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: A r and omized intervention trial is in progress in Kerala , India , to evaluate the effectiveness of oral visual inspection by trained health workers ( HWs ) in the prevention of oral cancer . Fourteen health workers with college graduation as the basic qualification were trained in oral visual inspection  to identify oral cancers and precancers among the participants of the screening trial and to refer them for further confirmation and management . The aim of the present study was to evaluate the reproducibility and validity of the  screening test  provided by the health worker against the reference oral visual findings of three physicians . A total of 2069 subjects who had already been examined were re-examined by the health workers and physicians . The sensitivity and the specificity of the oral visual inspection were 94.3 % and 99.3 % respectively . There was moderate agreement between the findings of the initial and the repeat mouth examinations carried out by the health workers , which were on average 6 months apart . There was almost perfect agreement ( kappa = 0.85 ) between the findings of the health workers and the physicians in identifying the different types of oral precancerous lesions . The findings of our study indicate that it is possible to train re source persons to perform the oral cancer screening test as accurately as doctors , although experience appears to be a crucial component of health workers ' accuracy . The efficacy of such an approach to reduce the incidence of and mortality from oral cancer , however , remains to be proven Objectives : The study aims to investigate the efficacy of screening by low-cost technology in down-staging and reduction of mortality due to breast and cervix cancer . Methods : The present trial is a community-based , cluster r and omised controlled cohort study on  screening for breast and cervix cancers ( clinical breast examination and visual inspection of the cervix after application of 4 % acetic acid ) . Univariate and multivariate logistic regression analyses are conducted to identify the predictors of compliance to referral among screen-positive women and to treatment among cancer cases . Results : The compliance to diagnostic investigations is 73 % among screen-positive women referred for breast cancer and 79 % among women referred for cervix cancer . Younger women , women working in service or being self-employed , school level-educated women , mother tongue Marathi , participation in screening in all 3 rounds and women referred as screen positive for cervix cancer had higher compliance to diagnostic investigations . The compliance to treatment completion is higher in women diagnosed with breast cancer , at 95 % , compared to 86 % for cervix cancers and 81 % for cervix pre-cancers . Conclusions : Good compliance rates along with a proper system of referral , further investigations , confirmation of diagnosis and treatment as demonstrated in this trial are crucial for successful screening programmes Summary Background Robust evidence of the effectiveness of task shifting of antiretroviral therapy ( ART ) from doctors to other health workers is scarce . We aim ed to assess the effects on mortality , viral suppression , and other health outcomes and quality indicators of the Streamlining Tasks and Roles to Exp and Treatment and Care for HIV ( STRETCH ) programme , which provides educational outreach training of nurses to initiate and represcribe ART , and to de central ise care . Methods We undertook a pragmatic , parallel , cluster-r and omised trial in South Africa between Jan 28 , 2008 , and June 30 , 2010 . We r and omly assigned 31 primary -care ART clinics to implement the STRETCH programme ( intervention group ) or to continue with st and ard care ( control group ) . The ratio of r and omisation depended on how many clinics were in each of nine strata . Two cohorts were enrolled : eligible patients in cohort 1 were adults ( aged ≥16 years ) with CD4 counts of 350 cells per μL or less who were not receiving ART ; those in cohort 2 were adults who had already received ART for at least 6 months and were being treated at enrolment . The primary outcome in cohort 1 was time to death ( superiority analysis ) . The primary outcome in cohort 2 was the proportion with undetectable viral loads ( < 400 copies per mL ) 12 months after enrolment ( equivalence analysis , prespecified difference < 6 % ) . Patients and clinicians could not be masked to group assignment . The interim analysis was blind , but data analysts were not masked after the data base was locked for final analysis . Analyses were done by intention to treat . This trial is registered , number IS RCT N46836853 . Findings 5390 patients in cohort 1 and 3029 in cohort 2 were in the intervention group , and 3862 in cohort 1 and 3202 in cohort 2 were in the control group . Median follow-up was 16·3 months ( IQR 12·2–18·0 ) in cohort 1 and 18·0 months ( 18·0–18·0 ) in cohort 2 . In cohort 1 , 997 ( 20 % ) of 4943 patients analysed in the intervention group and 747 ( 19 % ) of 3862 in the control group with known vital status at the end of the trial had died . Time to death did not differ ( hazard ratio [ HR ] 0·94 , 95 % CI 0·76–1·15 ) . In a preplanned subgroup analysis of patients with baseline  CD4 counts of 201–350 cells per μL , mortality was slightly lower in the intervention group than in the control group ( 0·73 , 0·54–1.00 ; p=0·052 ) , but it did not differ between groups in patients with baseline CD4 of 200 cells per μL or less ( 0·94 , 0·76–1·15 ; p=0·577 ) . In cohort 2 , viral load suppression 12 months after enrolment was equivalent in intervention ( 2156 [ 71 % ] of 3029 patients ) and control groups ( 2230 [ 70 % ] of 3202 ; risk difference 1·1 % , 95 % CI −2·4 to 4·6 ) . Interpretation Expansion of primary -care nurses ' roles to include ART initiation and represcription can be done safely , and improve health outcomes and quality of care , but might not reduce time to ART or mortality . Funding UK Medical Research Council , Development Cooperation Irel and , and Canadian International Development Agency OBJECTIVE To carry out an economic evaluation of a task-shifting intervention for the treatment of depressive and anxiety disorders in primary -care setting s in Goa , India . METHODS Cost-utility and cost-effectiveness analyses based on generalized linear models were performed within a trial set in 24 public and private primary -care facilities . Subjects were r and omly assigned to an intervention or a control arm . Eligible subjects in the intervention arm were given psycho-education , case management , interpersonal psychotherapy and /or antidepressants by lay health workers . Subjects in the control arm were treated by physicians . The use of health-care re sources , the disability of each subject and degree of psychiatric morbidity , as measured by the Revised Clinical Interview Schedule , were determined at 2 , 6 and 12 months . FINDINGS Complete data , from all three follow-ups , were collected from 1243 ( 75.4 % ) and 938 ( 81.7 % ) of the subjects enrolled in the study facilities from the public and private sectors , respectively . Within the public facilities , subjects in the intervention arm showed greater improvement in all the health outcomes investigated than those in the control arm . Time costs were also significantly lower in the intervention arm than in the control arm , whereas health system costs in the two arms were similar . Within the private facilities , however , the effectiveness and costs recorded in the two arms were similar . CONCLUSION Within public primary -care facilities in Goa , the use of lay health workers in the care of subjects with common mental disorders was not only cost-effective but also cost-saving This paper has been corrected post-publication in deviation from print and in accordance with a correction printed in the February 2012 issue of the Journal . Background Depressive and anxiety disorders ( common mental disorders ) are the most common psychiatric condition encountered in primary healthcare . Aims To test the effectiveness of an intervention led by lay health counsellors in primary care setting s ( the MANAS intervention ) to improve the outcomes of people with common mental disorders . Method Twenty-four primary care facilities ( 12 public , 12 private ) in Goa ( India ) were r and omised to provide either collaborative stepped care or enhanced usual care to adults who screened positive for common mental disorders . Participants were assessed at 2 , 6 and 12 months for presence of ICD-10 common mental disorders , the severity of symptoms of depression and anxiety , suicidal behaviour and disability levels . All analyses were intention to treat and carried out separately for private and public facilities and adjusted for the design . The trial has been registered with clinical trials.gov ( NCT00446407 ) . Results A total of 2796 participants were recruited . In public facilities , the intervention was consistently associated with strong beneficial effects over the 12 months on all outcomes . There was a 30 % decrease in the prevalence of common mental disorders among those with baseline ICD-10 diagnoses ( risk ratio ( RR ) = 0.70 , 95 % CI 0.53–0.92 ) ; and a similar effect among the subgroup of participants with depression ( RR = 0.76 , 95 % CI 0.59–0.98 ) . Suicide attempts/plans showed a 36 % reduction over 12 months ( RR = 0.64 , 95 % CI 0.42–0.98 ) among baseline ICD-10 cases . Strong effects were observed on days out of work and psychological morbidity , and modest effects on overall disability . In contrast , there was little evidence of impact of the intervention on any outcome among participants attending private facilities . Conclusions Trained lay counsellors working within a collaborative-care model can reduce prevalence of common mental disorders , suicidal behaviour , psychological morbidity and disability days among those attending public primary care facilities Summary Background The treatment of perinatal depression is a public-health priority because of its high prevalence and association with disability and poor infant development . We integrated a cognitive behaviour therapy-based intervention into the routine work of community-based primary health workers in rural Pakistan and assessed the effect of this intervention on  maternal depression and infant outcomes . Methods We r and omly assigned 40 Union Council clusters in rural Rawalpindi , Pakistan , in equal numbers to intervention or control . Married women ( aged 16–45 years ) in their third trimester of pregnancy with perinatal depression were eligible to participate . In the intervention group , primary health workers were trained to deliver the psychological intervention , whereas in the control group untrained health workers made an equal number of visits to the depressed mothers . The primary outcomes were infant weight and height at 6 months and 12 months , and secondary outcome was maternal depression . The interviewers were unaware of what group the participants were assigned to . Analysis was by intention to treat . The study is registered as IS RCT N65316374 . Findings The number of clusters per group was 20 , with 463 mothers in the intervention group and 440 in the control group . At 6 months , 97 ( 23 % ) of 418 and 211 ( 53 % ) of 400 mothers in the intervention and control groups , respectively , met the criteria for major depression ( adjusted odds ratio ( OR ) 0·22 , 95 % CI 0·14 to 0·36 , p<0·0001 ) . These effects were sustained at 12 months ( 111/412 [ 27 % ] vs 226/386 [ 59 % ] , adjusted OR 0·23 , 95 % CI 0·15 to 0·36 , p<0·0001 ) . The differences in weight-for-age and height-for-age Z scores for infants in the two groups were not significant at 6 months ( −0·83 vs −0·86 , p=0·7 and −2·03 vs −2·16 , p=0·3 , respectively ) or 12 months ( −0·64 vs −0·8 , p=0·3 and −1·10 vs −1·36 , p=0·07 , respectively ) . Interpretation This psychological intervention delivered by community-based primary health workers has the potential to be integrated into health systems in re source -poor setting s. Funding Wellcome Trust OBJECTIVE To evaluate  oral cancer screening by visual inspection . METHODS A cluster r and omized controlled trial was initiated in Triv and rum district , Kerala , India . Of 13 population clusters , seven were r and omly allocated to three rounds of screening between 1996 and 2004 , while st and ard care  was provided in six ( control arm ) . An activity-based approach was employed to calculate costs associated with various components of the screening trial . Information on the re sources used and on clinical events in each trial arm was derived from trial data bases . Total costs for each cluster were estimated in 2004 United States dollars ( US$ ) . The incremental cost per life-year saved was calculated for all eligible individuals and for high-risk individuals ( i.e. tobacco or alcohol users ) . FINDINGS The proportion of oral cancers detected at an early stage ( i.e. stage I or II ) was higher in the intervention arm than the control arm ( 42 % versus 24 % , respectively ) . The incremental cost per life-year saved was US$ 835 for all individuals eligible for screening and US$ 156 for high-risk individuals . Oral cancer screening  by  visual inspection  was 
    Output:
    
agent
The majority of studies showed improved health outcomes when compared with usual healthcare , including reductions in blood pressure , increased uptake of medications and lower depression scores .
Factors such as training of NPHWs , provision of algorithms and protocol s for screening , treatment and drug titration were the main enablers of the task-shifting intervention .
The main barriers identified were restrictions on prescribing medications and availability of medicines .
CONCLUSIONS Task-shifting from physicians to NPHWs , if accompanied by health system re-structuring is a potentially effective and affordable strategy for improving access to healthcare for NCDs .
***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: A r and omized intervention trial is in progress in Kerala , India , to evaluate the effectiveness of oral visual inspection by trained health workers ( HWs ) in the prevention of oral cancer . Fourteen health workers with college graduation as the basic qualification were trained in oral visual inspection  to identify oral cancers and precancers among the participants of the screening trial and to refer them for further confirmation and management . The aim of the present study was to evaluate the reproducibility and validity of the  screening test  provided by the health worker against the reference oral visual findings of three physicians . A total of 2069 subjects who had already been examined were re-examined by the health workers and physicians . The sensitivity and the specificity of the oral visual inspection were 94.3 % and 99.3 % respectively . There was moderate agreement between the findings of the initial and the repeat mouth examinations carried out by the health workers , which were on average 6 months apart . There was almost perfect agreement ( kappa = 0.85 ) between the findings of the health workers and the physicians in identifying the different types of oral precancerous lesions . The findings of our study indicate that it is possible to train re source persons to perform the oral cancer screening test as accurately as doctors , although experience appears to be a crucial component of health workers ' accuracy . The efficacy of such an approach to reduce the incidence of and mortality from oral cancer , however , remains to be proven Objectives : The study aims to investigate the efficacy of screening by low-cost technology in down-staging and reduction of mortality due to breast and cervix cancer . Methods : The present trial is a community-based , cluster r and omised controlled cohort study on  screening for breast and cervix cancers ( clinical breast examination and visual inspection of the cervix after application of 4 % acetic acid ) . Univariate and multivariate logistic regression analyses are conducted to identify the predictors of compliance to referral among screen-positive women and to treatment among cancer cases . Results : The compliance to diagnostic investigations is 73 % among screen-positive women referred for breast cancer and 79 % among women referred for cervix cancer . Younger women , women working in service or being self-employed , school level-educated women , mother tongue Marathi , participation in screening in all 3 rounds and women referred as screen positive for cervix cancer had higher compliance to diagnostic investigations . The compliance to treatment completion is higher in women diagnosed with breast cancer , at 95 % , compared to 86 % for cervix cancers and 81 % for cervix pre-cancers . Conclusions : Good compliance rates along with a proper system of referral , further investigations , confirmation of diagnosis and treatment as demonstrated in this trial are crucial for successful screening programmes Summary Background Robust evidence of the effectiveness of task shifting of antiretroviral therapy ( ART ) from doctors to other health workers is scarce . We aim ed to assess the effects on mortality , viral suppression , and other health outcomes and quality indicators of the Streamlining Tasks and Roles to Exp and Treatment and Care for HIV ( STRETCH ) programme , which provides educational outreach training of nurses to initiate and represcribe ART , and to de central ise care . Methods We undertook a pragmatic , parallel , cluster-r and omised trial in South Africa between Jan 28 , 2008 , and June 30 , 2010 . We r and omly assigned 31 primary -care ART clinics to implement the STRETCH programme ( intervention group ) or to continue with st and ard care ( control group ) . The ratio of r and omisation depended on how many clinics were in each of nine strata . Two cohorts were enrolled : eligible patients in cohort 1 were adults ( aged ≥16 years ) with CD4 counts of 350 cells per μL or less who were not receiving ART ; those in cohort 2 were adults who had already received ART for at least 6 months and were being treated at enrolment . The primary outcome in cohort 1 was time to death ( superiority analysis ) . The primary outcome in cohort 2 was the proportion with undetectable viral loads ( < 400 copies per mL ) 12 months after enrolment ( equivalence analysis , prespecified difference < 6 % ) . Patients and clinicians could not be masked to group assignment . The interim analysis was blind , but data analysts were not masked after the data base was locked for final analysis . Analyses were done by intention to treat . This trial is registered , number IS RCT N46836853 . Findings 5390 patients in cohort 1 and 3029 in cohort 2 were in the intervention group , and 3862 in cohort 1 and 3202 in cohort 2 were in the control group . Median follow-up was 16·3 months ( IQR 12·2–18·0 ) in cohort 1 and 18·0 months ( 18·0–18·0 ) in cohort 2 . In cohort 1 , 997 ( 20 % ) of 4943 patients analysed in the intervention group and 747 ( 19 % ) of 3862 in the control group with known vital status at the end of the trial had died . Time to death did not differ ( hazard ratio [ HR ] 0·94 , 95 % CI 0·76–1·15 ) . In a preplanned subgroup analysis of patients with baseline  CD4 counts of 201–350 cells per μL , mortality was slightly lower in the intervention group than in the control group ( 0·73 , 0·54–1.00 ; p=0·052 ) , but it did not differ between groups in patients with baseline CD4 of 200 cells per μL or less ( 0·94 , 0·76–1·15 ; p=0·577 ) . In cohort 2 , viral load suppression 12 months after enrolment was equivalent in intervention ( 2156 [ 71 % ] of 3029 patients ) and control groups ( 2230 [ 70 % ] of 3202 ; risk difference 1·1 % , 95 % CI −2·4 to 4·6 ) . Interpretation Expansion of primary -care nurses ' roles to include ART initiation and represcription can be done safely , and improve health outcomes and quality of care , but might not reduce time to ART or mortality . Funding UK Medical Research Council , Development Cooperation Irel and , and Canadian International Development Agency OBJECTIVE To carry out an economic evaluation of a task-shifting intervention for the treatment of depressive and anxiety disorders in primary -care setting s in Goa , India . METHODS Cost-utility and cost-effectiveness analyses based on generalized linear models were performed within a trial set in 24 public and private primary -care facilities . Subjects were r and omly assigned to an intervention or a control arm . Eligible subjects in the intervention arm were given psycho-education , case management , interpersonal psychotherapy and /or antidepressants by lay health workers . Subjects in the control arm were treated by physicians . The use of health-care re sources , the disability of each subject and degree of psychiatric morbidity , as measured by the Revised Clinical Interview Schedule , were determined at 2 , 6 and 12 months . FINDINGS Complete data , from all three follow-ups , were collected from 1243 ( 75.4 % ) and 938 ( 81.7 % ) of the subjects enrolled in the study facilities from the public and private sectors , respectively . Within the public facilities , subjects in the intervention arm showed greater improvement in all the health outcomes investigated than those in the control arm . Time costs were also significantly lower in the intervention arm than in the control arm , whereas health system costs in the two arms were similar . Within the private facilities , however , the effectiveness and costs recorded in the two arms were similar . CONCLUSION Within public primary -care facilities in Goa , the use of lay health workers in the care of subjects with common mental disorders was not only cost-effective but also cost-saving This paper has been corrected post-publication in deviation from print and in accordance with a correction printed in the February 2012 issue of the Journal . Background Depressive and anxiety disorders ( common mental disorders ) are the most common psychiatric condition encountered in primary healthcare . Aims To test the effectiveness of an intervention led by lay health counsellors in primary care setting s ( the MANAS intervention ) to improve the outcomes of people with common mental disorders . Method Twenty-four primary care facilities ( 12 public , 12 private ) in Goa ( India ) were r and omised to provide either collaborative stepped care or enhanced usual care to adults who screened positive for common mental disorders . Participants were assessed at 2 , 6 and 12 months for presence of ICD-10 common mental disorders , the severity of symptoms of depression and anxiety , suicidal behaviour and disability levels . All analyses were intention to treat and carried out separately for private and public facilities and adjusted for the design . The trial has been registered with clinical trials.gov ( NCT00446407 ) . Results A total of 2796 participants were recruited . In public facilities , the intervention was consistently associated with strong beneficial effects over the 12 months on all outcomes . There was a 30 % decrease in the prevalence of common mental disorders among those with baseline ICD-10 diagnoses ( risk ratio ( RR ) = 0.70 , 95 % CI 0.53–0.92 ) ; and a similar effect among the subgroup of participants with depression ( RR = 0.76 , 95 % CI 0.59–0.98 ) . Suicide attempts/plans showed a 36 % reduction over 12 months ( RR = 0.64 , 95 % CI 0.42–0.98 ) among baseline ICD-10 cases . Strong effects were observed on days out of work and psychological morbidity , and modest effects on overall disability . In contrast , there was little evidence of impact of the intervention on any outcome among participants attending private facilities . Conclusions Trained lay counsellors working within a collaborative-care model can reduce prevalence of common mental disorders , suicidal behaviour , psychological morbidity and disability days among those attending public primary care facilities Summary Background The treatment of perinatal depression is a public-health priority because of its high prevalence and association with disability and poor infant development . We integrated a cognitive behaviour therapy-based intervention into the routine work of community-based primary health workers in rural Pakistan and assessed the effect of this intervention on  maternal depression and infant outcomes . Methods We r and omly assigned 40 Union Council clusters in rural Rawalpindi , Pakistan , in equal numbers to intervention or control . Married women ( aged 16–45 years ) in their third trimester of pregnancy with perinatal depression were eligible to participate . In the intervention group , primary health workers were trained to deliver the psychological intervention , whereas in the control group untrained health workers made an equal number of visits to the depressed mothers . The primary outcomes were infant weight and height at 6 months and 12 months , and secondary outcome was maternal depression . The interviewers were unaware of what group the participants were assigned to . Analysis was by intention to treat . The study is registered as IS RCT N65316374 . Findings The number of clusters per group was 20 , with 463 mothers in the intervention group and 440 in the control group . At 6 months , 97 ( 23 % ) of 418 and 211 ( 53 % ) of 400 mothers in the intervention and control groups , respectively , met the criteria for major depression ( adjusted odds ratio ( OR ) 0·22 , 95 % CI 0·14 to 0·36 , p<0·0001 ) . These effects were sustained at 12 months ( 111/412 [ 27 % ] vs 226/386 [ 59 % ] , adjusted OR 0·23 , 95 % CI 0·15 to 0·36 , p<0·0001 ) . The differences in weight-for-age and height-for-age Z scores for infants in the two groups were not significant at 6 months ( −0·83 vs −0·86 , p=0·7 and −2·03 vs −2·16 , p=0·3 , respectively ) or 12 months ( −0·64 vs −0·8 , p=0·3 and −1·10 vs −1·36 , p=0·07 , respectively ) . Interpretation This psychological intervention delivered by community-based primary health workers has the potential to be integrated into health systems in re source -poor setting s. Funding Wellcome Trust OBJECTIVE To evaluate  oral cancer screening by visual inspection . METHODS A cluster r and omized controlled trial was initiated in Triv and rum district , Kerala , India . Of 13 population clusters , seven were r and omly allocated to three rounds of screening between 1996 and 2004 , while st and ard care  was provided in six ( control arm ) . An activity-based approach was employed to calculate costs associated with various components of the screening trial . Information on the re sources used and on clinical events in each trial arm was derived from trial data bases . Total costs for each cluster were estimated in 2004 United States dollars ( US$ ) . The incremental cost per life-year saved was calculated for all eligible individuals and for high-risk individuals ( i.e. tobacco or alcohol users ) . FINDINGS The proportion of oral cancers detected at an early stage ( i.e. stage I or II ) was higher in the intervention arm than the control arm ( 42 % versus 24 % , respectively ) . The incremental cost per life-year saved was US$ 835 for all individuals eligible for screening and US$ 156 for high-risk individuals . Oral cancer screening  by  visual inspection  was 
    Output:
    