***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 The presence of clinical signs have implication s for diagnosis , prognosis and treatment . Therefore , the aim of this study was to examine the inter-observer agreement of clinical signs in pre-school children presenting to primary care . Methods A nested study comparing two clinical assessment s within a prospect i ve cohort of 256 pre-school children with acute cough recruited from eight general practice s in Leicestershire , UK . We examined agreement ( using kappa statistics ) between unst and ardised and st and ardised clinical assessment s of tachypnoea , chest signs and fever . Results Kappa values were poor or fair for all clinical signs ( range 0.12 to 0.39 ) with chest signs the most reliable . Conclusions Primary care clinicians should be aware that clinical signs may be unreliable when making diagnosis , prognosis and treatment decisions in pre-school children with cough . Future research should aim to further our underst and ing of how best to identify abnormal clinical signs Background Cough is the most common symptom presenting to doctors . The quality of cough ( productive or wet vs dry ) is used clinical ly as well as in epidemiology and clinical research . There is however no data on the validity of cough quality descriptors . The study aims were to compare ( 1 ) cough quality ( wet/dry and brassy/non-brassy ) to bronchoscopic findings of secretions and tracheomalacia respectively and , ( 2 ) parent 's vs clinician 's evaluation of the cough quality ( wet/dry ) . Methods Cough quality of children ( without a known underlying respiratory disease ) undergoing elective bronchoscopy  was independently evaluated by clinicians and parents . A ' blinded ' clinician scored the secretions seen at bronchoscopy on pre-determined criteria and grade d ( 1 to 6 ) . Kappa ( K ) statistics was used for agreement , and inter-rater and intra-rater agreement examined on digitally recorded cough . A receiver operating characteristic ( ROC ) curve was used to determine if cough quality related to amount of airway secretions present at bronchoscopy . Results Median age of the 106 children ( 62 boys , 44 girls ) enrolled was 2.6 years ( IQR 5.7 ) . Parent 's assessment of cough quality ( wet/dry ) agreed with clinicians ' ( K = 0.75 , 95%CI 0.58–0.93 ) . When compared to bronchoscopy ( bronchoscopic secretion grade 4 ) , clinicians ' cough assessment had the highest sensitivity ( 0.75 ) and specificity ( 0.79 ) and were marginally better than parent(s ) . The area under the ROC curve was 0.85 ( 95%CI 0.77–0.92 ) . Intra-observer ( K = 1.0 ) and inter-clinician agreement for wet/dry cough ( K = 0.88 , 95%CI 0.82–0.94 ) was very good . Weighted K for inter-rater agreement for bronchoscopic secretion grade s was 0.95 ( 95%CI 0.87–1 ) . Sensitivity and specificity for brassy cough ( for tracheomalacia ) were 0.57 and 0.81 respectively . K for both intra and inter-observer clinician agreement for brassy cough was 0.79 ( 95%CI 0.73–0.86 ) . Conclusions Dry and wet cough in children , as determined by clinicians and parents has good clinical validity . Clinicians should however be cognisant that children with dry cough may have minimal to mild airway secretions . Brassy cough determined by respiratory physicians is highly specific for tracheomalacia Background Chronic cough is common and is associated with significant economic and human costs . While cough can be a problematic symptom without serious consequences , it could also reflect a serious underlying illness . Evidence shows that the management of  chronic cough in children needs to be improved . Our study tests the hypothesis that the management of  chronic cough in children with an evidence -based management pathway is feasible and reliable , and improves clinical outcomes . Methods / Design We are conducting a multicentre r and omised controlled trial based in respiratory clinics in 5 major Australian cities . Children ( n = 250 ) fulfilling inclusion criteria ( new patients with chronic cough ) are r and omised ( allocation concealed ) to the st and ardised clinical management pathway ( specialist starts clinical pathway within 2 weeks ) or usual care ( existing care until review by specialist at 6 weeks ) . Cough diary , cough-specific quality of life ( QOL ) and generic QOL are collected at baseline and at 6 , 10 , 14 , 26 , and 52 weeks . Children are followed-up for 6 months after diagnosis and cough resolution ( with at least monthly contact from study nurses ) . A r and om sample from each site will be independently examined to determine adherence to the pathway . Primary outcomes are group differences in QOL and proportion of children that are cough free at week 6 . Discussion The clinical management pathway is based on data from Cochrane Review s combined with collective clinical experience ( 250 doctor years ) . This study will provide additional evidence on the optimal management of chronic cough in children . Trial registration OBJECTIVES The goals of this study were to : ( 1 ) determine if management according to a st and ardized clinical management pathway/algorithm ( compared with usual treatment ) improves clinical outcomes by 6 weeks ; and ( 2 ) assess the reliability and validity of a st and ardized clinical management pathway for chronic cough in children . METHODS : A total of 272 children ( mean ± SD age : 4.5 ± 3.7 years ) were enrolled in a pragmatic , multicenter , r and omized controlled trial in 5 Australian centers . Children were r and omly allocated to 1 of 2 arms : ( 1 ) early review and use of cough algorithm ( “ early-arm ” ) ; or ( 2 ) usual care until review and use of cough algorithm ( “ delayed-arm ” ) . The primary outcomes were proportion of children whose cough resolved and cough-specific quality of life scores at week 6 . Secondary measures included cough duration postr and omization and the algorithm ’s reliability , validity , and feasibility . RESULTS : Cough resolution ( at week 6 ) was significantly more likely in the early-arm group compared with the delayed-arm group ( absolute risk reduction : 24.7 % [ 95 % confidence interval : 13–35 ] ) . The difference between cough-specific quality of life scores at week 6 compared with baseline was significantly better in the early-arm group ( mean difference between groups : 0.6 [ 95 % confidence interval : 0.29–1.0 ] ) . Duration of cough postr and omization was significantly shorter in the early-arm group than in the delayed-arm group ( P = .001 ) . The cough algorithm was reliable ( κ = 1 in key steps ) . Feasibility was demonstrated by the algorithm ’s validity ( 93%–100 % ) and efficacy ( 99.6 % ) . Eighty-five percent of children had etiologies easily diagnosed in primary care . CONCLUSIONS : Management of children with chronic cough , in accordance with a st and ardized algorithm , improves clinical outcomes irrespective of when it is implemented . Further testing of this st and ardized clinical algorithm in different setting s is recommended Background To evaluate the diagnostic accuracy of the integrated Practical Approach to Lung Health in  South  Africa ( PALSA ) guideline in identifying patients requiring bacteriological screening for tuberculosis ( TB ) , and to determine which clinical features best predict suspected and bacteriologically-confirmed tuberculosis among patients with respiratory symptoms . Methods A prospect i ve , cross-sectional study in which 1392 adult patients with cough and /or difficult breathing , attending a primary care facility in Cape Town , South Africa , were evaluated by a nurse using the guideline . The accuracy of a nurse using the guideline to identify TB suspects was compared to that of primary care physicians ' diagnoses of ( 1 ) suspected TB , and ( 2 ) proven TB supported by clinical information and chest radiographs . Results The nurse using the guideline identified 516 patients as TB suspects compared with 365 by the primary care physicians , representing a sensitivity of 76 % ( 95 % confidence interval ( CI ) 71%–79 % ) , specificity of 77 % ( 95 % CI 74%–79 % ) , positive predictive value of 53 % ( 95 % CI 49%–58 % ) , negative predictive value of 90 % ( 95 % CI 88%–92 % ) , and area under the receiver operating characteristic curve ( ARUC ) of 0.76 ( 95 % CI 0.74–0.79 ) . Sputum results were obtained in 320 of the 365 primary care physicians TB suspects ( 88 % ) ; 40 ( 13 % ) of these were positive for TB . Only 4 cases were not identified by the nurse using the guideline . The primary care physicians diagnostic accuracy in diagnosing bacteriologically-confirmed TB ( n = 320 ) was as follows : sensitivity 90 % ( 95 % CI 76%–97 % ) , specificity 65 % ( 95 % CI 63%–68 % ) , negative predictive value 7 % ( 95 % CI 5%–10 % ) , positive predictive value 99.5 % ( 95 % CI 98.8%–99.8 % ) , and ARUC 0.78 ( 95 % CI 0.73–0.82 ) . Weight loss , pleuritic pain , and night sweats were independently associated with the diagnosis of bacteriologically-confirmed tuberculosis ( positive likelihood ratio if all three present = 16.7 , 95 % CI 5.9–29.4 ) . Conclusion The PALSA guideline is an effective screening tool for identifying patients requiring bacteriological screening for pulmonary tuberculosis in this primary care setting . This supports the r and omized trial finding that use of the guideline increased TB case detection A successful , systematic , anatomic , diagnostic protocol for evaluating patients with chronic cough  was presented in 1981 . To determine whether it was still valid , we prospect ively evaluated , over a 22-month interval , 102 consecutive and unselected immunocompetent patients complaining of cough an average of 53 + /- 97 months ( range , 3 wk to 50 yr ) . Utilizing the anatomic , diagnostic protocol modified to include prolonged esophageal pH monitoring ( EPM ) , the causes of cough were determined in 101 of 102 ( 99 % ) patients , leading to specific therapy that was successful in 98 % . Cough was due to one condition in 73 % , two in 23 % , and three in 3 % . Postnasal drip syndrome was a cause 41 % of the time , asthma 24 % , gastroesophageal reflux ( GER ) 21 % , chronic bronchitis 5 % , bronchiectasis 4 % , and miscellaneous conditions 5 % . Cough was the sole presenting manifestation of asthma and GER 28 and 43 % of the time , respectively . While history , physical examination , methacholine inhalational challenge ( MIC ) , and EPM yielded the most frequent true positive results , MIC was falsely positive 22 % of the time in predicting that asthma was the cause of cough . Laboratory testing was particularly useful in ruling out suspected possibilities . We conclude that the anatomic diagnostic protocol is still valid and that it has well-defined strengths and limitations The aim of this general practice study was to examine how the consulting behaviour of patients with a cough was affected when the tasks and responsibilities of patients , practice nurses and general practitioners were reorganized . In four ' average ' single-h and ed general practice s the effects on the consulting behaviour of patients of a rational practice policy on cough and the provision of systematic patient education on cough  were compared with patient behaviour in four matched control practice s.  Changes of behaviour were measured in 548 patients who consulted for cough at least twice , in two successive autumn-winter periods . Significantly more patients in the experimental practice changed their behaviour to follow the practice guidelines than did patients in the control practice s ( 56 % versus 30 % , P less than 0.001 ) . The proportion of patients who continued to consult in the approved manner was greater among patients receiving intervention ( 66 % versus 29 % , P less than 0.001 ) . This was equally true for patients who had suffered less than four episodes of cough or more than four episodes . The more often the patients received the education , the more effective it was . All patients who consulted the general practitioner for cough during the first autumn-winter period filled in a cough diary during the second period . From this it appeared that the intervention did not result in patients delaying consultation when they had a cough lasting longer than three weeks or one with ' serious ' symptoms . It would appear that a rational practice policy and the provision of patient education can stimulate patients to modify their consulting behaviour . This could result in a reduction in the costs of health care The aim of the present study was make chronic cough guidelines more practical and user friendly by developing an internet-based interactive diagnostic question naire for chronic cough . A prospect i ve cohort study of chronic cough sufferers was conducted in the UK , following European Respiratory Society guidelines for the diagnosis and management of chronic cough . Depending on the response to 16 specific questions , the medical condition responsible for the patient 's chronic cough was ascertained according to a predetermined diagnostic algorithm design ed to differentiate the three common causes of chronic cough . Appropriate advice and treatment recommendations were then provided . 8,546 adults with chronic cough completed the Cough Clinic diagnostic question  naire .  
    Output:
    
Current evidence suggests that using a clinical algorithm for the management of children with chronic cough in hospital outpatient setting s is more effective than providing wait-list care .