***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 and Purpose — The effect of aspirin in primary prevention of stroke is controversial among clinical trials conducted in Western countries , and no data are available for Asian population s with a high risk of intracranial hemorrhage . The objective of this study was to evaluate the effect of aspirin on the risk of stroke and intracranial hemorrhage in the Japanese Primary Prevention Project ( JPPP ) . Methods — A total of 14 464 patients ( age , 60–85 years ) with hypertension , dyslipidemia , and diabetes mellitus participated and were r and omized into 2 treatment groups : 100 mg of aspirin or no aspirin . The median follow-up period was 5.02 years . Results — The cumulative rate of fatal or nonfatal stroke was similar for the aspirin ( 2.068 % ; 95 % confidence interval [ CI ] , 1.750–2.443 ) and no aspirin ( 2.299 % ; 95 % CI , 1.963–2.692 ) groups at 5 years ; the estimated hazard ratio was 0.927 ( 95 % CI , 0.741–1.160 ; P=0.509 ) . Aspirin nonsignificantly reduced the risk of ischemic stroke or transient ischemic attack ( hazard ratio , 0.783 ; 95 % CI , 0.606–1.012 ; P=0.061 ) and nonsignificantly increased the risk of intracranial hemorrhage ( hazard ratio , 1.463 ; 95 % CI ; 0.956–2.237 ; P=0.078 ) . A Cox regression adjusted by the risk factors for all stroke , which were age > 70 years , smoking , and diabetes mellitus , supported the above result . Conclusions — Aspirin did not show any net benefit for the primary prevention of stroke in elderly Japanese patients with risk factors for stroke , whereas age > 70 years , smoking , and diabetes mellitus were risk factors for stroke regardless of aspirin treatment . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00225849 OBJECTIVE Our purpose was to measure the agreement , reliability , construct validity , and feasibility of a measurement tool to assess  systematic review s ( AMSTAR ) . STUDY DESIGN AND SETTING We r and omly selected 30 systematic review s from a data base . Each was assessed by two review ers using : ( 1 ) the enhanced quality assessment question naire ( Overview of Quality Assessment Question naire [ OQAQ ] ) ; ( 2 ) Sacks ' instrument ; and ( 3 ) our newly developed measurement tool ( AMSTAR ) . We report on reliability ( interobserver kappas of the 11 AMSTAR items ) , intraclass correlation coefficients ( ICCs ) of the sum scores , construct validity ( ICCs of the sum scores of AMSTAR compared with those of other instruments ) , and completion times . RESULTS The interrater agreement of the individual items of AMSTAR was substantial with a mean kappa of 0.70 ( 95 % confidence interval [ CI ] : 0.57 , 0.83 ) ( range : 0.38 - 1.0 ) . Kappas recorded for the other instruments were 0.63 ( 95 % CI : 0.38 , 0.78 ) for enhanced OQAQ and 0.40 ( 95 % CI : 0.29 , 0.50 ) for the Sacks ' instrument . The ICC of the total score for AMSTAR was 0.84 ( 95 % CI : 0.65 , 0.92 ) compared with 0.91 ( 95 % CI : 0.82 , 0.96 ) for OQAQ and 0.86 ( 95 % CI : 0.71 , 0.94 ) for the Sacks ' instrument . AMSTAR proved easy to apply , each review taking about 15 minutes to complete . CONCLUSIONS AMSTAR has good agreement , reliability , construct validity , and feasibility . These findings need confirmation by a broader range of assessors and a more diverse range of review Background Multimorbidity is increasing in aging population s with a corresponding increase in polypharmacy as well as inappropriate prescribing . Depending on definitions , 25 - 50 % of patients aged 75 years or older are exposed to at least five drugs . Evidence is increasing that polypharmacy , even when guidelines advise the prescribing of each drug individually , can potentially cause more harm than benefit to older patients , due to factors such as drug-drug and drug-disease interactions . Several approaches reducing polypharmacy and inappropriate prescribing have been proposed , but evidence showing a benefit of these measures regarding clinical ly relevant endpoints is scarce . There is an urgent need to implement more effective strategies . We therefore set out to develop an evidence -based electronic decision support ( eDS ) tool to aid physicians in reducing inappropriate prescribing and test its effectiveness in a large-scale cluster-r and omized controlled trial . Methods The “ Polypharmacy in chronic diseases – Reduction of Inappropriate Medication and Adverse drug events in older population s ” (PRIMA)-eDS tool is a tool comprising an indication check and recommendations for the reduction of polypharmacy and inappropriate prescribing based on systematic review s and guidelines , the European list of inappropriate medications for older people , the SFINX- data base of interactions , the PHARAO- data base on adverse effects , and the RENBASE- data base on renal dosing . The tool will be evaluated in a cluster-r and omized controlled trial involving 325 general practitioners ( GPs ) and around 3500 patients across five study centres in the United Kingdom , Germany , Austria and Italy . GP practice s will be asked to recruit 11 patients aged 75 years or older who are taking at least eight medications and will be cluster-r and omized after completion of patient recruitment . Intervention GPs will have access to the PRIMA-eDS tool , while control GPs will treat their patients according to current guidelines ( usual care ) without access to the PRIMA-eDS tool . After an observation time of 2 years , intervention and control groups will be compared regarding the primary composite endpoint of first non-elective hospitalization or death . Discussion The principal hypothesis is that reduction of polypharmacy and inappropriate prescribing can improve the clinical composite outcome of hospitalization or death . A positive result of the trial will contribute substantially to the improvement of care in multimorbidity . The trial is necessary to investigate not only whether the reduction of polypharmacy improves outcome , but also whether GPs and patients are willing to follow the recommendations of the PRIMA-eDS tool . Trial registration This trial has been registered with Current Controlled Trials Ltd. on 31 July 2014 ( IS RCT N10137559 ) CONTEXT Previous trials have investigated the effects of low-dose aspirin on primary prevention of cardiovascular events , but not in patients with type 2 diabetes . OBJECTIVE To examine the efficacy of low-dose aspirin for the primary prevention of atherosclerotic events in patients with type 2 diabetes . DESIGN , SETTING , AND PARTICIPANTS Multicenter , prospect i ve , r and omized , open-label , blinded , end-point trial conducted from December 2002 through April 2008 at 163 institutions throughout Japan , which enrolled 2539 patients with type 2 diabetes without a history of atherosclerotic disease and had a median follow-up of 4.37 years . INTERVENTIONS Patients were assigned to the low-dose aspirin group ( 81 or 100 mg per day ) or the nonaspirin group . MAIN OUTCOME MEASURES Primary end points were atherosclerotic events , including fatal or nonfatal ischemic heart disease , fatal or nonfatal stroke , and peripheral arterial disease . Secondary end points included each primary end point and combinations of primary end points as well as death from any cause . RESULTS A total of 154 atherosclerotic events occurred : 68 in the aspirin group ( 13.6 per 1000 person-years ) and 86 in the nonaspirin group ( 17.0 per 1000 person-years ) ( hazard ratio [ HR ] , 0.80 ; 95 % confidence interval [ CI ] , 0.58 - 1.10 ; log-rank test , P = .16 ) . The combined end point of fatal coronary events and fatal cerebrovascular events occurred in 1 patient ( stroke ) in the aspirin group and 10 patients ( 5 fatal myocardial infa rct ions and 5 fatal strokes ) in the nonaspirin group ( HR , 0.10 ; 95 % CI , 0.01 - 0.79 ; P = .0037 ) . A total of 34 patients in the aspirin group and 38 patients in the nonaspirin group died from any cause ( HR , 0.90 ; 95 % CI , 0.57 - 1.14 ; log-rank test , P = .67 ) . The composite of hemorrhagic stroke and significant gastrointestinal bleeding was not significantly different between the aspirin and nonaspirin groups . CONCLUSION In this study of patients with type 2 diabetes , low-dose aspirin as primary prevention did not reduce the risk of cardiovascular events . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00110448 Background — Patients with a non – ST-elevation acute coronary syndrome and prior CABG are at high risk of a recurrent ischemic event despite aspirin therapy . This trial investigated the potential benefit of secondary prevention with warfarin . Methods and Results —In a double-blind r and omized trial , 135 patients with unstable angina or non – ST-segment elevation myocardial infa rct ion , with prior CABG , and who were poor c and i date s for a revascularization procedure received therapy with aspirin and placebo+warfarin , warfarin and placebo+aspirin , or aspirin and warfarin for 12 months . Warfarin was titrated to an international normalized ratio of 2.0 to 2.5 . The primary end point ( death or myocardial infa rct ion or unstable angina requiring hospitalization 1 year after r and omization ) occurred in 14.6 % of the patients in the warfarin-alone group , in 11.5 % of patients in the aspirin-alone group , and in 11.3 % of patients r and omized to the combination therapy ( P = 0.76 ) . Subgroup analyses by risk features provided no indications that warfarin alone or in combination with aspirin could be of benefit over aspirin alone . Bleeding was more frequent in the 2 groups of patients administered warfarin . Conclusions —Moderate-intensity oral anticoagulation alone or combined with low-dose aspirin does not appear to be superior to low-dose aspirin in the prevention of recurrent ischemic events in patients with non – ST-elevation acute coronary syndromes and previous CABG OBJECTIVE We have assessed the influence of gender and age on the main outcome results of the Hypertension Optimal Treatment ( HOT ) study . DESIGN AND INTERVENTIONS The aims of the HOT study were to study the relationship between three levels of target office diastolic blood pressure ( BP ) ( < or = 90 , < or = 85 or < or = 80 mmHg ) and  cardiovascular ( CV ) events in hypertensive patients , and to examine the effects of 75 mg acetylsalicylic acid ( ASA ) daily versus placebo . SETTING Outpatient clinical trial in 26 countries . PATIENTS A total of 18790 patients ( mean age 61.5 years , range 50 - 80 ) were r and omized and followed for an average of 3.8 years until 71051 patient-years and 683 events had occurred . MAIN OUTCOME MEASURES CV death , myocardial infa rct ion ( MI ) and stroke . RESULTS There were significantly fewer MIs in those in the lower diastolic BP target groups ( 3.0 versus 1.2 and 1.7 MIs/1000 patient-years , P for trend = 0.034 ) in women ( n = 8883 ) , whereas the similar but smaller trend ( 4.1 versus 4.1 and 3.4 MIs/1000 patient-years ) was not statistically significant in men nor in the subgroup analysis of younger and older subjects . The effect of ASA on preventing MI was not influenced by age < 65 years ( P= 0.02 ) or age > or = 65 years ( P = 0.04 ) but was influenced by gender ( P = 0.38 in women and P = 0.001 in men , lowered by 42 % corresponding to a reduction from 5.0 to 2.9 MIs/1000 patient-years ) . CONCLUSIONS The data of this HOT study sub- analysis suggest somewhat differentiated optimal gender- and age-dependent effects of anti-hypertensive and anti-platelet therapies ; lowering of diastolic BP to about 80 mmHg in hypertensive women and , in addition , the administration of 75 mg of ASA to well-treated hypertensive men appear to effectively reduce the most common cardiovascular complication , i.e. myocardial infa rct ion , in patients with essential hypertension BACKGROUND Clopidogrel was superior to aspirin in patients with previous manifestations of atherothrombotic disease in the CAPRIE study and its benefit 
    Output:
    
First , the use of acetylsalicylic acid ( ASA ) for primary prevention of cardiovascular disease ( CVD ) in older people can not be recommended due to an uncertainty in the risk-benefit ratio ( weak recommendation ; low quality of evidence ) .
Secondly , the combination of ASA and clopidogrel in patients without specific indications should be avoided ( strong recommendation ; moderate quality of evidence ) .
Conclusions The use of ASA for the primary prevention of CVD and the combination therapy of ASA and clopidogrel for the secondary prevention of vascular events in older people may not be justified .