***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: BACKGROUND Recent reports have drawn attention to the importance of pulse pressure as a predictor of cardiovascular events .  Pulse pressure is used neither by clinicians nor by guidelines to define treatable levels of blood pressure . METHODS In the Cardiovascular Health Study , 5888 adults 65 years and older were recruited from 4 US centers . At baseline in 1989 - 1990 , participants underwent an extensive examination , and all subsequent cardiovascular events were ascertained and classified . RESULTS At baseline , 1961 men and 2941 women were at risk for an incident myocardial infa rct ion or stroke . During follow-up that averaged 6.7 years , 572 subjects had a coronary event , 385 had a stroke , and 896 died . After adjustment for potential confounders , systolic blood pressure ( SBP ) , diastolic blood pressure ( DBP ) , and pulse pressure were directly associated with the risk of incident myocardial infa rct ion and stroke . Only SBP was associated with total mortality . Importantly , SBP was a better predictor of cardiovascular events than DBP or pulse pressure . In the adjusted model for myocardial infa rct ion , a 1-SD change in SBP , DBP , and pulse pressure was associated with hazard ratios ( 95 % confidence intervals ) of 1.24 ( 1.15 - 1.35 ) , 1.13 ( 1.04 - 1.22 ) , and 1.21 ( 1.12 - 1.31 ) , respectively ; and adding pulse pressure or DBP to the model did not improve the fit . For stroke , the hazard ratios ( 95 % confidence intervals ) were 1.34 ( 1.21 - 1.47 ) with SBP , 1.29 ( 1.17 - 1.42 ) with DBP , and 1.21 ( 1.10 - 1.34 ) with pulse pressure . The association between blood pressure level and cardiovascular disease risk was generally linear ; specifically , there was no evidence of a J-shaped relationship . In those with treated hypertension , the hazard ratios for the association of SBP with the risks for myocardial infa rct ion and stroke were less pronounced than in those without treated hypertension . CONCLUSION In this population -based study of older adults , although all measures of blood pressure were strongly and directly related to the risk of coronary and cerebrovascular events , SBP was the best single predictor of cardiovascular events Abstract OBJECTIVE : To examine the impact of a nurse-coordinated intervention delivered to patients with non-insulin-dependent diabetes mellitus between office visits to primary care physicians . DESIGN : R and omized , controlled trial . SETTING : Veterans Affairs general medical clinic . PATIENTS : 275 veterans who had NIDDM and were receiving primary care from general internists . INTERVENTION : Nurse-initiated contacts were made by telephone at least monthly to provide patient education ( with special emphasis on regimens and significant signs and symptoms of hyperglycemia and hypoglycemia ) , reinforce compliance with regimens , monitor patients ’ health status , facilitate resolution of identified problems , and facilitate access to primary care . MEASUREMENTS : Glycemic control was assessed using glycosylated hemoglobin ( GHb ) and fasting blood sugar ( FBS ) levels . Health-related quality of life ( HRQOL ) was measured with the Medical Outcomes Study SF-36 , and diabetes-related symptoms were assessed using patients ’ self-reports of signs and symptoms of hyper- and hypoglycemia during the previous month . MAIN RESULTS : At one year , between-group differences favored intervention patients for FBS ( 174.1 mg/dL vs 193.1 mg/dL , p=0.011 ) and GHb ( 10.5 % vs 11.1 % , p=0.046 ) . Statistically significant differences were not observed for either SF-36 scores ( p=0.66 ) or diabetes-related symptoms ( p=0.23 ) . CONCLUSIONS : The intervention , design ed to be a pragmatic , low-intensity adjunct to care delivered by physicians , modestly improved glycemic control but not HRQOL or diabetes-related symptoms OBJECTIVE A controlled trial with 15-month follow-up was conducted in two outpatient clinics to study the effects of using the problem-based learning technique to implement a diabetes clinical practice guideline . RESEARCH DESIGN AND METHODS A total of 144 patients with type 2 diabetes aged 25 - 65 years in two internal medicine outpatient clinics were enrolled in the study . African-Americans and Hispanics made up > 75 % of the patients . Doctors and staff in one of the clinics were trained in the use of a clinical practice guideline based on Staged Diabetes Management . A problem-based learning educational program was instituted to reach consensus on a stepped intensification scheme for glycemic control and to determine the st and ards of care used in the clinic . HbA1c was obtained at baseline and at 9 and 15 months after enrollment . RESULTS At 9 months , there was a mean -0.90 % within-subject change in HbA1c in the intervention group , with no significant changes in the control group . The 15-month mean within-subject change in HbA1c of -0.62 % in the intervention group was also significant . Among intervention patients , those with the poorest glycemic control at baseline realized the greatest benefit in improvement of HbA1c . The intervention group also exhibited significant changes in physician adherence with American Diabetes Association st and ards of care . CONCLUSIONS Clinical practice guidelines are an effective way of improving the processes and outcomes of care for patients with diabetes . Problem-based learning is a useful strategy to gain physician support for clinical practice guidelines . More intensive interventions are needed to maintain treatment gains The aim of this study was to evaluate the effect of a structured teaching/treatment programme on the clinical and metabolic control of non-insulin-dependent ( type 2 ) diabetic patients . The programme was aim ed at improving the overall treatment quality in these patients through measures involving self-care , diet , exercise and weight reduction . Four theoretical-practical teaching units were given once a week to group of 5–8 ambulatory patients by previously trained general practitioners .  Clinical and biochemical parameters were recorded at the beginning of the course and 1 year after its completion in 40 patients attending the programme and in 39 patients of similar clinical characteristics under conventional diabetes treatment , but receiving no structured teaching before or during the survey period ( control group ) . The drop-out percentage in the intervention group ( 25 % ) was significantly lower than in the control group (45%),P<0.05 , suggesting an incentive toward greater compliance in the former . At the end of the 1-year follow-up , the mean differences observed in the control and in the intervention groups were : body weight loss −2.4±0.5 kg vs −0.4±0.5 ( P<0.001 ) ; haemoglobin HbA1 −0.2%±0.4 % vs + 0.8±0.4 % ( NS ) ; number of daily oral hypoglycaemic agent intake −1.4±0.2 vs + 0.9±0.2 tablets ( P<0.001 ) . Our results strongly suggest that this programme , applied through family doctors , may constitute an efficient tool to improve the compliance and clinico-metabolic control of type 2 patients at the primary health care level Abstract Objectives : To evaluate integrated care for diabetes in clinical , psychosocial , and economic terms . Design : Pragmatic r and omised trial . Setting : Hospital diabetic clinic and three general practice groups in Grampian . Patients : 274 adult diabetic patients attending a hospital clinic and registered with one of three general practice s. Intervention - R and om allocation to conventional hospital clinic care or integrated care . Integrated care patients seen in general practice every three or four months and in the hospital clinic annually . General practitioners were given written guidelines for integrated care . Main outcome measures : Metabolic control , psychosocial status , knowledge of diabetes , beliefs about control of diabetes , satisfaction with treatment , disruption of normal activities , numbers of consultations and admissions , frequency of metabolic monitoring , costs to patients and NHS . Results - A higher proportion of patients defaulted from conventional care ( 14 ( 10 % ) ) than from integrated care ( 4 ( 3 % ) , 95 % confidence interval of difference 2 % to 13 % ) . After two years no significant differences were found between the groups in metabolic control , psychosocial status , knowledge , beliefs about control , satisfaction with treatment , unscheduled admissions , or disruption of normal activities .  Integrated care was as effective for insulin dependent as non-insulin dependent patients . Patients in integrated care had more visits and higher frequencies of examination . Costs to patients were lower in integrated care ( mean pounds sterling 1.70 ) than in conventional care ( pounds sterling 8) . 88 % of patients who experienced integrated care wished to continue with it . Conclusions : This model of integrated care for diabetes was at least as effective as conventional hospital clinic care OBJECTIVE --To evaluate the effectiveness and acceptability of central ly organised prompting for coordinating community care of non-insulin dependent diabetic patients . DESIGN --R and omised single centre trial . Patients allocated to prompted care in the community or to continued attendance at hospital diabetic clinic ( controls ) . Median follow up two years . SETTING --Two hospital outpatient clinics , 38 general practice s , and 11 optometrists in the catchment area of a district general hospital in Islington . PATIENTS --181 patients attending hospital outpatient clinics . NULL HYPOTHESIS -- There is no difference in process of medical care measures and medical outcome between prompted community care and hospital clinic care . RESULTS --14 hospital patients failed to receive a single review in the clinic as compared with three patients in the prompted group ( chi 2 = 6.1 , df = 1 ; p = 0.013 ) . Follow up for retinal screening was better in prompted patients than in controls ; two prompted patients defaulted as against 12 controls ( chi 2 = 6.9 , df = 1 ; p = 0.008 ) . Three measures per patient yearly were more frequent in prompted patients : tests for albuminuria ( median 3.0 v 2.3 ; p = 0.03 ) , plasma glucose estimations ( 3.1 v 2.5 ; p = 0.003 ) , and glycated haemoglobin estimations ( 2.4 v 0.9 ; p < 0.001 ) . Continuity of care was better in the prompted group ( 3.2 v 2.2 review s by each doctor seen ; p < 0.001 ) . The study ended with no significant differences between the groups in last recorded r and om plasma glucose concentration , glycated haemoglobin value , numbers admitted to hospital for a diabetes related reason , and number of deaths . Question naires revealed a high level of patient , general practitioner , and optometrist satisfaction . CONCLUSIONS --Six monthly prompting of non-insulin treated diabetic patients for care by inner city general practitioners and by optometrists is effective and acceptable OBJECTIVE We evaluated automated telephone disease management ( ATDM ) with telephone nurse follow-up as a strategy for improving diabetes treatment processes and outcomes in Department of Veterans Affairs ( VA ) clinics . We also compared the results with those of a prior ATDM trial conducted in a county health care system . RESEARCH DESIGN AND METHODS A total of 272 VA patients with diabetes using hypoglycemic medications were r and omized . During the 1-year study period , intervention patients received biweekly ATDM health assessment and self-care education calls , and a nurse educator followed up with patients based on their ATDM assessment reports . Telephone surveys were used to measure patients ' self-care , symptoms , and satisfaction with care . Outpatient service use was evaluated using electronic data bases and self-reports , and glycemic control was measured by HbA1c and serum glucose testing . RESULTS At 12 months , intervention patients reported more frequent glucose self-monitoring and foot inspections than patients receiving usual care and were more likely to be seen in podiatry and diabetes specialty clinics . Intervention patients also were more likely than control patients to have had a cholesterol test . Among patients with baseline HbA1c levels > or = 8 % , mean end-point values were lower among intervention patients than control patients ( 8.7 vs. 9.2 % , respectively ; P = 0.04 ) . Among intervention and control patients with baseline values > or = 9 % , mean end-point values were 9.1 and 10.2 % , respectively ( P = 0.04 ) . At follow-up , intervention patients reported fewer symptoms of poor glycemic control than control patients and greater satisfaction with their health care . CONCLUSIONS This intervention improved the quality of VA diabetes care . Intervention effects for most end points replicated findings from the prior county clinic trial , although intervention-control differences in the current study were smaller because of the relatively good self-care and health status among the current study 's enrollees In patients with non-insulin-dependent diabetes mellitus ( NIDDM ) , the influence of knowledge about their disease on the treatment and control of the disease is not clear . We evaluated the efficacy of educational group meetings with NIDDM patients on improving their knowledge of the disease and on disease management .  Fifty-one NIDDM patients were r and omly assigned to either intervention or control groups . The intervention group participated in courses of three weekly lessons presented by a physician , nurse 
    Output:
    
Evidence also supports program benefits in improving screening for retinopathy and foot lesions .
CONCLUSIONS Diabetes disease management programs can improve glycemic control to a modest extent and can increase screening for retinopathy and foot complications .