human
***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 Countries in sub-Saharan Africa ( SSA ) are experiencing an epidemic of cardiovascular disease ( CVD ) propelled by rapidly increasing rates of hypertension . Barriers to hypertension control in SSA include poor access to care and high out-of-pocket costs . Although SSA bears 24 % of the global disease burden , it has only 3 % of the global health workforce . Given such limited re sources , cost-effective strategies , such as task shifting , are needed to mitigate the rising CVD epidemic in SSA . Ghana , a country in SSA with an established community health worker program integrated within a national health insurance scheme provides an ideal platform to evaluate implementation of the World Health Organization ( WHO ) task-shifting strategy . This study will evaluate the comparative effectiveness of the implementation of the WHO Package targeted at CV risk assessment versus provision of health insurance coverage , on blood pressure ( BP ) reduction . Methods Using a cluster r and omized design , 32 community health centers ( CHCs ) and district hospitals in Ghana will be r and omized to either the  intervention  group ( 16 CHCs ) or the control group ( 16 CHCs ) . A total of 640 patients with uncomplicated hypertension ( BP 140–179/90–99 mm Hg and absence of target organ damage ) will be enrolled in this study ( 20 patients per CHC ) . The intervention consists of WHO Package of CV risk assessment , patient education , initiation and titration of antihypertensive medications , behavioral counseling on lifestyle behaviors , and medication adherence every three months for 12 months . The primary outcome is the mean change in systolic BP from baseline to 12 months . The secondary outcomes are rates of BP control at 12 months ; levels of physical activity , percent change in weight , and dietary intake of fruits and vegetables at 12 months ; and sustainability of intervention effects at 24 months . All outcomes will be assessed at baseline , six months and 12 months . Trained community health nurses will deliver the intervention as part of Ghana ’s community-based health planning and services ( CHPS ) program . Discussion Findings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive CV risk reduction and hypertension control in re source -poor setting s . Trial registration NCT01802372 Background —Family members of patients with cardiovascular disease ( CVD ) may be at increased risk due to shared genes and lifestyle . Hospitalization of a family member with CVD may represent a “ motivational moment ” to take preventive action . Methods and Results —A r and omized , controlled clinical trial was conducted in healthy adult family members ( N=501 ; 66 % female ; 36 % nonwhite ; mean age , 48 years ) of patients hospitalized with CVD to evaluate a special intervention ( SI )  with personalized risk factor screening , therapeutic lifestyle-change counseling , and progress reports to physicians versus a control intervention ( CIN ) on the primary outcome , mean percent change in low-density lipoprotein cholesterol ( LDL-C ) , and other risk factors . Vali date d dietary assessment s and st and ardized risk factors were obtained at baseline and 1 year ( 94 % follow-up ) . At baseline , for 93 % of subjects , saturated fat comprised ≥7 % of total caloric intake , and 79 % had nonoptimal LDL-C levels ( of which 50 % were unaware ) . There was no difference in the SI versus the CIN with respect to the mean percent change in LDL-C ( −1 % versus −2 % , respectively ; P=0.64 ) , owing to a similar significant reduction in LDL-C in both groups ( −4.4 mg/dL and −4.5 mg/dL , respectively ) . Diet score significantly improved in the SI versus the CIN ( P=0.04 ) . High-density lipoprotein cholesterol declined significantly in the CIN but not in the SI ( −3.2 % [ 95 % CI , −5.1 to −1.3 ] versus + 0.3 % [ 95 % CI , −1.7 to + 2.4 ] ; P=0.01 ) . At 1 year , SI subjects were more likely than controls to exercise > 3 days per week ( P=0.04 ) . Conclusion —The SI was not more effective than the CIN in reducing the primary end point , LDL-C. The screening process identified many family members of hospitalized patients with CVD who were unaware of their risk factors , and further work is needed to develop and test interventions to reduce their CVD risk OBJECTIVE To determine if lifestyle improved at a short term through an intervention to involve patients in cardiovascular risk management by the practice nurse . METHODS The IMPALA study ( 2006 , the Netherl and s ) was a cluster-r and omised controlled trial involving 25 general practice s and 615 patients who were eligible for cardiovascular risk management . The intervention consisted of ( 1 ) individual 10-year cardiovascular risk assessment , ( 2 ) risk communication , ( 3 ) use of a decision aid and ( 4 ) adapted motivational interviewing , applied by practice nurses in two consultations . Outcomes were smoking , alcohol , diet , physical activity and the secondary outcomes risk perception , anxiety , confidence about the decision and satisfaction with the communication , measured at baseline and after 12 weeks . RESULTS Patients of both groups improved their lifestyle , but no relevant significant differences between the groups were found . Intervention group patients improved in terms of the appropriateness of risk perception , although not significantly . Intervention group patients improved significantly in terms of appropriateness of anxiety and were more satisfied with the communication compared to control group patients . CONCLUSION The intervention seems to have improved the patients ' risk perception , anxiety and satisfaction with the communication , which are important conditions for shared decision making . However , we found no additional effect of the intervention on lifestyle Background Primary care provides most of the evidence -based chronic disease prevention and screening services offered by the healthcare system . However , there remains a gap between recommended preventive services and actual practice . This trial ( the BETTER Trial ) aim ed to improve preventive care of heart disease , diabetes , colorectal , breast and cervical cancers , and relevant lifestyle factors through a practice facilitation intervention set in primary care . Methods Pragmatic two-way factorial cluster RCT with Primary Care Physicians ’ practice s as the unit of allocation and individual patients as the unit of analysis . The setting was urban Primary Care Team practice s in two Canadian provinces . Eight Primary Care Team practice s were r and omly assigned to receive the practice -level intervention or wait-list control ;  4 physicians in each team ( 32 physicians ) were r and omly assigned to receive the patient-level intervention or wait-list control .  Patients r and omly selected from physicians ’ rosters were stratified into two groups : 1 ) general and 2 ) moderate mental illness . The interventions involved a multifaceted , evidence -based , tailored practice -level intervention with a Practice Facilitator , and a patient-level intervention involving a one-hour visit with a Prevention Practitioner where patients received a tailored ‘ prevention prescription ’ . The primary outcome was a composite Summary Quality Index of 28 evidence -based chronic disease prevention and screening actions with pre-defined targets , expressed as the ratio of eligible actions at baseline that were met at follow-up . A cost-effectiveness analysis was conducted . Results 789 of 1,260 ( 63 % ) eligible patients participated . On average , patients were eligible for 8.96 ( SD 3.2 ) actions at baseline . In the adjusted analysis , control patients met 23.1 % ( 95 % CI : 19.2 % to 27.1 % ) of target actions , compared to 28.5 % ( 95 % CI : 20.9 % to 36.0 % ) receiving the practice -level intervention , 55.6 % ( 95 % CI : 49.0 % to 62.1 % ) receiving the patient-level intervention , and 58.9 % ( 95 % CI : 54.7 % to 63.1 % ) receiving both practice - and patient-level interventions ( patient-level intervention versus control , P < 0.001 ) . The benefit of the patient-level intervention was seen in both strata . The extra cost of the intervention was $ 26.43CAN ( 95 % CI : $ 16 to $ 44 ) per additional action met . Conclusions A Prevention Practitioner can improve the implementation of clinical ly important prevention and screening for chronic diseases in a cost-effective manner Background The Portuguese National Health Directorate has issued clinical practice guidelines on prescription of anti-inflammatory drugs , acid suppressive therapy , and antiplatelets . However , their effectiveness in changing actual practice is unknown . Methods The study will compare the effectiveness of educational outreach visits regarding the improvement of compliance with clinical guidelines in primary care against usual dissemination strategies . A cost-benefit analysis will also be conducted . We will carry out a parallel , open , superiority , r and omized trial directed to primary care physicians . Physicians will be recruited and allocated at a cluster-level ( primary care unit ) by minimization . Data will be analyzed at the physician level . Primary care units will be eligible if they use electronic prescribing and have at least four physicians willing to participate . Physicians in intervention units will be offered individual educational outreach visits ( one for each guideline ) at their workplace during a six-month period . Physicians in the control group will be offered a single unrelated group training session . Primary outcomes will be the proportion of cyclooxygenase-2 inhibitors prescribed in the anti-inflammatory class , and the proportion of omeprazole in the proton pump inhibitors class at 18 months post-intervention . Prescription data will be collected from the regional pharmacy cl aims data base . We estimated a sample size of 110 physicians in each group , corresponding to 19 clusters with a mean size of 6 physicians . Outcome collection and data analysis will be blinded to allocation , but due to the nature of the intervention , physicians and detailers can not be blinded . Discussion This trial will attempt to address unresolved issues in the literature , namely , long term persistence of effect , the importance of sequential visits in an outreach program , and cost issues . If successful , this trial may be the cornerstone for deploying large scale educational outreach programs within the Portuguese National Health Service . Trial registration Clinical Trials.gov number NCT01984034 OBJECTIVES To investigate the impact of general health screenings and discussion s with general practitioners on the cardiovascular risk profile of a r and om population of patients . STUDY DESIGN A population -based , r and omized , controlled , 5-year follow-up trial conducted in a primary care setting . POPULATION The study group consisted of 2000 patients , r and omly selected middle-aged men and women aged 30 to 50 years from family practice s in the district of Ebeltoft , Denmark . Of these patients , 1507 ( 75.4 % ) agreed to participate . Patients were r and omized into ( 1 ) a control group who did not receive health screenings , ( 2 ) an intervention group that received 2 health screenings , ( 3 ) an intervention group that received both the 2 screenings and a 45-minute follow-up consultation annually with their general practitioner . OUTCOMES MEASURED Cardiovascular risk score ( CRS ) , body mass index ( BMI ) , blood pressure , serum cholesterol , carbon monoxide in expiratory air , and tobacco use . RESULTS After 5 years , the CRS , BMI , and serum cholesterol levels were lower in the intervention groups compared with the control group . The improved outcome was greater in the baseline risk groups . The number of patients with elevated CRS in the intervention groups was approximately half the number of patients with elevated CRS in the control group . The difference was not a result of medication use . There was no difference between the group that received consultations after the screenings and the group that had health screenings alone . CONCLUSIONS Health screenings reduced the CRS in the intervention groups . After 5 years of follow-up , the number of persons at elevated cardiovascular risk was about half that expected , based on the prevalence/proportion in a population not receiving the health checks ( the control group ) . The impact of intervention was higher among at-risk individuals . Consultations about health did not appear to improve the cardiovascular profile of the study population Incidence and mortality results are presented from an international controlled trial of multifactorial prevention of coronary heart disease , involving r and omization of 66 factories ( 49 781 men ) in U.K. , Belgium , Italy and Pol and ( Cracow ) . Results for Pol and ( Warsaw ) are not yet complete . Net average reductions in risk factors ( all subjects ) were 1.2 % for plasma cholesterol , 8.9 % for daily cigarettes , 0.4 % for weight , 2.0 % for systolic blood pressure , and 11.1 % for a combined risk estimate . Greater reductions occurred in high-risk subjects ( 19.4 % for the combined estimate ) . The net overall reduction in CHD rates was 7.4 % ( 95 % confidence interval -29 to + 15 % ) for deaths ( 722 cases ) , and 3.9 % ( 95 % confidence interval -10 to + 2 % ) for fatal CHD + non-fatal myocardial infa rct ion ( 1502 cases ) . Among men aged 40 - 49 the reduction for this end-point was 15 % ; at ages 50 - 59 there was a small net increase . All-causes deaths after an early adverse trend showed 2.7 % reduction overall . There were large differences between centres , ranging from a 5 % net increase in CHD for U.K. to a decrease of  
    Output:
    
agent
Limited data suggest that systematic risk assessment for CVD has no statistically significant effects on clinical endpoints .
There is limited evidence to suggest that CVD systematic risk assessment may have some favourable effects on cardiovascular risk factors .
***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 Countries in sub-Saharan Africa ( SSA ) are experiencing an epidemic of cardiovascular disease ( CVD ) propelled by rapidly increasing rates of hypertension . Barriers to hypertension control in SSA include poor access to care and high out-of-pocket costs . Although SSA bears 24 % of the global disease burden , it has only 3 % of the global health workforce . Given such limited re sources , cost-effective strategies , such as task shifting , are needed to mitigate the rising CVD epidemic in SSA . Ghana , a country in SSA with an established community health worker program integrated within a national health insurance scheme provides an ideal platform to evaluate implementation of the World Health Organization ( WHO ) task-shifting strategy . This study will evaluate the comparative effectiveness of the implementation of the WHO Package targeted at CV risk assessment versus provision of health insurance coverage , on blood pressure ( BP ) reduction . Methods Using a cluster r and omized design , 32 community health centers ( CHCs ) and district hospitals in Ghana will be r and omized to either the  intervention  group ( 16 CHCs ) or the control group ( 16 CHCs ) . A total of 640 patients with uncomplicated hypertension ( BP 140–179/90–99 mm Hg and absence of target organ damage ) will be enrolled in this study ( 20 patients per CHC ) . The intervention consists of WHO Package of CV risk assessment , patient education , initiation and titration of antihypertensive medications , behavioral counseling on lifestyle behaviors , and medication adherence every three months for 12 months . The primary outcome is the mean change in systolic BP from baseline to 12 months . The secondary outcomes are rates of BP control at 12 months ; levels of physical activity , percent change in weight , and dietary intake of fruits and vegetables at 12 months ; and sustainability of intervention effects at 24 months . All outcomes will be assessed at baseline , six months and 12 months . Trained community health nurses will deliver the intervention as part of Ghana ’s community-based health planning and services ( CHPS ) program . Discussion Findings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive CV risk reduction and hypertension control in re source -poor setting s . Trial registration NCT01802372 Background —Family members of patients with cardiovascular disease ( CVD ) may be at increased risk due to shared genes and lifestyle . Hospitalization of a family member with CVD may represent a “ motivational moment ” to take preventive action . Methods and Results —A r and omized , controlled clinical trial was conducted in healthy adult family members ( N=501 ; 66 % female ; 36 % nonwhite ; mean age , 48 years ) of patients hospitalized with CVD to evaluate a special intervention ( SI )  with personalized risk factor screening , therapeutic lifestyle-change counseling , and progress reports to physicians versus a control intervention ( CIN ) on the primary outcome , mean percent change in low-density lipoprotein cholesterol ( LDL-C ) , and other risk factors . Vali date d dietary assessment s and st and ardized risk factors were obtained at baseline and 1 year ( 94 % follow-up ) . At baseline , for 93 % of subjects , saturated fat comprised ≥7 % of total caloric intake , and 79 % had nonoptimal LDL-C levels ( of which 50 % were unaware ) . There was no difference in the SI versus the CIN with respect to the mean percent change in LDL-C ( −1 % versus −2 % , respectively ; P=0.64 ) , owing to a similar significant reduction in LDL-C in both groups ( −4.4 mg/dL and −4.5 mg/dL , respectively ) . Diet score significantly improved in the SI versus the CIN ( P=0.04 ) . High-density lipoprotein cholesterol declined significantly in the CIN but not in the SI ( −3.2 % [ 95 % CI , −5.1 to −1.3 ] versus + 0.3 % [ 95 % CI , −1.7 to + 2.4 ] ; P=0.01 ) . At 1 year , SI subjects were more likely than controls to exercise > 3 days per week ( P=0.04 ) . Conclusion —The SI was not more effective than the CIN in reducing the primary end point , LDL-C. The screening process identified many family members of hospitalized patients with CVD who were unaware of their risk factors , and further work is needed to develop and test interventions to reduce their CVD risk OBJECTIVE To determine if lifestyle improved at a short term through an intervention to involve patients in cardiovascular risk management by the practice nurse . METHODS The IMPALA study ( 2006 , the Netherl and s ) was a cluster-r and omised controlled trial involving 25 general practice s and 615 patients who were eligible for cardiovascular risk management . The intervention consisted of ( 1 ) individual 10-year cardiovascular risk assessment , ( 2 ) risk communication , ( 3 ) use of a decision aid and ( 4 ) adapted motivational interviewing , applied by practice nurses in two consultations . Outcomes were smoking , alcohol , diet , physical activity and the secondary outcomes risk perception , anxiety , confidence about the decision and satisfaction with the communication , measured at baseline and after 12 weeks . RESULTS Patients of both groups improved their lifestyle , but no relevant significant differences between the groups were found . Intervention group patients improved in terms of the appropriateness of risk perception , although not significantly . Intervention group patients improved significantly in terms of appropriateness of anxiety and were more satisfied with the communication compared to control group patients . CONCLUSION The intervention seems to have improved the patients ' risk perception , anxiety and satisfaction with the communication , which are important conditions for shared decision making . However , we found no additional effect of the intervention on lifestyle Background Primary care provides most of the evidence -based chronic disease prevention and screening services offered by the healthcare system . However , there remains a gap between recommended preventive services and actual practice . This trial ( the BETTER Trial ) aim ed to improve preventive care of heart disease , diabetes , colorectal , breast and cervical cancers , and relevant lifestyle factors through a practice facilitation intervention set in primary care . Methods Pragmatic two-way factorial cluster RCT with Primary Care Physicians ’ practice s as the unit of allocation and individual patients as the unit of analysis . The setting was urban Primary Care Team practice s in two Canadian provinces . Eight Primary Care Team practice s were r and omly assigned to receive the practice -level intervention or wait-list control ;  4 physicians in each team ( 32 physicians ) were r and omly assigned to receive the patient-level intervention or wait-list control .  Patients r and omly selected from physicians ’ rosters were stratified into two groups : 1 ) general and 2 ) moderate mental illness . The interventions involved a multifaceted , evidence -based , tailored practice -level intervention with a Practice Facilitator , and a patient-level intervention involving a one-hour visit with a Prevention Practitioner where patients received a tailored ‘ prevention prescription ’ . The primary outcome was a composite Summary Quality Index of 28 evidence -based chronic disease prevention and screening actions with pre-defined targets , expressed as the ratio of eligible actions at baseline that were met at follow-up . A cost-effectiveness analysis was conducted . Results 789 of 1,260 ( 63 % ) eligible patients participated . On average , patients were eligible for 8.96 ( SD 3.2 ) actions at baseline . In the adjusted analysis , control patients met 23.1 % ( 95 % CI : 19.2 % to 27.1 % ) of target actions , compared to 28.5 % ( 95 % CI : 20.9 % to 36.0 % ) receiving the practice -level intervention , 55.6 % ( 95 % CI : 49.0 % to 62.1 % ) receiving the patient-level intervention , and 58.9 % ( 95 % CI : 54.7 % to 63.1 % ) receiving both practice - and patient-level interventions ( patient-level intervention versus control , P < 0.001 ) . The benefit of the patient-level intervention was seen in both strata . The extra cost of the intervention was $ 26.43CAN ( 95 % CI : $ 16 to $ 44 ) per additional action met . Conclusions A Prevention Practitioner can improve the implementation of clinical ly important prevention and screening for chronic diseases in a cost-effective manner Background The Portuguese National Health Directorate has issued clinical practice guidelines on prescription of anti-inflammatory drugs , acid suppressive therapy , and antiplatelets . However , their effectiveness in changing actual practice is unknown . Methods The study will compare the effectiveness of educational outreach visits regarding the improvement of compliance with clinical guidelines in primary care against usual dissemination strategies . A cost-benefit analysis will also be conducted . We will carry out a parallel , open , superiority , r and omized trial directed to primary care physicians . Physicians will be recruited and allocated at a cluster-level ( primary care unit ) by minimization . Data will be analyzed at the physician level . Primary care units will be eligible if they use electronic prescribing and have at least four physicians willing to participate . Physicians in intervention units will be offered individual educational outreach visits ( one for each guideline ) at their workplace during a six-month period . Physicians in the control group will be offered a single unrelated group training session . Primary outcomes will be the proportion of cyclooxygenase-2 inhibitors prescribed in the anti-inflammatory class , and the proportion of omeprazole in the proton pump inhibitors class at 18 months post-intervention . Prescription data will be collected from the regional pharmacy cl aims data base . We estimated a sample size of 110 physicians in each group , corresponding to 19 clusters with a mean size of 6 physicians . Outcome collection and data analysis will be blinded to allocation , but due to the nature of the intervention , physicians and detailers can not be blinded . Discussion This trial will attempt to address unresolved issues in the literature , namely , long term persistence of effect , the importance of sequential visits in an outreach program , and cost issues . If successful , this trial may be the cornerstone for deploying large scale educational outreach programs within the Portuguese National Health Service . Trial registration Clinical Trials.gov number NCT01984034 OBJECTIVES To investigate the impact of general health screenings and discussion s with general practitioners on the cardiovascular risk profile of a r and om population of patients . STUDY DESIGN A population -based , r and omized , controlled , 5-year follow-up trial conducted in a primary care setting . POPULATION The study group consisted of 2000 patients , r and omly selected middle-aged men and women aged 30 to 50 years from family practice s in the district of Ebeltoft , Denmark . Of these patients , 1507 ( 75.4 % ) agreed to participate . Patients were r and omized into ( 1 ) a control group who did not receive health screenings , ( 2 ) an intervention group that received 2 health screenings , ( 3 ) an intervention group that received both the 2 screenings and a 45-minute follow-up consultation annually with their general practitioner . OUTCOMES MEASURED Cardiovascular risk score ( CRS ) , body mass index ( BMI ) , blood pressure , serum cholesterol , carbon monoxide in expiratory air , and tobacco use . RESULTS After 5 years , the CRS , BMI , and serum cholesterol levels were lower in the intervention groups compared with the control group . The improved outcome was greater in the baseline risk groups . The number of patients with elevated CRS in the intervention groups was approximately half the number of patients with elevated CRS in the control group . The difference was not a result of medication use . There was no difference between the group that received consultations after the screenings and the group that had health screenings alone . CONCLUSIONS Health screenings reduced the CRS in the intervention groups . After 5 years of follow-up , the number of persons at elevated cardiovascular risk was about half that expected , based on the prevalence/proportion in a population not receiving the health checks ( the control group ) . The impact of intervention was higher among at-risk individuals . Consultations about health did not appear to improve the cardiovascular profile of the study population Incidence and mortality results are presented from an international controlled trial of multifactorial prevention of coronary heart disease , involving r and omization of 66 factories ( 49 781 men ) in U.K. , Belgium , Italy and Pol and ( Cracow ) . Results for Pol and ( Warsaw ) are not yet complete . Net average reductions in risk factors ( all subjects ) were 1.2 % for plasma cholesterol , 8.9 % for daily cigarettes , 0.4 % for weight , 2.0 % for systolic blood pressure , and 11.1 % for a combined risk estimate . Greater reductions occurred in high-risk subjects ( 19.4 % for the combined estimate ) . The net overall reduction in CHD rates was 7.4 % ( 95 % confidence interval -29 to + 15 % ) for deaths ( 722 cases ) , and 3.9 % ( 95 % confidence interval -10 to + 2 % ) for fatal CHD + non-fatal myocardial infa rct ion ( 1502 cases ) . Among men aged 40 - 49 the reduction for this end-point was 15 % ; at ages 50 - 59 there was a small net increase . All-causes deaths after an early adverse trend showed 2.7 % reduction overall . There were large differences between centres , ranging from a 5 % net increase in CHD for U.K. to a decrease of  
    Output:
    