***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: In a cluster r and omized trial , Kojo Yeboah-Antwi and colleagues find that integrated management of malaria and pneumonia in children under five by community health workers is both feasible and effective Objective To test in West Africa the impact of rapid diagnostic tests on the prescription of antimalarials and antibiotics both where microscopy is used for the diagnosis of malaria and in clinical ( peripheral ) setting s that rely on clinical diagnosis . Design R and omised , controlled , open label clinical trial . Setting Four clinics in the rural Dangme West district of southern Ghana , one in which microscopy is used for diagnosis of malaria ( “ microscopy setting ” ) and three where microscopy is not available and diagnosis of malaria is made on the basis of clinical symptoms ( “ clinical setting ” ) . Participants Patients with suspected malaria . Interventions Patients were r and omly assigned to either a rapid diagnostic test or the current diagnostic method at the clinic ( microscopy or clinical diagnosis ) . A blood sample for a research microscopy slide was taken for all patients . Main outcome measures The primary outcome was the prescription of antimalarials to patients of any age whose double read research slide was negative for malaria . The major secondary outcomes were the correct prescription of antimalarials , the impact of test results on antibiotic prescription , and the correct prescription of antimalarials in children under 5 years .  Results Of the 9236 patients screened , 3452 were r and omised in the clinical setting and 3811 in the microscopy setting . Follow-up to 28 days was 97.6 % ( 7088/7263 ) . In the microscopy setting , 722 ( 51.6 % ) of the 1400 patients with negative research slides in the rapid diagnostic test arm were treated for malaria compared with 764 ( 55.0 % ) of the 1389 patients in the microscopy arm ( adjusted odds ratio 0.87 , 95 % CI 0.71 to 1.1 ; P=0.16 ) . In the clinical setting , 578 ( 53.9 % ) of the 1072 patients in the rapid diagnostic test arm with negative research slides were treated for malaria compared with 982 ( 90.1 % ) of the 1090 patients with negative slides in the clinical diagnosis arm ( odds ratio 0.12 , 95 % CI 0.04 to 0.38 ; P=0.001 ) . The use of rapid diagnostic tests led to better targeting of antimalarials and antibiotics in the clinical but not the microscopy setting , in both children and adults . There were no deaths in children under 5 years at 28 days follow-up in either arm . Conclusion Where microscopy already exists , introducing rapid diagnostic tests had limited impact on prescriber behaviour . In setting s where microscopy was not available , however , using rapid diagnostic tests led to a significant reduction in the overprescription of antimalarials , without any evidence of clinical harm , and to better targeting of antibiotics . Trial registration Clinical Trials.gov NCT00493922 Background Early diagnosis and prompt , effective treatment of uncomplicated malaria is critical to prevent severe disease , death and malaria transmission . We assessed the impact of rapid malaria diagnostic tests ( RDTs ) by community health workers ( CHWs ) on provision of artemisinin-based combination therapy ( ACT ) and health outcome in fever patients . Methodology /Principal Findings Twenty-two CHWs from five villages in Kibaha District , a high-malaria transmission area in Coast Region , Tanzania , were trained to manage uncomplicated malaria using RDT aided diagnosis or clinical diagnosis ( CD ) only . Each CHW was r and omly assigned to use either RDT or CD the first week and thereafter alternating weekly . Primary outcome was provision of ACT and main secondary outcomes were referral rates and health status by days 3 and 7 . The CHWs enrolled 2930 fever patients during five months of whom 1988 ( 67.8 % ) presented within 24 hours of fever onset . ACT was provided to 775 of 1457 ( 53.2 % ) patients during RDT weeks and to 1422 of 1473 ( 96.5 % ) patients during CD weeks ( Odds Ratio ( OR ) 0.039 , 95 % CI 0.029–0.053 ) . The CHWs adhered to the RDT results in 1411 of 1457 ( 96.8 % , 95 % CI 95.8–97.6 ) patients . More patients were referred on inclusion day during RDT weeks ( 10.0 % ) compared to CD weeks ( 1.6 % ) . Referral during days 1–7 and perceived non-recovery on days 3 and 7 were also more common after RDT aided diagnosis . However , no fatal or severe malaria occurred among 682 patients in the RDT group who were not treated with ACT , supporting the safety of withholding ACT to RDT negative patients . Conclusions / Significance RDTs in the h and s of CHWs may safely improve early and well-targeted ACT treatment in malaria patients at community level in Africa . Trial registration Clinical Trials.gov Objective To compare rapid diagnostic tests ( RDTs ) for malaria with routine microscopy in guiding treatment decisions for febrile patients . Design R and omised trial . Setting Outpatient departments in northeast Tanzania at varying levels of malaria transmission . Participants 2416 patients for whom a malaria test was requested . Intervention Staff received training on rapid diagnostic tests ; patients sent for malaria tests were r and omised to rapid diagnostic test or routine microscopy Main outcome measure Proportion of patients with a negative test prescribed an antimalarial drug .  Results Of 7589 outpatient consultations , 2425 ( 32 % ) had a malaria test requested . Of 1204 patients r and omised to microscopy  , 1030 ( 86 % ) tested negative for malaria ; 523 ( 51 % ) of these were treated with an antimalarial drug . Of 1193 patients r and omised to rapid diagnostic test , 1005 ( 84 % ) tested negative ; 540 ( 54 % ) of these were treated for malaria ( odds ratio 1.13 , 95 % confidence interval 0.95 to 1.34 ; P=0.18 ) . Children aged under 5 with negative rapid diagnostic tests were more likely to be prescribed an antimalarial drug than were those with negative slides ( P=0.003 ) . Patients with a negative test by any method were more likely to be prescribed an antibiotic ( odds ratio 6.42 , 4.72 to 8.75 ; P<0.001 ) . More than 90 % of prescriptions for antimalarial drugs in low-moderate transmission setting s were for patients for whom a test requested by a clinician was negative for malaria . Conclusions Although many cases of malaria are missed outside the formal sector , within it malaria is massively over-diagnosed . This threatens the sustainability of deployment of artemisinin combination treatment , and treatable bacterial diseases are likely to be missed . Use of rapid diagnostic tests , with basic training for clinical staff , did not in itself lead to any reduction in over-treatment for malaria . Interventions to improve clinicians ' management of febrile illness are essential but will not be easy . Trial registration Clinical trials NCT00146796 Background Presumptive treatment of all febrile patients with anti-malarials leads to massive over-treatment . The aim was to assess the effect of implementing malaria rapid diagnostic tests ( m RDTs ) on prescription of anti-malarials in urban Tanzania . Methods The design was a prospect i ve collection of routine statistics from ledger books and cross-sectional surveys before and after intervention in r and omly selected health facilities ( HF ) in Dar es Salaam , Tanzania . The participants were all clinicians and their patients in the above health facilities . The intervention consisted of training and introduction of m RDTs in all three hospitals and in six HF . Three HF without m RDTs were selected as matched controls . The use of routine m RDT and treatment upon result was advised for all patients complaining of fever , including children under five years of age . The main outcome measures were : ( 1 ) anti-malarial consumption recorded from routine statistics in ledger books of all HF before and after intervention ; ( 2 ) anti-malarial prescription recorded during observed consultations in cross-sectional surveys conducted in all HF before and 18 months after m RDT implementation . Results Based on routine statistics , the amount of artemether-lumefantrine blisters used post-intervention was reduced by 68 % ( 95%CI 57 - 80 ) in intervention and 32 % ( 9 - 54 ) in control HF . For quinine vials , the reduction was 63 % ( 54 - 72 ) in intervention and an increase of 2.49 times ( 1.62 - 3.35 ) in control HF . Before- and -after cross-sectional surveys showed a similar decrease from 75 % to 20 % in the proportion of patients receiving anti-malarial treatment ( Risk ratio 0.23 , 95%CI 0.20 - 0.26 ) . The cluster r and omized analysis showed a considerable difference of anti-malarial prescription between intervention HF ( 22 % ) and control HF ( 60 % ) ( Risk ratio 0.30 , 95%CI 0.14 - 0.70 ) . Adherence to test result was excellent since only 7 % of negative patients received an anti-malarial . However , antibiotic prescription increased from 49 % before to 72 % after intervention ( Risk ratio 1.47 , 95%CI 1.37 - 1.59 ) . Conclusions Programmatic implementation of m RDTs in a moderately endemic area reduced drastically over-treatment with anti-malarials . Properly trained clinicians with adequate support complied with the recommendation of not treating patients with negative results . Implementation of m RDT should be integrated h and -in-h and with training on the management of other causes of fever to prevent irrational use of antibiotics OBJECTIVES To assess if the clinical outcome of patients treated after performing a Rapid Diagnostic Test for malaria ( RDT )  is at least equivalent to that of controls ( treated presumptively without test ) and to determine the impact of the introduction of a malaria RDT on clinical decisions . METHODS R and omized , multi-centre , open clinical trial in two arms in 2006 at the end of the dry and of the rainy season in 10 peripheral health centres in Burkina Faso : one arm with use of RDT before treatment decision , one arm managed clinical ly . Primary endpoint : persistence of fever at day 4 . Secondary endpoints : frequency of malaria treatment and of antibiotic treatment .  RESULTS A total of 852 febrile patients were recruited in the dry season and 1317 febrile patients in the rainy season , and r and omized either to be su bmi tted to RDT ( P_RTD ) or to be managed presumptively ( P_CLIN ) . In both seasons , no significant difference was found between the two r and omized groups in the frequency of antimalarial treatment , nor of antibiotic prescription . In the dry season , 80.8 % and 79.8 % of patients with a negative RDT were nevertheless diagnosed and treated for malaria , and so were 85.0 % and 82.6 % negative patients in the rainy season . In the rainy season only , both diagnosis and treatment of other conditions were significantly less frequent in RDT positive vs. negative patients ( 48.3 % vs. 61.4 % and 46.2 % vs. 59.9 % , P = 0.00 and 0.00 , respectively ) . CONCLUSION Our study was inconclusive on RDT safety ( clinical outcome in the two r and omized groups ) , because of an exceedingly and unexpectedly low compliance with the negative test result . Further research is needed on best strategies to promote adherence and on the safety of a test based strategy compared with the current , presumptive treatment strategy Shortly after Kenya introduced artemether-lumefantrine ( AL ) for first-line treatment of uncomplicated malaria , we conducted a pre-post cluster r and omized controlled trial to assess the effect of providing malaria rapid diagnostic tests ( RDTs ) on recommended treatment ( patients with malaria prescribed AL ) and overtreatment ( patients without malaria prescribed AL ) in out patients > /= 5 years old . Sixty health facilities were r and omized to receive either  RDTs plus training , guidelines , and supervision ( TGS ) or  TGS alone .  Of 1,540 patients included in the analysis , 7 % had uncomplicated malaria . The provision of RDTs coupled with TGS emphasizing AL use only after laboratory confirmation of malaria reduced recommended treatment by 63%-points ( P = 0.04 ) , because diagnostic test use did not change ( -2%-points ) , but health workers significantly reduced presumptive treatment with AL for patients with a clinical diagnosis of malaria who did not undergo testing ( -36%-points ; P = 0.03 ) . Health workers generally adhered to RDT results when prescribing AL : 88 % of RDT-positive and 9 % of RDT-negative patients were treated with AL , respectively . Overtreatment was low in both arms and was not significantly reduced by the provision of RDTs ( -12%-points , P = 0.30 ) . RDTs could potentially improve malaria case management , but we urgently need to develop more effective strategies for implementing guidelines before large scale implementation 
    Output:
    
Authors ' conclusions Algorithms incorporating RDTs can substantially reduce antimalarial prescribing if health workers adhere to the test results .
Introducing RDTs has not been shown to improve health outcomes for patients , but adherence to the test result does not seem to result in worse clinical outcomes than presumptive treatment .
Concentrating on improving the care of RDT negative patients could improve health outcomes in febrile children