***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 Upper-gastrointestinal haemorrhage is a frequent reason for hospital admission . Although most risk scoring systems for this disorder incorporate endoscopic findings , the Glasgow-Blatchford bleeding score ( GBS ) is based on simple clinical and laboratory variables ; a score of 0 identifies low-risk patients who might be suitable for outpatient management . We aim ed to evaluate the GBS then assess the effect of a protocol based on this score for non-admission of low-risk individuals . METHODS Our study was undertaken at four hospitals in the UK . We calculated GBS and admission ( pre-endoscopy ) and full ( post-endoscopy ) Rockall scores  for consecutive patients presenting with upper-gastrointestinal haemorrhage . With receiver-operating characteristic ( ROC ) curves , we compared the ability of these scores to predict either need for clinical intervention or death . We then prospect ively assessed at two hospitals the introduction of GBS scoring to avoid admission of low-risk patients . FINDINGS Of 676 people presenting with upper-gastrointestinal haemorrhage , we identified 105 ( 16 % ) who scored 0 on the GBS . For prediction of need for intervention or death , GBS ( area under ROC curve 0.90 [ 95 % CI 0.88 - 0.93 ] ) was superior to full Rockall score ( 0.81 [ 0.77 - 0.84 ] ) , which in turn was better than the admission Rockall score ( 0.70 [ 0.65 - 0.75 ] ) . When introduced into clinical practice , 123 patients ( 22 % ) with upper-gastrointestinal haemorrhage were classified as low risk , of whom 84 ( 68 % ) were managed as out patients without adverse events . The proportion of individuals with this condition admitted to hospital also fell ( 96 % to 71 % , p<0.00001 ) . INTERPRETATION The GBS identifies many patients presenting to general hospitals with upper-gastrointestinal haemorrhage who can be managed safely as out patients . This score reduces admissions for this condition , allowing more appropriate use of in-patient re sources Objectives Hypertension is common among patients with dyslipidemia but is often poorly treated . The objective of this analysis was to evaluate how a decision aid , used by primary care physicians to improve lipid therapy , impacted on the treatment of hypertension . Study Design Data were analyzed from patients enrolled in a r and omized trial focusing primarily on the treatment of dyslipidemia . Patients received usual care or a coronary risk profile every three months to monitor the risk reduction following lifestyle changes and /or pharmacotherapy to treat dyslipidemia . Hypertension management was assessed based on a post hoc analysis of individuals whose blood pressure exceeded current national hypertension guidelines . Results There were 2,631 subjects who completed the study . Among 1,352 patients without diagnosed hypertension , 30 % were above target on at least three consecutive visits . Among 1,279 individuals with known hypertension , 69 % were above target on at least two consecutive visits . Overall , patients receiving risk profiles were more likely to receive appropriate antihypertensive therapy  ( OR = 1.40 , 95 % CI 1.11 – 1.78 ) compared to those receiving usual care . After adjustment for inter-physician variability and potential confounders , the use of the risk profile was associated with an increased likelihood of starting therapy ( OR = 1.78 , 95 % CI 1.06 – 3.00 ) or modifying therapy ( OR = 1.40 , 95 % CI 1.03 – 1.91 ) . Conclusions In this clinical trial of dyslipidemia management , inadequately controlled hypertension was common , occurring in nearly 50 % of individuals . Ongoing coronary risk assessment was associated with more appropriate blood pressure management . Cardiovascular risk assessment decision aids should be further evaluated in a r and omized trial of hypertension therapy OBJECTIVE To vali date a score based on clinical symptoms and signs for the identification of group A Streptococcus ( GAS ) infection in general practice patients with score throat . DESIGN A single throat swab was used as the gold st and ard for diagnosing GAS infection . Clinical information was recorded by experienced family physicians on st and ardized encounter forms . Score criteria were identified by means of logistic regression modelling of data from patients enrolled in the first half of the study . The score was then vali date d among the remaining patients . SETTING University-affiliated family medicine centre in Toronto . PATIENTS A total of 521 patients aged 3 to 76 years presenting with a new upper respiratory tract infection from December 1995 to February 1997 . OUTCOME MEASURES Sensitivity , specificity and likelihood ratios for identification of GAS infection with the  score approach compared with throat culture . Proportion of patients prescribed antibiotics , throat culture use , and sensitivity and specificity with usual physician care and with score-based recommendations were compared . RESULTS A score was developed ranging in value from 0 to 4 . The sensitivity of the score  for identifying GAS infection was 83.1 % , compared with 69.4 % for usual physician care ( p = 0.06 ) ; the specificity values of the 2 approaches were similar . Among patients aged 3 to 14 years , the sensitivity of the score approach was higher than that of usual physician care ( 96.9 % v. 70.6 % ) ( p < 0.05 ) . The proportion of patients receiving initial antibiotic prescriptions would have been reduced 48 % by following score-based recommendations compared with observed physician prescribing ( p < 0.001 ) , without any increase in throat culture use . CONCLUSIONS An age-appropriate sore throat score identified GAS infection in children and adults with sore throat better than usual care by family physicians , with significant reductions in unnecessary prescribing of antibiotics . A r and omized trial comparing the 2 approaches is recommended to determine the ability of the score approach to reduce unnecessary prescribing of antibiotics during routine clinical encounters Cardiovascular disease causes the death of around 80 % of patients with type 2 diabetes.1 However , risk factors for cardiovascular disease in such patients are often untreated2 despite the proved benefits of intervention . 3 4 One way to help clinicians identify patients at high risk of cardiovascular disease is to use cardiovascular primary prevention risk tables . These tables integrate the multiple risk factors into a single score . We did a pilot study to test the hypothesis that documentation of a  cardiovascular risk score in the case notes would improve the management of cardiovascular risk factors . We recruited patients with type 2 diabetes who had no history of cardiovascular disease or renal disease . All patients were aged 35–75 years and attending a hospital Background : The Low Risk Ankle Rule is a vali date d clinical decision rule that has the potential to safely reduce radiography in children with acute ankle injuries . We performed a phased implementation of the Low Risk Ankle Rule and evaluated its effectiveness in reducing the frequency of radiography in children with ankle injuries . Methods : Six Canadian emergency departments participated in the study from Jan. 1 , 2009 , to Aug. 31 , 2011 . At the 3 intervention sites , there were 3 consecutive 26-week phases . In phase 1 , no interventions were implemented . In phase 2 , we activated strategies to implement the ankle rule , including physician education , reminders and a computerized decision support system . In phase 3 , we included only the decision support system . No interventions were introduced at the 3 pair-matched control sites . We examined the management of ankle injuries among children aged 3–16 years . The primary outcome was the proportion of children undergoing radiography . Results : We enrolled 2151 children with ankle injuries , 1055 at intervention and 1096 at control hospitals . During phase 1 , the baseline frequency of pediatric ankle radiography at intervention and control sites was 96.5 % and 90.2 % , respectively . During phase 2 , the frequency of ankle radiography decreased significantly at intervention sites relative to control sites ( between-group difference −21.9 % [ 95 % confidence interval [ CI ] −28.6 % to −15.2 % ] ) , without significant differences in patient or physician satisfaction . All effects were sustained in phase 3 . The sensitivity of the Low Risk Ankle Rule  during implementation was 100 % ( 95 % CI 85.4 % to 100 % ) , and the specificity was 53.1 % ( 95 % CI 48.1 % to 58.1 % ) . Interpretation : Implementation of the Low Risk Ankle Rule in several different emergency department setting s reduced the rate of pediatric ankle radiography significantly and safely , without an accompanying change in physician or patient satisfaction . Trial registration : Clinical Trials.gov , no. NCT00785876 Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Background The number of primary care referrals of women with breast symptoms to symptomatic breast units ( SBUs ) has increased exponentially in the past decade in Irel and . The aim of this study is to develop and vali date a  clinical prediction rule ( CPR ) to identify women with breast cancer so that a more evidence based approach to referral from primary care to these SBUs can be developed . Methods We analysed routine data from a prospect i ve cohort of consecutive women review ed at a SBU with breast symptoms . The data set was split into a derivation and validation cohort . Regression analysis was used to derive a CPR from the patient ’s history and clinical findings . Validation of the CPR consisted of estimating the number of breast cancers predicted to occur compared with the actual number of observed breast cancers across deciles of risk . Results A total of 6,590 patients were included in the derivation study and 4.9 % were diagnosed with breast cancer . Independent clinical predictors for breast cancer were : increasing age by year ( adjusted odds ratio 1.08 , 95 % CI 1.07 - 1.09 ) ; presence of a lump ( 5.63 , 95 % CI 4.2 - 7.56 ) ; nipple change ( 2.77 , 95 % CI 1.68 - 4.58 ) and nipple discharge ( 2.09 , 95 % CI 1.1 - 3.97 ) . Validation of the rule ( n = 911 ) demonstrated that the probability of breast cancer was higher with an increasing number of these independent variables . The Hosmer-Lemeshow goodness of fit showed no overall significant difference between the expected and the observed numbers of breast cancer ( χ2HL : 6.74 , p-value : 0.56 ) . Conclusions This study derived and vali date d a CPR for breast cancer in women attending an Irish national SBU . We found that increasing age , presence of a lump , nipple discharge and nipple change are all associated with increased risk of breast cancer . Further validation of the rule is necessary as well as an assessment of its impact on referral practice OBJECTIVES Infections with group A streptococcus ( GAS ) occur in 10 % to 20 % of patients with sore throats , whereas antibiotics are prescribed 50 % of the time . Clinical scoring rules can more accurately predict the likelihood of GAS infection , but whether family physicians will adopt such approaches is unclear . This study sought to determine whether repeated clinical prompts to use a scoring approach could help family physicians lower antibiotic use in patients with a sore throat . STUDY DESIGN R and omized trial in which physicians were assigned to use either ( 1 ) chart stickers that prompted them to calculate a score based on clinical findings and provided management recommendations linked to score totals or ( 2 ) a clinical checklist . POPULATION Ninety-seven family physicians in Ontario , Canada , assessed 621 children and adults with sore throat and obtained a throat swab for culture . OUTCOMES MEASURED ( 1 ) Unnecessary antibiotic prescriptions given to patients with a negative throat culture and ( 2 ) overall antibiotic use . RESULTS There were no differences between the control and intervention group in unnecessary antibiotic prescriptions ( 16.1 % vs 20.4 % , respectively , P = .29 ) or overall antibiotic use ( 27.9 % vs 28.1 % , P = .97 ) . However , a number of physicians dropped out of the study ; as a result , the characteristics of the physicians in the 2 groups were dissimilar in factors related to prescribing . After adjusting for these differences and patient clustering by physician , the odds ratio for the effect of the intervention on unnecessary antibiotic prescriptions was 0.76 ( 95 % confidence interval [ CI ] = 0.42 , 1.40 ) and 0.57 for overall antibiotic use ( 95 % CI = 0.27 , 1.17 ) . CONCLUSIONS Chart prompts during clinical encounters to use a clinical score in the assessment of patients with a sore throat did not reduce unnecessary antibiotic prescribing by family physicians . The problems encountered in conducting this community-based intervention trial are discussed in relation to the negative result Abstract Objective : To assess the feasibility and impact of introducing the Ottawa ankle rules to a large number of physicians in a wide variety of hospital and community setting s over a prolonged period of time . Design : Multicentre before and after controlled clinical trial . Setting : Emergency departments of eight teaching and community hospitals in Canadian communities ( population 10000 to 3 
    Output:
    
To date , research has focused on a small number of CPRs across few clinical domains only