***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 Diabetic retinopathy ( DR ) is a common microvascular complication of diabetes mellitus , and more than 75 % of patients who have had diabetes for more than 20 years will have some degree of DR . This disease is highly destructive to self-esteem and puts a high burden on public health and pension systems due to the effects that it has on people of working age . The current mainstay of treatment is laser photocoagulation , which causes impairment of vision and discomfort to patients . Thus , finding a systemic drug that could act on all microcirculation and prevent direct manipulation of the eyes would be highly desirable . Objective To assess the efficacy and safety of the drugs in the statin and /or fibrate groups for the prevention and treatment of DR . Methods In this systematic review , we will select r and omized controlled trials of fibrates or statins used for the treatment or prevention of DR . Our search strategy will include free text terms and controlled vocabulary ( eg , MeSH , Emtree ) for , “ diabetic retinopathy ” , “ statins ” , “ fibrates ” , “ hypolipidemic agents ” , and for drugs from both groups . Data bases that will be used include Medical Literature Analysis and Retrieval System/ PubMed , Embase , Cochrane Central Register of Controlled Trials , Latin American and Caribbean Center on Health Sciences Information , Clinical trials.gov , World Health Organization International Clinical Trials Registry Platform , and OpenGrey , and we will not have language or date limits . Two review authors will independently select eligible studies and assess the risk of bias using the Cochrane Collaboration ’s tool . We will report structured summaries of the included studies and , if possible , conduct meta-analyses . Results This is a protocol for a systematic review , therefore results are not available . We registered a short version of this protocol before progressing in the review and we are currently in the process of selecting the studies for inclusion . Conclusions Intensive glucose control and lowering blood pressure and lipids are mechanisms that protect macrocirculation in diabetic patients . Both macrovascular and microvascular events in diabetic patients appear to have a common pathway , starting with endothelial injury . Thus , prevention and treatment of microvascular events may benefit from the same interventions . In the review for which we have written this protocol , we will assess whether the use of lipid-lowering oral drugs of the statin and /or fibrate groups may prevent and /or retard progression of DR , with the added benefit of preserving visual acuity . Trial Registration PROSPERO A three-year trial of Atromid treatment in exudative diabetic retinopathy was carried out in twenty-three patients and twenty-five controls . In comparison with those of the controls the eyes of the Atromid-treated patients showed a highly significant decrease in hard waxy exu date s ( p = < 0.0001 ) which was not , however , accompanied by appreciable improvement in visual acuity . No improvement in the vascular retinal lesions occurred . The initial severity of the exudative lesions was not related to the fasting serum cholesterol or triglyceride levels ; there was also no correlation between the effect of Atromid on the exu date s and on these serum lipids . The way in which Atromid might influence exu date deposition and its possible use in the treatment of exudative diabetic retinopathy are discussed Background Synthesis of multiple r and omized controlled trials ( RCTs ) in a systematic review can summarize the effects of individual outcomes and provide numerical answers about the effectiveness of interventions . Filtering of search es is time consuming , and no single method fulfills the principal requirements of speed with accuracy . Automation of systematic review s is driven by a necessity to expedite the availability of current best evidence for policy and clinical decision-making . We developed Rayyan ( http://rayyan.qcri.org ) , a free web and mobile app , that helps expedite the initial screening of abstract s and titles using a process of semi-automation while incorporating a high level of usability . For the beta testing phase , we used two published Cochrane review s in which included studies had been selected manually . Their search es , with 1030 records and 273 records , were uploaded to Rayyan . Different features of Rayyan were tested using these two review s. We also conducted a survey of Rayyan ’s users and collected feedback through a built-in feature . Results Pilot testing of Rayyan focused on usability , accuracy against manual methods , and the added value of the prediction feature . The “ taster ” review ( 273 records ) allowed a quick overview of Rayyan for early comments on usability . The second review ( 1030 records ) required several iterations to identify the previously identified 11 trials . The “ suggestions ” and “ hints , ” based on the “ prediction model , ” appeared as testing progressed beyond five included studies . Post rollout user experiences and a reflexive response by the developers enabled real-time modifications and improvements . The survey respondents reported 40 % average time savings when using Rayyan compared to others tools , with 34 % of the respondents reporting more than 50 % time savings . In addition , around 75 % of the respondents mentioned that screening and labeling studies as well as collaborating on review s to be the two most important features of Rayyan . As of November 2016 , Rayyan users exceed 2000 from over 60 countries conducting hundreds of review s totaling more than 1.6 M citations . Feedback from users , obtained mostly through the app web site and a recent survey , has highlighted the ease in exploration of search es , the time saved , and simplicity in sharing and comparing include-exclude decisions . The strongest features of the app , identified and reported in user feedback , were its ability to help in screening and collaboration as well as the time savings it affords to users . Conclusions Rayyan is responsive and intuitive in use with significant potential to lighten the load of review ers PURPOSE To report additional ocular outcomes of intensive treatment of hyperglycemia , blood pressure , and dyslipidemia in the Action to Control Cardiovascular Risk in Diabetes ( ACCORD ) study . DESIGN Double 2 × 2 factorial , multicenter , r and omized clinical trials in people with type 2 diabetes who had cardiovascular disease or cardiovascular risk factors . In the glycemia trial , targets of intensive and st and ard treatment were : hemoglobin A1c < 6.0 % and 7.0 % to 7.9 % , respectively , and in the blood pressure trial : systolic blood pressures of < 120 and < 140 mmHg , respectively . The dyslipidemia trial compared fenofibrate plus simvastatin with placebo plus simvastatin . PARTICIPANTS Of the 3472 ACCORD Eye Study participants enrolled , 2856 had 4-year data ( 85 % of survivors ) . METHODS Eye examinations and fundus photographs were taken at baseline and year 4 . Photographs were grade d central ly for retinopathy severity and macular edema using the Early Treatment Diabetic Retinopathy Study ( ETDRS ) methods . MAIN OUTCOME MEASURES Three or more steps of progression on the ETDRS person scale or treatment of retinopathy with photocoagulation or vitrectomy . RESULTS As previously reported , there were significant reductions in the primary outcome in the glycemia and dyslipidemia trials , but no significant effect in the blood pressure trial . Results were similar for retinopathy progression by 1 , 2 , and 4 or more steps on the person scale and for ≥ 2 steps on the eye scale . In the subgroup of patients with mild retinopathy at baseline , effect estimates were large ( odds ratios , ∼0.30 ; P < 0.001 ) , but did not reach nominal significance for participants with no retinopathy or for those with moderate to severe retinopathy at baseline . CONCLUSIONS Slowing of progression of retinopathy by intensive treatment of glycemia was observed in ACCORD participants , whose average age and diabetes duration were 62 and 10 years , respectively , and who had cardiovascular disease or cardiovascular risk factors . The effect seemed stronger in patients with mild retinopathy . Similar slowing of progression was observed in patients treated with fenofibrate , with no effect observed with intensive blood pressure treatment . This is the second study to confirm the benefits of fenofibrate in reducing diabetic retinopathy progression , and fenofibrate should be considered for treatment of diabetic retinopathy INTRODUCTION Lipid-lowering drugs preserve vision and reduce the risk of hard exu date s in clinical ly-significant macular edema(CSME ) in diabetics with an abnormal lipid profile . But their role in reducing CSME in diabetics with a normal lipid profile is not yet known . OBJECTIVE To evaluate the role of atorvastatin in CSME in diabetics with a normal lipid profile . MATERIAL S AND METHODS A prospect i ve , r and omized clinical trial was carried out . Thirty CSME patients with a normal lipid profile were r and omly divided into Group A and B. Atorvastatin had been started in Group A four weeks prior to laser treatment . The main outcome measures were any improvement or deterioration in visual acuity and macular edema and hard exu date s at six months follow-up . STATISTICS Both the groups were compared using unpaired t test for quantitative parameters and chi-square test for qualitative parameters . A p value of less than 0.05 was taken as significant . RESULTS Visual acuity , macular edema and hard exu date s resolution was not significantly different in the two groups ( P = 0.14 , 0.62 , 0.39 respectively ) . CONCLUSION Atorvastatin does not affect treatment outcome in CSME with a normal lipid profile over a short term follow-up OBJECTIVE To evaluate the relationship between serum lipid levels , retinal hard exu date , and visual acuity in patients with diabetic retinopathy . DESIGN Observational data from the Early Treatment Diabetic Retinopathy Study . PARTICIPANTS Of the 3711 patients enrolled in the Early Treatment Diabetic Retinopathy Study , the first 2709 enrolled had serum lipid levels measured  . MAIN OUTCOME MEASURES Baseline fasting serum lipid levels , best-corrected visual acuity , and assessment of retinal thickening and hard exu date from stereoscopic macular photographs . RESULTS Patients with elevated total serum cholesterol levels or serum low-density lipoprotein cholesterol levels at baseline were twice as likely to have retinal hard exu date s as patients with normal levels . These patients were also at higher risk of developing hard exu date during the course of the study . The risk of losing visual acuity was associated with the extent of hard exu date even after adjusting for the extent of macular edema . CONCLUSIONS These data demonstrate that elevated serum lipid levels are associated with an increased risk of retinal hard exu date in persons with diabetic retinopathy . Although retinal hard exu date usually accompanies diabetic macular edema , increasing amounts of exu date appear to be independently associated with an increased risk of visual impairment . Lowering elevated serum lipid levels has been shown to decrease the risk of cardiovascular morbidity . The observational data from the Early Treatment Diabetic Retinopathy Study suggest that lipid lowering may also decrease the risk of hard exu date formation and associated vision loss in patients with diabetic retinopathy . Preservation of vision may be an additional motivating factor for lowering serum lipid levels in persons with diabetic retinopathy and elevated serum lipid levels Besides hyperglycemia and hypertension , a recently recognized risk factor for diabetic retinopathy ( DR ) appears to be hyperlipidemia . While studies using earlier generation lipid lowering agents in DR were disappointing , a r and omized trial using HMG-CoA Reductase Inhibitors has strong rationale , though hitherto not attempted . The aim of the present study was to compare the HMG-CoA Reductase Inhibitor , simvastatin , with placebo in patients having DR in a double-blind r and omized placebo-controlled trial . Fifty patients with diabetes mellitus ( Type 1 and 2 ) with good glycemic control and hypercholesterolemia and having DR ( non- clinical ly significant macular edema and visual acuity 6/24 or better ) in either or both eyes were r and omized to simvastatin 20-mg per day or placebo , and were followed up for 180 days . On simvastatin therapy , total cholesterol and low-density lipoprotein cholesterol ( LDL-C ) decreased ( P < 0.001 , respectively ) , and the level of high-density lipoprotein cholesterol ( HDL-C ) increased ( P < 0.001 ) . VA improved in four patients using simvastatin , ( not statistically different from placebo group ) and worsening of VA occurred in seven patients in the placebo group and none in the simvastatin group ( P = 0.009 ) . Fundus fluorescein angiography and color fundus photograph showed improvement in one patient in the simvastatin group , while seven patients showed worsening in the placebo group ( P = 0.009 ) . The observations of the current study suggest that the HMG-CoA Reductase Inhibitor simvastatin significantly retards the progression of retinopathy in diabetic patients with hypercholesterolemia . The potential of this class of drugs for the primary prevention of DR and other microvascular complications needs to be explored further AIM Hyperlipidemia and diabetic retinopathy increase the risk of cardiovascular disease ( CVD ) . The st and ard versus intEnsive statin therapy for hypercholesteroleMic Patients with diAbetic retinopaTHY ( EMPATHY ) study examines whether intensive lipid-lowering therapy is superior to st and ard therapy in reducing the incidence of cardiov 
    Output:
    
Overall , adverse events seemed to be similar between fibrate and placebo , but again based on the width of the confidence intervals , an important increase of adverse events can not be rule out .
Based on these findings , we are uncertain about the effects of statins for DR .