweenFebruary 2001 and May 2012 . We analyzed mean blood glucose concentration (BG),coefficient of variation ( CV ) , and minimal BG  and created multivariable models toanalyze their independent association with mortality . Patients were stratifiedaccording to the diagnosis of diabetes . Results Among patients without diabetes , mean BG b and s between 80 and 140 mg/dl wereindependently associated with decreased risk of mortality , and mean BG b and s > 140 mg/dl , with increased risk of mortality . Among patients withdiabetes , mean BG from 80 to 110 mg/dl was associated with increased risk ofmortality and mean BG from 110 to 180 mg/dl with decreased risk of mortality . Aneffect of center was noted on the relation between mean BG and mortality . Hypoglycemia , defined as minimum BG < 70 mg/dl , was independently associatedwith increased risk of mortality among patients with and without diabetes and increased glycemic variability , defined as CV > 20 % , was independentlyassociated with increased risk of mortality only among patients without diabetes . Derangements of more than one domain of glycemic control had a cumulativeassociation with mortality , especially for patients without diabetes . Conclusions Although hyperglycemia , hypoglycemia , and increased glycemic variability is eachindependently associated with mortality in critically ill patients , diabeticstatus modulates these relations in clinical ly important ways . Our findings suggest that patients with diabetes may benefit from higher glucose target rangesthan will those without diabetes . Additionally , hypoglycemia is independentlyassociated with increased risk of mortality regardless of the patient 's diabeticstatus , and increased glycemic variability is independently associated withincreased risk of mortality among patients without diabetes . See related commentary by Krinsley , http://ccforum.com/content/17/2/131See related commentary by Finfer and Billot , BACKGROUND Nutritional support has been recognized as an essential part of intensive care unit management . However , the appropriate caloric intake for critically ill patients remains ill defined . OBJECTIVE We examined the effect of permissive underfeeding compared with that of target feeding and of intensive insulin therapy ( IIT ) compared with that of conventional insulin therapy ( CIT ) on the outcomes of critically ill patients . DESIGN This study had a 2 × 2 factorial , r and omized , controlled design . Eligible patients were r and omly assigned to permissive underfeeding or target feeding groups ( caloric goal : 60 - 70 % compared with 90 - 100 % of calculated requirement , respectively ) with either IIT or CIT ( target blood glucose : 4.4 - 6.1 compared with 10 - 11.1 mmol/L , respectively ) . RESULTS Twenty-eight-day all-cause mortality was 18.3 % in the permissive underfeeding group compared with 23.3 % in the target feeding group ( relative risk : 0.79 ; 95 % CI : 0.48 , 1.29 ; P = 0.34 ) . Hospital mortality was lower in the permissive underfeeding group than in the target group ( 30.0 % compared with 42.5 % ; relative risk : 0.71 ; 95 % CI : 0.50 , 0.99 ; P = 0.04 ) . No significant differences in outcomes were observed between the IIT and CIT groups . CONCLUSION In critically ill patients , permissive underfeeding may be associated with lower mortality rates than target feeding . This trial was registered at controlled-trials.com as IS RCT N96294863 Objective : To study the clinical and laboratory characteristics of patients with severe sepsis and baseline hyperglycemia and investigate the impact of hyperglycemia on the final outcome . Patients : A total of 265 patients admitted with severe sepsis in 3 major hospitals in South-Western Greece , during a 1-year period , were included in the study . Patients were divided in 3 groups according to their glycemic profile at admission :  patients with stress hyperglycemia  ( group SH , n = 47 ) , with diabetes mellitus  ( group DM , n = 65 ) , and with normal glucose level  ( group NG , n = 153 ) . Hyperglycemia was defined as an admission or in-hospital fasting glucose level of ≥126 mg/dL or a r and om blood glucose level of ≥200 mg/dL on ≥2 determinations . Results : A total of 42.2 % of patients with severe sepsis had baseline hyperglycemia with 17.7 % having sepsis-induced stress hyperglycemia . No family history was noted in the SH group . A higher percentage of septic patients with stress hyperglycemia died compared with patients with normal glucose levels ( 42.5 % versus 13.7 % ) and diabetics ( 42.5 % versus 24.6 % ) . Group DM had also a poorer prognosis than group NG ( 24.6 % versus 13.7 % ) . A positive correlation was detected between the fasting blood glucose levels of group SH and the severity of sepsis indicated by sepsis-related organ failure assessment score . Conclusion : Baseline hyperglycemia , including stress-induced hyperglycemia , is common in patients with severe sepsis . Stress-induced hyperglycemia is related to a more severe disease and poorer prognosis Objective : This study sought to determine whether aggressive glycemic control ( 90–120 mg/dL ) would result in more optimal clinical outcomes and less morbidity than moderate glycemic control ( 120–180 mg/dL ) in diabetic patients undergoing coronary artery bypass graft ( CABG ) surgery . Summary of Background Data : Maintaining serum glucose levels between 120 and 180 mg/dL with continuous insulin infusions decreases morbidity in diabetic patients undergoing CABG surgery . Studies in surgical patients requiring prolonged ventilation suggest that aggressive glycemic control ( < 120 mg/dL ) may improve survival ; however , its effect in diabetic CABG patients is unknown . Methods : Eighty-two diabetic patients undergoing CABG were prospect ively r and omized to aggressive glycemic control ( 90–120 mg/dL ) or moderate glycemic control ( 120–180 mg/dL ) using continuous intravenous insulin solutions ( 100 units regular insulin in 100 mL : normal saline ) beginning at the induction of anesthesia and continuing for 18 hours after CABG . Primary end points were the incidence of major adverse events ( major adverse events = 30-day mortality , myocardial infa rct ion , neurologic events , deep sternal infections , and atrial fibrillation ) , the level of serum glucose , and the incidence of hypoglycemic events . Results : There were no differences in the incidence of major adverse events between the groups ( 17 moderate vs 15 aggressive ; P = 0.91 ) . Patients with aggressive control had a lower mean glucose at the end of 18 hours of insulin infusion ( 135 ± 12 mg/dL moderate vs 103 ± 17 mg/dL aggressive ; P < 0.0001 ) . Patients with aggressive control had a higher incidence of hypoglycemic events ( 4 vs 30 ; P < 0.0001 ) . Conclusions : In diabetic patients undergoing CABG surgery , aggressive glycemic control increases the incidence of hypoglycemic events and does not result in any significant improvement in clinical outcomes that can be achieved with moderate control . Clinical Trials.gov ( ID # NCT00460499 BACKGROUND Hyperglycemia is common among patients admitted to intensive care units , and carries the risk for complications and prolonged ICU stay . With intensive insulin control of blood glucose , morbidity and mortality can be reduced . OBJECTIVES To determine whether intensive or conventional insulin control of blood glucose in hyperglycemic ICU patients correlated with the prognosis . METHODS Following admission to the ICU , hyperglycemic patients were r and omly assigned to a group treated intensively with insulin targeting glucose at 110 - 140 mg/dl , or to a conventional insulin therapy group , where glucose , upon exceeding 200 mg/dl , was controlled at 140 - 200 mg/dl . Rates of morbidity and mortality , hypoglycemic episodes , and insulin dosage were compared . RESULTS In the 41 patients treated intensively with insulin  the glucose level was 142 + /- 14 mg/dl , as compared to 174+/-20 mg/dl in the 48 patients on conventional insulin treatment .  Both groups were similar in age , acute physiology and chronic health evaluation score . Morbidity was also similar , except for increased vascular damage in the conventional treatment group and slightly shorter ICU stay in the intensive therapy group . Both groups had similar in-ICU , in-hospital , and 28 day mortalities , and similar rates of hypoglycemic episodes . The daily dosage of insulin  was significantly higher with the conventional treatment ( P= 0.004 ) . CONCLUSIONS Intensive insulin treatment did not affect the mortality or morbidity rates in ICU patients . The increased  insulin dosage of conventional insulin treatment was attributable to the group 's higher prevalence of diabetes . Future studies should address this bias and determine the optimal glucose target Background and Purpose — Intensive insulin therapy ( IIT ) has not yet proven its efficacy on stroke prognosis or in the reduction of MRI infa rct growth . The INSULINFA RCT study aims at determining in patients with hyperacute stroke whether IIT , with a better control of poststroke hyperglycemia , would 
    Output:
    
Conclusions : Critically ill patients undergoing intensive glucose control  showed significantly reduced all-cause mortality , length of ICU stay and incidence of acquired infection and sepsis compared to the same parameters in patients treated with the usual care strategy , while the intensive glucose control strategy was associated with higher occurrence of severe hypoglycemic events