***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 In some r and omized trials comparing revascularization strategies for patients with diabetes , coronary-artery bypass grafting ( CABG ) has had a better outcome than percutaneous coronary intervention ( PCI ) . We sought to discover whether aggressive medical therapy and the use of drug-eluting stents could alter the revascularization approach for patients with diabetes and multivessel coronary artery disease . METHODS In this r and omized trial , we assigned patients with diabetes and multivessel coronary artery disease to undergo either PCI with drug-eluting stents or CABG . The patients were followed for a minimum of 2 years ( median among survivors , 3.8 years ) . All patients were prescribed currently recommended medical therapies for the control of low-density lipoprotein cholesterol , systolic blood pressure , and glycated hemoglobin . The primary outcome measure was a composite of death from any cause , nonfatal myocardial infa rct ion , or nonfatal stroke . RESULTS From 2005 through 2010 , we enrolled 1900 patients at 140 international centers . The patients ' mean age was 63.1±9.1 years , 29 % were women , and 83 % had three-vessel disease . The primary outcome occurred more frequently in the PCI group ( P=0.005 ) , with 5-year rates of 26.6 % in the PCI group and 18.7 % in the CABG group . The benefit of CABG was driven by differences in rates of both myocardial infa rct ion ( P<0.001 ) and death from any cause ( P=0.049 ) . Stroke was more frequent in the CABG group , with 5-year rates of 2.4 % in the PCI group and 5.2 % in the CABG group ( P=0.03 ) . CONCLUSIONS For patients with diabetes and advanced coronary artery disease  , CABG was superior to PCI in that it significantly reduced rates of death and myocardial infa rct ion , with a higher rate of stroke . ( Funded by the National Heart , Lung , and Blood Institute and others ; FREEDOM Clinical Trials.gov number , NCT00086450 . ) OBJECTIVES To investigate the until now undefined extent of differences in baseline characteristics , practice patterns and clinical outcomes of patients undergoing coronary artery bypass grafting ( CABG ) for complex coronary artery disease in the USA versus Europe . METHODS The impact of geographic enrollment on clinical outcomes was explored using the as-treated population of 1510 patients with de novo left main and /or three-vessel disease who underwent CABG in either the SYNTAX r and omized trial or registries , and who were followed up for 5 years . RESULTS There were 259 ( 17 % ) patients enrolled in the USA . Patients in the USA had more comorbidities . Off-pump procedures were more frequent in the USA ( 32 vs 13 % in Europe ; P < 0.001 ) , and crystalloid cardioplegia was used less often ( 17 vs 38 % in Europe ; P < 0.001 ) . In the USA , more grafts per patient were used ( 3.1 ± 0.8 vs 2.7 ± 0.7 in Europe ; P < 0.001 ) , with less complete arterial grafting ( 5 vs 18 % in Europe ; P < 0.001 ) but more complete revascularization ( 80 vs 66 % in Europe ; P < 0.001 ) . At 5-year follow-up , patients treated in the USA versus Europe had comparable rates of major adverse cardiac and cerebrovascular events ( MACCEs : 28.7 vs 24.3 % , respectively ; P = 0.11 ) and the composite safety endpoint of death , stroke and myocardial infa rct ion ( MI ; 15.3 vs 17.5 % , respectively ; P = 0.43 ) , but a significantly higher rate of repeat revascularization ( 15.0 vs 9.8 % , respectively ; P = 0.011 ) driven by repeat percutaneous coronary intervention ( 14.6 vs 9.2 % ; P = 0.005 ) and not repeat CABG ( 0.4 vs 0.8 % ; P = 0.48 ) . Rates of graft occlusion were significantly higher in the USA versus Europe ( 8.7 vs 3.2 % ; P < 0.001 ) . In multivariate analysis , enrollment in the USA was a non-significant predictor of MACCE [ hazard ratio ( HR ) = 1.31 , 95 % confidence interval ( 95 % CI ) 1.00 - 1.73 ; P = 0.053 ] , but independently predicted repeat revascularization ( HR = 1.66 , 95 % CI 1.12 - 2.46 ; P = 0.011 ) and graft occlusion ( HR = 2.65 , 95 % CI 1.52 - 4.62 ; P = 0.001 ) . It was also a non-significant predictor of reduced rates of MI ( HR = 0.38 , 95 % CI 0.14 - 1.06 ; P = 0.064 ) . Differences between the USA and Europe were most pronounced among patients who underwent off-pump CABG . CONCLUSIONS Repeat revascularization rates following CABG in the USA versus Europe were increased at 5 years , particularly in off-pump patients . There was no significant difference in the rate of death , stroke and MI OBJECTIVES The purpose of this study was to quantitatively examine the association of patient- and trial-specific factors with participation in cardiovascular r and omized clinical trials . BACKGROUND R and omized clinical trials are central to evidence d-based medicine , but low patient participation rates and potentially modifiable barriers are not well understood . METHODS At a large U.S. academic health system , we examined screening logs from December 1 , 2005 , to February 28 , 2011 , from 15 cardiovascular r and omized clinical trials . We identified 655 patients who were screened and potentially eligible for participation in at least 1 trial . We used multivariable Poisson regression to quantify the risk of not participating in a trial associated with patient- and trial-specific factors . RESULTS The median age was 63 years ( interquartile range : 54 to 72 ) , 35 % were women , and the median Charlson Index was 2 ( interquartile range : 1 to 5 ) . Forty-two percent of patients did not participate in a trial . In multivariable regression ( C-Index 0.85 ) , trial-specific factors strongly associated with not participating included intensive trial-related testing ( relative risk [ RR ] : 1.89 ; 95 % confidence interval [ CI ] : 1.63 to 2.20 ) and anticipated trial participation > 6 months ( RR : 4.10 ; 95 % CI : 2.30 to 7.29 ) . Patient-specific factors associated with not participating included older age ( RR : 1.23 ; 95 % CI : 1.11 to 1.36 , per 10-year increase if age ≥65 years ) , out-of-state residence ( RR : 1.26 ; 95 % CI : 1.04 to 1.54 ) , and female sex ( RR : 1.17 ; 95 % CI : 1.01 to 1.35 ) . Race was not associated with participation . CONCLUSIONS While patient-specific factors were associated with not participating in cardiovascular trials , longer trial duration and intensive trial-related testing were most strongly associated with risk for patients not participating . Innovative trial design s fostering convenience may most enhance trial participation BACKGROUND The regional prevalence of risk factors can vary over time . The Study of Health in Pomerania ( SHIP ) addresses prevalence trends for common risk factors in a region in northeast Germany . METHODS A longitudinal study was carried out from 1997 to 2001 ( SHIP-0 , with 4308 subjects ) , and a second , independent r and om sample of the population in the same region was studied from 2008 to 2012 ( SHIP-Trend , with 4420 subjects ) . All data were st and ardized with post-stratification weighting derived from the adult population of the state of Mecklenburg-West Pomerania . RESULTS SHIP reveals a marked decline of mean alcohol consumption in the adult population , from 5.57 g/day ( 95 % confidence interval , 5.51 - 5.63 ) to 3.12 g/day ( 95 % CI 3.09 - 3.15 ) . The percentage of active smokers among men declined from 38.6 % ( 95 % CI 36.0 - 41.2 ) to 34.3 % ( 95 % CI 32.1 - 36.6 ) . Simultaneously , however , there was a rightward shift of the BMI distribution , with a marked increase in the prevalence of obesity , from 24.7 % to 32.0 % . There was a corresponding increase in the prevalence of diabetes , from 9.1 % to 13.8 % . Compared to eleven years ago , the amount of exercise taken during free time has risen among the elderly , but fallen among young women . CONCLUSION Tobacco and alcohol consumption have declined over the past decade , although this study may have overestimated these trends through a combination of selection bias and reporting bias . Meanwhile , the northeast German population now has a worse metabolic risk profile , as indicated by the increased prevalence of obesity and diabetes . Society as a whole must take measures to combat this trend Minority underrepresentation exists in medical research including cardiovascular clinical trials , but the hypothesis that this relates to distrust in medical research ers is unproven . Therefore , we examined whether African American persons differ from white persons in perceptions of the risks/ benefits of trial participation and distrust toward medical research ers , and whether these factors influence willingness to participate ( WTP ) in a clinical drug trial . Participants were self-administered a survey regarding WTP in a cardiovascular drug trial given to 1440 r and omly selected patients from 13 Maryl and outpatient cardiology and general medicine clinics . Patients reported their WTP , rated their perceived chances of experiencing health benefit and harm , and rated their distrust toward research ers . Of eligible participants , 70 % responded , and 717 individuals were included : 36 % African American and 64 % white . African American participants possessed lower WTP than white participants ( 27 % vs. 39 % , p = 0.001 ) and had higher mean distrust scores than whites ( p < 0.0001 ) . African American participants more frequently reported that doctors would less fully explain research participation to them ( 24 % vs. 13 % , p < 0.001 ) , use them as guinea pigs without their consent ( 72 % vs. 49 % , p < 0.001 ) , prescribe medication as a way of experimenting on people without their knowledge ( 35 % vs. 16 % , p < 0.001 ) , and ask them to participate in research even if it could harm them ( 24 % vs. 15 % , p = 0.002 ) . African American participants also more often believed they could less freely ask their doctor questions ( 8 % vs. 2 % , p < 0.001 ) and that doctors had previously experimented on them without their consent ( 58 % vs. 25 % , p < 0.001 ) . African American participants expressed lesser WTP than white participants after controlling for racial differences in age , sex , socioeconomic status and cardiovascular disease risk profiles ( multivariable odds ratio [ OR ] , 0.57 ; 95 % confidence interval [ CI ] , 0.39 - 0.85 ) . The impact of race was attenuated and nonsignificant after adjustment for potential mediating factors of racial differences in medical research er distrust and perceived risk of harm ( explanatory model OR , 0.84 ; 95 % CI 0.54 - 1.30 ) . In summary , African American participants expressed markedly greater concerns about experiencing harm from participation in clinical trials and distrust toward medical research ers than white participants . These factors , in turn , appear to explain much of the resistance among African American persons to participate in clinical trials compared to white persons . Abbreviations : AIDS = acquired immunodeficiency syndrome , CI = confidence interval , CVD = cardiovascular disease , HIV = human immunodeficiency virus , OR = odds ratio , WTP = willingness to participate OBJECTIVE To examine differences in outcomes and patient management between patients in the United States and outside the United States undergoing thrombolysis for acute myocardial infa rct ion . DESIGN , SETTING , AND PATIENTS Patients in the United States ( n = 23,105 ) and 14 other countries ( n = 17,916 ) were r and omized to receive streptokinase plus either subcutaneous or intravenous ( IV ) heparin , accelerated recombinant tissue-type plasminogen activator ( rt-PA ) plus IV heparin , or combined streptokinase and rt-PA plus IV heparin . OUTCOME MEASURES Differences in 30-day mortality and patient management were compared among treatments and between US and non-US patients . Treatment-by-country interactions were assessed by logistic regression analyses . Expected mortality of US and non-US patients was estimated 
    Output:
    
Conclusions There are major continental differences in risk factors among patients enrolled in PCI trials from various continents .