***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 
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    ***EXAMPLES*** 
    Input: Laboratory tests are purported to affect patients even if they have no diagnostic values . We tested this hypothesis by measuring clinical outcomes of 176 patients thought clinical ly to have nonspecific chest pain . They were r and omly allocated either to have a routine electrocardiogram and serum creatine phosphokinase tests ( test group ) or to have all diagnostic tests withheld ( no-test group ) . Fewer patients in the tests group ( 20 % ) reported short-term disability after the index visit than patients in the no-test group ( 46 % ) ( p = 0.001 ) . Logistic discriminant analysis confirmed that the use of diagnostic tests was an independent predictor of recovery . Patients in the test group felt that care was " better than usual " more often ( 57 % ) than patients in the no-test group ( 31 % ) ( p = 0.001 ) . After the index visit , the two groups were equally worried about serious disease and equally sparing in their use of other medial care for chest pain Objective To investigate whether providing information about normal findings before a diagnostic test improves patients ' reassurance and reduces anxiety about symptoms . Design R and omised controlled trial . Setting Outpatient cardiology clinic . Participants 92 patients with chest pain referred for a diagnostic exercise stress test . Intervention Before undergoing testing patients were r and omised to receive st and ard information ( n=28 ; control group ) , a pamphlet explaining the function of the test and the meaning of normal test results ( n=30 ; pamphlet group ) , or the pamphlet and a brief discussion about the meaning of normal test results ( n=34 ; discussion group ) . Main outcome measures The primary outcome was patients ' reported reassurance on a 5 item scale immediately after the test and at one month . Secondary outcomes were the proportion of patients still with chest pain and still taking cardiac drugs at one month . Results The mean levels of reassurance after testing and feedback from the doctor were significantly higher in the discussion group ( 42.0 , 95 % confidence interval 39.7 to 44.2 ) than in the pamphlet ( 39.2 , 36.1 to 42.3 ) and control groups ( 35.8 , 31.6 to 39.9 ) . This difference was maintained at one month . The proportion of patients still reporting chest pain at one month decreased significantly in the discussion group ( to 17 % ) and pamphlet group ( to 28 % ) but not in the control group ( to 36 % ) . A trend was for fewer patients in the discussion group to be taking cardiac drugs at one month . Conclusion Providing patients with information about normal test results before testing can improve rates of reassurance and reduce the likelihood of future reports of chest pain . Trial registration Current Controlled Trials IS RCT N87589121 Objectives : Aims were to investigate ( a ) whether neuroimaging in patients with chronic daily headache reassures patients or fails to reassure them and /or worsens outcome , impacting on service use , costs , health anxieties , and symptoms , and ( b ) whether this reassurance process occurs differentially in patients with different levels of psychological morbidity . Methods : Design : r and omised controlled trial ; setting : headache clinic in secondary care , South London ; participants : 150 patients fulfilling criteria for chronic daily headache , stratified using the Hospital Anxiety and Depression Scale ( HADS ) ; intervention : treatment as usual or the offer of an MRI brain scan ; main outcome measures : use of services , costs , and health anxiety . Results : Seventy six patients were r and omised to the offer of a brain scan and 74 patients to treatment as usual . One hundred and thirty seven ( 91 % ) primary care case notes were examined at 1 year , 103 ( 69 % ) patients completed question naires at 3 months and 96 ( 64 % ) at 1 year . Sixty six ( 44 % ) patients were HADS positive ( scored > 11 on either subscale ) . Patients offered a scan were less worried about a serious cause of the headaches at 3 months ( p = 0.004 ) , but this was not maintained at 1 year ; other health anxiety measures did not differ by scan status . However , at 1 year HADS positive patients offered a scan cost significantly less , by £ 465 ( 95 % confidence interval ( CI ) : −£1028 to −£104 ) , than such patients not offered a scan , due to lower utilisation of medical re sources . Conclusions : Neuroimaging  significantly reduces costs for patients with high levels of psychiatric morbidity , possibly by changing subsequent referral patterns of the general practitioner Abstract Objective : To determine the cost effectiveness of a strategy of near patient Helicobacter pylori testing and endoscopy for managing dyspepsia . Design : R and omised controlled trial . Setting : 31 UK primary care centres . Participants : 478 patients under 50 years old presenting with dyspepsia of longer than four weeks duration . Interventions : Near patient testing for H pylori and open access endoscopy for patients with positive results . Control patients received acid suppressing drugs or specialist referral at general practitioner 's discretion . Main outcome measures : Cost effectiveness based on improvement in symptoms and use of re sources at 12 months ; quality of life . Results : 40 % of the study group tested positive for H pylori . 45 % of study patients had endoscopy compared with 25 % of controls . More peptic ulcers were diagnosed in the study group ( 7.4 % v 2.1 % , P=0.011 ) . Paired comparison of symptom scores and quality of life showed that all patients improved over time with no difference between study and control groups . No significant differences were observed in rates of prescribing , consultation , or referral . Costs were higher in the study group ( £ 367.85 v £ 253.16 per patient ) . Conclusions : The test and endoscopy strategy increases endoscopy rates over usual practice in primary care . The additional cost is not offset by benefits in symptom relief or quality of life . What is already known on this topic Patients younger than 50 without H pylori infection are unlikely to have treatable disease detected at endoscopy Such patients can be managed by acid suppression and reassurance alone Test and endoscopy ( referral of patients testing positive for H pyloriin primary care ) has been recommended as a way to reduce endoscopic workload What this paper adds Applying a test and endoscopy strategy increased the endoscopy referral rate from 25 % to 40 % The strategy produced no significant differences in symptoms or quality of life compared with usual management The increased costs of this strategy can not be Objectives To determine whether providing an information sheet to patients with acute chest pain reduces anxiety , improves health related quality of life , improves satisfaction with care , or alters subsequent symptoms or actions . Design Single centre , non-blinded , r and omised controlled trial . Setting Chest pain unit of an emergency department . Participants 700 consecutive patients with acute chest pain and no clear diagnosis at initial presentation . Interventions After a diagnostic assessment patients were r and omised to receive either st and ard verbal advice or verbal advice followed by an information sheet . Main outcome measures The primary outcome was anxiety ( hospital anxiety and depression scale ) . Secondary outcomes were depression ( hospital anxiety and depression scale ) , health related quality of life ( SF-36 ) , patient satisfaction , presentation with further chest pain within one month , lifestyle change ( smoking cessation , diet , exercise ) , further information sought from other sources , and planned healthcare seeeking behaviour in response to further pain . Results 494 of 700 ( 70.6 % ) patients responded . Compared with those receiving st and ard verbal advice those receiving advice and an information sheet had lower mean hospital anxiety and depression scale scores for anxiety ( 7.61 v 8.63 , difference 1.02 , 95 % confidence interval 0.20 to 1.84 ) and depression ( 4.14 v 5.28 , difference 1.14 , 0.41 to 1.86 ) and higher scores for mental health and perception of general health on the SF-36 . The information sheet had no significant effect on satisfaction with care , subsequent symptoms , lifestyle change , information seeking , or planned actions in the event of further pain . Conclusions Provision of an information sheet to patients with acute chest pain can reduce anxiety and depression and improve mental health and perception of general health but does not alter satisfaction with care or other outcomes . Trial registration Current Controlled Trials IS RCT N85248020 BACKGROUND Lumbar spine radiography has limited use in diagnosing the cause of acute low back pain . Consensus-based guidelines recommend that lumbar spine x-rays are not used routinely . However there have been no studies of the effect of referral for radiography at first presentation with low back pain in primary care . AIM To compare short and long-term physical , social , and psychiatric outcomes for patients with low back pain who are referred or not referred for lumbar spine x-ray at first presentation in general practice . DESIGN OF STUDY A r and omised unblinded controlled trial with an observational arm to enable comparisons to be made with patients not recruited to the trial . SETTING Ninety-four general practice s in south London and the South Thames region . METHOD Patients consulting their general practitioner ( GP ) with low back pain at first presentation were recruited to a r and omised controlled trial ( RCT ) or to an observational group . Patients in the trial were r and omly allocated to immediate referral for x-ray or to no referral . All patients were asked to complete question naires initially , and then at six weeks and one year after recruitment . RESULTS Six hundred and fifty-nine patients were recruited over 26 months : 153 to the r and omised trial and 506 to the observational arm . In the RCT referral for x-ray had no effect on physical functioning , pain or disability , but was associated with a small improvement in psychological wellbeing at six weeks and one year . These findings were supported by the observational study in which there were no differences between the groups in physical outcomes after adjusting for length of episode at presentation ; however , those referred for x-ray had lower depression scores . CONCLUSIONS Referral for lumbar spine radiography for first presentation of low back pain in primary care is not associated with improved physical functioning , pain or disability . The possibility of minor psychological improvement should be balanced against the high radiation dose involved PURPOSE To establish whether early use of magnetic resonance ( MR ) imaging or computed tomography ( CT ) influences treatment and outcome of patients with low back pain ( LBP ) and whether it is cost-effective . MATERIAL S AND METHODS In a multicenter r and omized study , two imaging policies for LBP were compared in 782 participants with symptomatic lumbar spine disorders who were referred to orthopedists or neurosurgeons . Participants were r and omly allocated to  early ( 393 participants ; mean age , 43.9 years ; range , 16 - 82 years ) or delayed selective ( 389 participants ; mean age , 42.8 years ; range , 14 - 82 years ) imaging groups . Delayed selective imaging referred to imaging restricted to patients in whom a clear clinical need subsequently developed . Main outcome measures were Aberdeen Low Back Pain ( ALBP ) score , Short Form 36 ( SF-36 ) score ( for multidimensional health status ) , EuroQol ( EQ-5D ) score ( for quality -adjusted life-year [ QALY ] estimates ) , and healthcare re source use at 8 and 24 months after r and omization . Data were evaluated with analysis of covariance , ordinal logistic regression analysis , and chi(2 ) and Mann-Whitney tests . RESULTS Both groups showed improvement in ALBP score , but this was greater in the early group ( adjusted mean difference between groups , -3.05 points [ 95 % CI : -5.16 , -0.95 ; P = .005 ] and -3.62 points [ 95 % CI : -5.92 , -1.32 ; P = .002 ] at 8 and 24 months , respectively ) . Scores for SF-36 ( bodily pain domain ) and EQ-5D were also significantly better at 24 months . Clinical treatment was similar in both groups . Differences in total costs reflected cost of imaging . Imaging provided an adjusted mean additional QALY of 0.041 during 24 months at a mean incremental cost per QALY of $ 2,124 . CONCLUSION Early use of imaging does not appear to affect treatment overall . Decisions about the use of imaging depend on judgments concerning whether the small observed improvement in outcome justifies additional cost CONTEXT Somatoform disorders are an important determinant of medical care utilization , but their independent effect on utilization is difficult to determine because somatizing patients frequently have psychiatric and medical comorbidity . OBJECTIVES To assess the extent of the overlap of somatization with other psychiatric disorders ; to compare the medical utilization of somatizing and nonsomatizing patients ; and to determine the independent contribution of somatization alone to utilization . DESIGN Patients were surveyed with self-report question naires assessing somatization and psychiatric disorder .  Medical care utilization was obtained from automated encounter data for the year preceding the index visit . Medical morbidity was indexed with a computerized medical record audit . SETTING Two hospital-affiliated primary care practice s. PARTICIPANTS Consecutive adults making scheduled visits to their primary care physicians on r and omly chosen days . In all , 2668 question naires were distributed , and 1914 ( 71.7 % ) were returned . Of these , 1546 ( 80.8 % ) contained complete data and met eligibility criteria . MAIN OUTCOME MEASURES Medical care utilization and costs within our hospital system in the preceding 12 months . RESULTS Two hundred ninety-nine patients ( 20.5 % ) received a provisional diagnosis of somatization ; 42.3 % of these patients had no comorbid depressive or anxiety disorder . Somatizing patients , when compared with nonsomatizing patients 
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AND RELEVANCE Diagnostic tests for symptoms with a low risk of serious illness do little to reassure patients , decrease their anxiety , or resolve their symptoms , although the tests may reduce further primary care visits .