***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: Forty patients with rheumatoid arthritis and upper gastrointestinal lesions due to non-steroidal anti-inflammatory drugs entered a prospect i ve 6-month double-blind placebo controlled study of dietary supplementation with gamma-linolenic acid 540 mg/day . Nineteen patients received active therapy ( as evening primrose oil 6 g/day ) and 21 received placebo ( olive oil 6 g/day ) . No patient stopped non-steroidal anti-inflammatory therapy but three patients in each group reduced their dose . Other results showed a significant reduction in morning stiffness with gamma-linolenic acid at 3 months and reduction in pain and articular index at 6 months with olive oil . Whilst gamma-linolenic acid may produce mild improvement in rheumatoid arthritis , olive oil may itself have hitherto unrecognized benefits The efficacy , tolerance , and safety of CPH 82 ( semisynthetic lignan glycosides ) ( Conpharm AB ) for patients with rheumatoid arthritis ( RA ) were assessed in a 12-week double-blind placebo-controlled study . Thirteen patients out of 15 in the CPH 82 group and 10 out of 15 in the placebo group completed the study .  No improvement was seen in placebo treated patients . Patients treated with CPH 82 showed a statistically significant improvement in most clinical and immunological variables . Some patients treated with CPH 82 reported gastrointestinal discomfort ( diarrhoea and abdominal pain ) CONTEXT A prior national survey documented the high prevalence and costs of  alternative medicine use in the United States in 1990 . OBJECTIVE To document trends in alternative medicine use in the United States between 1990 and 1997 . DESIGN Nationally representative r and om household telephone surveys using comparable key questions were conducted in 1991 and 1997 measuring utilization in 1990 and 1997 , respectively . PARTICIPANTS A total of 1539 adults in 1991 and 2055 in 1997 . MAIN OUTCOMES MEASURES Prevalence , estimated costs , and disclosure of alternative therapies to physicians . RESULTS Use of at least 1 of 16 alternative therapies during the previous year increased from 33.8 % in 1990 to 42.1 % in 1997 ( P < or = .001 ) . The therapies increasing the most included herbal medicine , massage , megavitamins , self-help groups , folk remedies , energy healing , and homeopathy . The probability of users visiting an alternative medicine practitioner increased from 36.3 % to 46.3 % ( P = .002 ) . In both surveys alternative therapies were used most frequently for chronic conditions , including back problems , anxiety , depression , and headaches . There was no significant change in disclosure rates between the 2 survey years ; 39.8 % of alternative therapies were disclosed to physicians in 1990 vs 38.5 % in 1997 . The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 ( 64.0 % ) and 1997 ( 58.3 % ) ( P=.36 ) . Extrapolations to the US population suggest a 47.3 % increase in total visits to alternative medicine practitioners , from 427 million in 1990 to 629 million in 1997 , thereby exceeding total visits to all US primary care physicians . An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and /or high-dose vitamins ( 18.4 % of all prescription users ) . Estimated expenditures for alternative medicine professional services increased 45.2 % between 1990 and 1997 and were conservatively estimated at $ 21.2 billion in 1997 , with at least $ 12.2 billion paid out-of-pocket . This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations . Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $ 27.0 billion , which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services . CONCLUSIONS  Alternative medicine use and expenditures increased substantially between 1990 and 1997 , attributable primarily to an increase in the proportion of the population seeking alternative therapies , rather than increased visits per patient In rheumatoid arthritis ( RA ) benefit from non-steroidal anti-inflammatory drugs ( NSAIDs ) is mediated through inhibition of the cyclo-oxygenase enzyme , thereby decreasing production of the 2 series prostagl and ins ( PGs ) . The lipoxygenase enzyme is intact , however , allowing leucotriene ( LT ) production , e.g. , LTB4 ( an inflammatory mediator ) . Treatment with evening primrose oil ( EPO ) which contains gamma-linolenic acid ( GLA ) leads to production of the 1 series PGs , e.g. , PGE1 , which has less inflammatory effects . Also LT production is inhibited . Eicosapentaenoic acid ( EPA , fish oil ) treatment provides a substrate for PGs and LTs , which are also less inflammatory . In this study 16 patients with RA were given  540 mg GLA/day ( EPO ) , 15 patients 240 mg EPA and 450 mg GLA/day ( EPO/fish oil ) , and 18 patients an inert oil ( placebo ) . The aim of this study was to determine if EPO or EPO/fish oil could replace NSAID treatment in RA . The initial 12 month treatment period was followed by three months of placebo for all groups . Results at 12 months showed a significant subjective improvement for EPO and EPO/fish oil compared with placebo . In addition , by 12 months the patients receiving EPO and EPO/fish oil had significantly reduced their NSAIDs . After 3 months of placebo those receiving active treatment had relapsed . Despite the decrease in NSAIDs , measures of disease activity did not worsen . It is suggested that EPO and EPO/fish oil produce a subjective improvement and allow some patients to reduce or stop treatment with NSAIDs . There is , however , no evidence that they act as disease modifying agents The serum concentration of lipids and composition of fatty acids after overnight fasting were studied in 18 patients with rheumatoid arthritis treated for 12 weeks with either 20 ml of evening primrose oil containing 9 % of gamma-linolenic acid or olive oil .  The serum concentrations of oleic acid , eicosapentaenoic acid , and apolipoprotein B decreased and those of linoleic acid , gamma-linolenic acid , dihomo-gamma-linolenic acid , and arachidonic acid increased during treatment with evening primrose oil . During olive oil treatment the serum concentration of eicosapentaenoic acid decreased and those of high density lipoprotein-cholesterol and apolipoprotein A-I increased slightly . The decrease in serum eicosapentaenoic acid and the increase in arachidonic acid concentrations induced by evening primrose oil may not be favourable effects in patients with rheumatoid arthritis in the light of the roles of these fatty acids as precursors of eicosanoids Feverfew , reputed by folklore to be effective in arthritis , has in vitro properties that could be beneficial in the control of inflammatory disease . Forty one female patients with symptomatic rheumatoid arthritis received either dried chopped feverfew ( 70 - 86 mg ) or placebo capsules once daily for six weeks . Allocation was r and om and not known by patient or observer . Variables assessed included stiffness , pain ( visual analogue scale ) , grip strength , articular index , full blood count , erythrocyte sedimentation rate , urea , creatinine , C reactive protein , complement breakdown products ( C3dg ) , rheumatoid factor titre , immunoglobulins ( IgG , IgA , IgM ) , functional capacity , and patient and observer global opinions . One patient ( placebo ) withdrew after three days and was not included in the analysis . Treatment and placebo groups ( 20 patients each ) were well matched at entry . No important differences between the clinical or laboratory variables of the groups were observed during the six week period . This study therefore shows no apparent benefit from oral feverfew in rheumatoid arthritis Eighty-two subjects with chronic arthritic pain were r and omly assigned for 2 months without cross-over to either Reumalex , a licenced over-the-counter ( OTC ) herbal medicine , or a placebo .  Entry characteristics were determined by a previous survey of arthritic customers at pharmacy and healthfood shop outlets . The AIMS 2 question naire was completed at monthly intervals throughout and for 2 months prior to the trial , and a modified Ritchie Index provided clinical scores . Subjects also completed diary recordings of their use of self-prescribed analgesics and events they considered significant . There was a small but statistically significant improvement in pain symptoms , less so in sufferers from osteoarthritis . There were no other significant changes in any other measures nor in the use of other self-prescribed analgesics . There were few side-effects noted . It is concluded that Reumalex has a mild analgesic effect in chronic arthritis at a level appropriate to self-medication The objective of this study was to assess the clinical efficacy and side effects of blackcurrant seed oil ( BCSO ) , in a r and omized , double-blind , placebo controlled , 24-week trial in patients with RA and active synovitis .  BCSO is rich in gammalinolenic acid ( GLA ) and alphalinolenic acid ( ALA ) . Both GLA and eicosapentaenoic acid which derives from ALA suppress inflammation and joint tissue injury in animal models . Treatment with BCSO result ed in reduction in signs and symptoms of disease activity in patients with RA ( P < 0.05 ) . In contrast , patients given a  placebo  showed no change in disease . Overall clinical responses ( significant change in four measures ) were no better in the treatment group than in the placebo group . No patients withdrew from BCSO treatment because of adverse reactions . However , many patients withdrew because BCSO and its placebo had to be administered in 15 large capsules daily . Nonetheless , the study indicates that BCSO is a potentially effective treatment for active RA . However , means must be found to reduce the size and number of capsules taken , so that larger studies of longer duration in RA patients can be done The search for better treatments for malignancies has been enhanced by use of a relatively inexpensive clinical protocol that encourages the preliminary screening of a large number of potential anticancer drugs with early elimination of those that are clearly ineffective , preserving re sources for more intensive evaluation of those that show some evidence of benefit . We adapted this method to determine whether the herbal medicine TJ-114 was worthy of further study for the treatment of rheumatoid arthritis ( RA ) patients .  TJ-114 is a traditional herbal medicine that has been used extensively in Japan for the treatment of RA , Reports suggest that it may be a useful second-line agent , well-tolerated and safe . For these reasons , a 6-month , open prospect i ve pilot study to evaluate the efficacy , safety and tolerability of TJ-114 in United States RA patients was undertaken . Thirty patients were enrolled ; 18 completed the study . There were five responders by predefined composite criteria . Twelve patients withdrew from the trial , six for lack of efficacy , four for non-compliance , one for diarrhea and one for constipation and abdominal pain . The anti-cancer drug screening protocol stipulates that the drug be discarded if there are no responders among the first 14 patients and only 1 or 2 among the first 30 patients . Using this approach , the response rate found in this study justifies placebo-controlled , double-blind studies to determine the relative efficacy and toxicity of TJ-114 in a more definitive manner Many r and omised controlled trials have been conducted in China to evaluate the effectiveness of traditional Chinese medicine , but much of the information is inaccessible to Western doctors . We estimated the total number of r and omised controlled trials published in China and identified problems in applying such methodology to the evaluation of traditional Chinese medicine , which would serve as preparatory work for systematic review and dissemination of the r and omised evidence for such medicine . We r and omly selected 28 journals using stratified sampling from a total of 100 Chinese journals of traditional Chinese medicine ( 4 national , 10 university , 10 provincial or regional , and 4 specialist journals ) . After special training , eight fifth year medical students ( working in pairs ) h and search ed all the issues of the journals published before 1 January 1997 to identify r and omised controlled trials . Discrepancies were settled by one of the principal investigators ( S-YZ ) . Data on method ological quality of r and omised controlled trials were extracted from 414 full length articles Improvements have been made in the management of patients with rheumatoid arthritis , mainly through development of many anti-inflammatory drugs , advances in the surgical repair and replacement of damaged joints , and more informed use of corticosteroids and second-line drugs such as methotrexate . Many of these interventions are associated with adverse effects , however , that can often be as difficult to manage as the disease itself . A need exists for new ways to treat these patients . Particular fatty acids may be effective anti-inflammatory and immunomodulating agents . For example , certain plant seed oils , notably those extracted from the seeds of Oenothera biennis ( evening primrose 
    Output:
    
However , the better quality studies suggest potential relief of pain , morning stiffness and joint tenderness .
REVIEW ER 'S CONCLUSIONS There appears to be some potential benefit for the use of GLA in rheumatoid arthritis although further studies are required to establish optimum dosage and duration of treatment .