***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: OBJECTIVE To study the effect of accuracy on the clinical outcome of local steroid injections to the shoulder . METHODS 37 patients with shoulder symptoms of at least two months ’ duration received local injections of a mixture of triamcinolone and radiographic contrast material using a st and ardised technique . Radiographs of the joint were taken immediately afterwards . Details of the patients ’ symptoms ( assessed by visual analogue scales ) and range of movement at the joint were obtained before and two weeks after the injection . At follow up the patients were also assessed by means of a five point global rating scale of maximum and current benefit . RESULTS 14 of the 38 procedures ( 37 % ) were judged to be accurately placed : four of the 14 attempted subacromial injections ( 29 % ) and 10 of the 24 attempted glenohumeral injections ( 42 % ) . There were significant differences in relation to outcome between the accurately placed and the inaccurately placed groups . CONCLUSIONS Accuracy of steroid placement by injection in patients with shoulder symptoms may significantly affect the clinical outcome Abstract Objective To investigate the efficacy of physiotherapy compared with a wait and see approach or corticosteroid injections over 52 weeks in tennis elbow . Design Single blind r and omised controlled trial . Setting Community setting , Brisbane , Australia . Participants 198 participants aged 18 to 65 years with a clinical diagnosis of tennis elbow of a minimum six weeks ' duration , who had not received any other active treatment by a health practitioner in the previous six months . Interventions Eight sessions of physiotherapy ; corticosteroid injections ; or wait and see . Main outcome measures Global improvement , grip force , and assessor 's rating of severity measured at baseline , six weeks , and 52 weeks . Results Corticosteroid injection showed significantly better effects at six weeks but with high recurrence rates thereafter ( 47/65 of successes subsequently regressed ) and significantly poorer outcomes in the long term compared with physiotherapy . Physiotherapy was superior to wait and see in the short term ; no difference was seen at 52 weeks , when most participants in both groups reported a successful outcome . Participants who had physiotherapy sought less additional treatment , such as non-steroidal anti-inflammatory drugs , than did participants who had wait and see or injections . Conclusion Physiotherapy combining elbow manipulation and exercise has a superior benefit to wait and see in the first six weeks and to corticosteroid injections after six weeks , providing a reasonable alternative to injections in the mid to long term . The significant short term benefits of corticosteroid injection are paradoxically reversed after six weeks , with high recurrence rates , implying that this treatment should be used with caution in the management of tennis elbow Abstract Objective : To compare the clinical effectiveness of local corticosteroid injection , st and ard non-steroidal anti-inflammatory drugs , and simple analgesics for the early treatment of lateral epicondylitis in primary care . Design : Multicentre pragmatic r and omised controlled trial . Setting : 23 general practice s in North Staffordshire and South Cheshire . Participants : 164 patients aged 18 - 70 years presenting with a new episode of lateral epicondylitis . Interventions : Local injection of 20 mg methylprednisolone plus lignocaine , naproxen 500 mg twice daily for two weeks , or placebo tablets . All participants received a st and ard advice sheet and co-codamol as required . Main outcome measures : Participants ' global assessment of improvement ( five point scale ) at four weeks . Pain , function , and “ main complaint ” measured on 10 point Likert scales at 4 weeks , 6 months , and 12 months . Results : Over 2 years , 53 subjects were r and omised to injection , 53 to naproxen , and 58 to placebo . Prognostic variables were similar between groups at baseline . At 4 weeks , 48 patients ( 92 % ) in the injection group were completely better or improved compared with 30 ( 57 % ) in the naproxen group ( P<0.001 ) and 28 ( 50 % ) in the placebo group ( P<0.001 ) . At 12 months , 43 patients ( 84 % ) in the injection group had pain scores ≤3 compared with 45 ( 85 % ) in the naproxen group and 44 ( 82 % ) in the placebo group ( P>0.05 ) . Conclusions : Early local corticosteroid injection is effective for lateral epicondylitis . Outcome at one year was good in all groups , and effective early treatment does not seem to influence this . Key messages Most lateral epicondylitis is managed by general practitioners , but optimum treatment is unclear This large pragmatic r and omised trial showed that corticosteroid injection was significantly better than non-steroidal anti-inflammatories or placebo tablets at four weeks A two week course of a st and ard non-steroidal anti-inflammatory was no better than placebo A few patients who respond well initially to injection relapse by six months . Long term outcome was good , irrespective of initial treatment Fifty-five patients with shoulder pain due to rotator cuff tendinitis of less than 12 weeks ' duration were r and omized to receive either 40 mg methylprednisolone and lignocaine or lignocaine alone . No statistically significant difference could be discerned between the two groups during 12 weeks of follow-up Subacromial corticosteroid injection is one of the most frequently used management tools in subacromial impingement syndrome ( SIS ) despite controversial reports on the efficacy . Our purpose , in this single blinded , r and omised and controlled study was to clarify whether the corticosteroid injection provides additional benefit when used with other conservative treatment modalities in 48 patients with stage 2 SIS . The patients were r and omly divided into three groups according to the two therapeutic injections applied with a 10-day interval : group 1 : 10 cc of 1 % lignocaine + 40 mg of methylprednisolone for the first and second injections , group 2 : 10 cc of 1 % lignocaine + 40 mg of methylprednisolone for the first injection and only 10 cc of 1 % lignocaine for the second injection , group 3 : only 10 cc of 1 % lignocaine for the first and second injections . All the patients were prescribed 500 mg of naproxen sodium to use two times daily , instructed to rest and perform Codman ’s pendulum exercises during the first 15 days . Shoulder pain during rest , activity , and causing disturbance of sleep was evaluated using a visual analogue scale and shoulder function was investigated by total Constant score and its subsectional parameters which are pain , daily living activities , active range of motion and strength before the therapy and 1 and 3 months after the therapy onset . Significant improvements from the baseline values in all pain and function parameters were observed at the first and second evaluation in all groups . Group 1 patients had more favourably improved values in pain causing sleep disturbance and daily living activity parameters than group 2 and 3 patients only in the 1st month after therapy onset . We found that subacromial corticosteroid injections in the acute or subacute phase of SIS provided additional short-term benefit without any complication when used together with nonsteroidal anti-inflammatory drugs ( NSAIDs ) and exercise As professionals , we want to use the best treatments ; as patients , we want to be given them . Knowing whether an intervention works ( or does not work ) is fundamental to clinical decision making . However , clinical decision making involves more than simply taking published results of research directly to the bedside . Physicians need to consider how similar their patients are to those in the published studies , to take the values and preferences of their patients into account , and to consider their own experience with a given test or treatment . Evidence from clinical research is becoming increasingly important in medical- practice decisions as more and better evidence is published . But when is the evidence strong enough to justify changing a practice ? Individual studies that involve only small numbers of patients may have results that are distorted by the r and om play of chance and thus lead to less than optimal decisions . As is clear from other papers in this series , systematic review s identify , critically appraise , and review all the relevant studies on a clinical question and are more likely to give a valid answer . They use explicit methods and quality st and ards to reduce bias . Their results are the closest we can come to reaching the truth given our current state of knowledge . The questions about an intervention that a systematic review should answer are the following : 1 . Does it work ? 2 . If it works , how well does it work in general and compared with placebo , no treatment , or other interventions that are currently in use ? 3 . Is it safe ? 4 . Will it be safe and effective for my patients ? Whereas the critical appraisal and qualitative synthesis provided by review articles can be interpreted directly , the numerical products of quantitative review s can be more difficult to underst and and apply in daily clinical practice . This paper provides guidance on how to interpret the numerical and statistical results of systematic review s , translate these results into more underst and able terms , and apply them directly to individual patients . Many of these principles can also be used to interpret the numerical results of individual clinical studies . They are particularly relevant to systematic review s , however , because such review s contain more information than do primary studies and often exert greater influence than do individual studies . Making Sense of the Numerical Results of Clinical Studies Although the results of clinical studies can be expressed in intuitively meaningful ways , such results do not always easily translate into clinical decision making . For example , results are frequently expressed in terms of risk , which is an expression of the frequency of a given outcome . ( Risks are probabilities , which can vary between 0.0 and 1.0 . A probability of 0.0 means that the event will never happen , and a probability of 1.0 means that it always happens . ) Consider a hypothetical study of the recurrence of migraine headaches in a control group receiving placebo and a treatment group receiving a new antimigraine preparation , drug M ( a secondary prevention trial ) . Suppose that at the end of the trial , migraines recurred in 30 % of the control group ( the risk for recurrence was 0.30 ) but in only 5 % of the drug M group ( risk of 0.05 ) ( Table 1 ) . Table 1 . Numerical Expression of Hypothetical Clinical Trial Results The outcomes of the study are clear enough for the two groups when they are examined separately . But clinicians and patients are more interested in the comparative results , that is , the outcome in one group relative to the outcome in the other group . This overall ( comparative ) result can be expressed in various ways . For example , the relative risk , which is the risk in the treatment group relative to that in the control group , is simply the ratio of the risks in the two groups . In other words , relative risk is the risk in the treatment group divided by that in the control group , 0.05 0.30 , or 0.17 . The comparison can also be expressed as the reduction in relative risk , which is the ratio between the decrease in risk ( in the treatment group ) and the risk in the control group , 0.25 0.30 , or 0.83 ( Table 1 ) . ( The relative risk reduction can also be calculated as 1 relative risk ) . Although the clinical meaning of relative risk ( and relative risk reduction ) is reasonably clear , relative risk has the distinct disadvantage that a given value ( for example , 0.17 ) is the same whether the risk with treatment decreases from 0.80 to 0.14 , from 0.30 to 0.05 , from 0.001 to 0.00017 , and so forth . The clinical implication s of these changes clearly differ from one another enormously and depend on the specific disease and intervention . An important alternate expression of comparative results , therefore , is the absolute risk reduction . Absolute risk reduction is determined by subtracting the risk in one group from the risk in the other ( for example , the risk in the treatment group is subtracted from the risk in the placebo group ) . In the case of our migraine study , the absolute risk reduction would be 0.30 0.05 , which equals 0.25 , or 25 percentage points . In contrast , for a study in which the risk decreased from 0.001 to 0.00017 , the absolute risk reduction would be only 0.00083 , or 0.083 percentage points , which is a trivial change in comparison ( Table 1 ) . This arithmetic emphasizes the difficulty of expressing the results of clinical studies in meaningful ways . Relative risk and relative risk reduction clearly give a quantitative sense of the effects of an intervention in proportional terms but provide no clue about the size of an effect on an absolute scale . In contrast , although it tells less about proportional effects , absolute risk says a great deal about whether an effect is likely to be clinical ly meaningful . Despite this benefit , even absolute risk is problematic because it is a dimensionless , abstract number ; that is , it lacks a direct connection with the clinical situation in which the patient and physician exist . However , another way of expressing clinical research results can provide that clinical link : the number needed to treat ( NNT ) . Number Needed To Treat The NNT for a given therapy is simply the reciprocal of the absolute risk reduction for that treatment [ 1 , 2 ] . In the case of our hypothetical migraine study ( in which risk decreased from 0.30 without treatment with drug M to 0.05 with treatment with drug M , for a relative risk of 0.17 , a relative risk reduction of 0.83 , and an absolute risk reduction of 0.25 ) , the NNT would be 1 0.25 , or 4 . In concrete clinical terms , an NNT of 4 means that you would need to treat four patients with drug M to prevent migraine from recurring in one patient . To emphasize the difference between the concepts embodied in NNT and relative risk , recall the various situations mentioned above , in all of which the relative risk was 0.17 but in which the absolute risk decreased from 0.80 to 0.14 in one case and from 0.001 to 0.00017 in another . Note that the corresponding NNTs in these two other cases are 1.5 and 12 
    Output:
    
Sensitivity analyses indicated similar results whatever the localisation , type of steroid and type of comparator except for NSAIDs : steroid injections were not significantly better than NSAIDs in the short-term .
Steroid injections appeared more effective than pooled other treatments in acute or subacute tendonitis .
Steroid injections are well tolerated and more effective for tendonitis in the short-term than pooled other treatments , though similar to NSAIDs .
No long-term benefit was shown