***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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    Input: OBJECTIVE To assess the efficacy of topical Tripterygium wilfordii ( TW ) , a Chinese herbal therapy , in rheumatoid arthritis ( RA ) . METHODS A 6 week r and omized double blind placebo controlled study of 61 patients with RA meeting American College of Rheumatology ( ACR ) criteria was conducted in China . The primary outcome was a modified ACR-20 response rate , analyzed by logistic regression analysis . RESULTS The modified ACR-20 response rate differed significantly ( topical TW 58 % vs placebo 20 % ; p = 0.002 ) . There was an 8.1-fold ( 95 % CI 1.9 - 35.4 ) increase in the modified ACR-20 response for the TW compared to the placebo group , adjusted for age and erythrocyte sedimentation rate . CONCLUSION Topical TW appears efficacious for the treatment of RA , but larger studies are needed Mixed treatment comparison ( MTC ) meta- analysis is a generalization of st and ard pairwise meta- analysis for A vs B trials , to data structures that include , for example , A vs B , B vs C , and A vs C trials . There are two roles for MTC : one is to strengthen inference concerning the relative efficacy of two treatments , by including both ' direct ' and ' indirect ' comparisons . The other is to facilitate simultaneous inference regarding all treatments , in order for example to select the best treatment . In this paper , we present a range of Bayesian hierarchical models using the Markov chain Monte Carlo software WinBUGS . These are multivariate r and om effects models that allow for variation in true treatment effects across trials . We consider models where the between-trials variance is homogeneous across treatment comparisons as well as heterogeneous variance models . We also compare models with fixed ( unconstrained ) baseline study effects with models with r and om baselines drawn from a common distribution . These models are applied to an illustrative data set and posterior parameter distributions are compared . We discuss model critique and model selection , illustrating the role of Bayesian deviance analysis , and node-based model criticism . The assumptions underlying the MTC models and their parameterization are also discussed Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Context In Chinese medicine , extracts of Tripterygium wilfordii Hook F ( TwHF , known as lei gong teng or thunder god vine ) are used to treat autoimmune and inflammatory conditions . Small clinical trials suggest that TwHF may benefit patients with rheumatoid arthritis . Contribution This trial compared TwHF extract with sulfasalazine in 121 patients with active rheumatoid arthritis who could continue oral prednisone and nonsteroidal anti-inflammatory drugs but not disease-modifying antirheumatic drugs .  Among patients who continued treatment for 24 weeks , achievement of 20 % improvement in American College of Rheumatology criteria was greater with TwHF than with sulfasalazine .  Adverse event rates were similar . Caution Only 62 % and 41 % of patients continued TwHF and sulfasalazine treatment , respectively , and provided 24 weeks of data . The Editors Rheumatoid arthritis is characterized by chronic inflammation of the joint lining ( synovial membrane ) ( 1 ) , which causes pain and swelling of diarthrodial joints . Over time , uncontrolled disease results in progressive joint damage , disability , and increased mortality ( 2 ) . The evolving underst and ing of the immune mechanisms that perpetuate the inflammatory response has led to effective targeted therapies , including inhibitors of inflammatory cytokines ( tumor necrosis factor , interleukin-1 , and interleukin-6 ) , modulators of activation of CD4 + T cells and dendritic cells , and agents that deplete B cells ( 3 , 4 ) . Despite the clinical efficacy of these therapies , many patients have no clinical ly meaningful response or discontinue treatment because of adverse events . Furthermore , the limited availability of effective biologics in developing countries , the need for parenteral administration of the biologics , and the relatively high cost all restrict access to these therapies in many patients with rheumatoid arthritis around the world ( 5 ) . In traditional Chinese medicine , extracts of the roots of the medicinal vine Tripterygium wilfordii Hook F ( TwHF ) ( known in China as lei gong teng or thunder god vine ) have shown therapeutic promise in treating autoimmune and inflammatory conditions as well as cancer ( 68 ) . More recently , different extracts of TwHF have been used in Chinese allopathic medicine for the treatment of autoimmune and inflammatory diseases , and small controlled trials reported good responses with TwHF extracts in patients with cadaveric kidney transplants ( 9 , 10 ) and Crohn disease ( 11 ) . Of the approximately 380 metabolites isolated from the plant , 95 % are terpenoids ( 12 , 13 ) . Three diterpenoidstriptolide , tripdiolide , and triptonide (13)are the most abundant and account for the immunosuppressive and anti-inflammatory effects observed with the root extracts in both in vitro and in vivo studies ( 6 ) . In 2 previous single-center trials of patients with rheumatoid arthritis , the extract was st and ardized by the content of triptolide and tripdiolide ( 14 ) . This made it possible to use optimal doses identified in an open-label trial ( 15 ) for the design of a subsequent small placebo-controlled study ( 16 ) . Although the number of patients was small , the apparent clinical impact and experimental results indicating potent inhibition of the expression of proinflammatory genes both in vitro and in vivo in animal models ( 1721 ) provided the rationale for our multicenter , double-blind , active comparator trial of a st and ardized TwHF extract in patients with active rheumatoid arthritis . Methods Design Overview This r and omized , controlled , 24-week study was conducted between March 2004 and October 2005 . All participants provided written informed consent to enter the trial , and the institutional review boards at the participating sites approved the protocol . All investigators and outcome assessors were blinded to group assignment of the patients . Our objective was to determine whether therapy with TwHF extract , 180 mg/d , was statistically significantly better than therapy with sulfasalazine , 2 g/d , over 24 weeks in patients with rheumatoid arthritis by using st and ard outcome measures . Setting and Participants Our study was conducted at 11 U.S. centers : 2 academic centers ( National Institutes of Health , Bethesda , Maryl and , and University of Texas , Dallas , Texas ) and 9 rheumatology subspecialty clinics ( 1 each in Dallas and Austin , Texas ; Tampa and Fort Lauderdale , Florida ; Arlington , Virginia ; Duncanville , Pennsylvania ; Wheaton and Greenbelt , Maryl and ; and Lansing , Michigan ) . Eligible patients had to be at least 18 years of age and have established rheumatoid arthritis , defined by the American College of Rheumatology ( ACR ) classification criteria ( 22 ) as rheumatoid arthritis lasting longer than 6 months . Eligible patients had active disease , defined as 6 or more painful and swollen joints , a visual analogue scale score for pain of at least 3 ( on a scale of 1 to 10 , with 1 being mild ) , and a C-reactive protein ( CRP ) level of 57.14 nmol/L or greater ( 0.6 mg/dL ) or an erythrocyte sedimentation rate ( ESR ) greater than 25 mm/h . Patients who were taking any disease-modifying antirheumatic drug at screening underwent a 28-day washout period . The use of oral prednisone , at stable doses up to 7.5 mg/d , and nonsteroidal anti-inflammatory drugs were allowed as long as the dose was not changed for 28 days before r and omization and the patient agreed to continue to take the medication during the study . Table 1 lists baseline patient characteristics . Table 1 . Patient Characteristics at Baseline R and omization and Interventions We used a computer-generated , pseudo-r and om code ( with r and om , permuted blocks ) to assign patients to treatment groups across all centers . We assigned eligible patients at a 1:1 ratio to receive either TwHF extract , 180 mg/d , or sulfasalazine , 2 g/d . In the event of gastrointestinal intolerance , the protocol allowed for temporary dose reduction of 50 % . As described elsewhere ( 15 , 16 ) , the triptolide and tripdiolide content of the ethanol and ethylacetate extract ( measured by high-performance liquid chromatography [ 22 ] ) was used to st and ardize the drug preparation for this study . On the basis of data on in vitro activity and in vivo toxicity , 30 mg of TwHF extract were formulated per capsule . Our study was conducted under the U.S Food and Drug Administrationapproved Investigational New Drug application 39191 . Outcomes and Measurements Patients were evaluated clinical ly and by laboratory measures at baseline , 2 weeks , and every 4 weeks for a total of 24 weeks . A rheumatologist or trained staff member masked to treatment allocation assessed the patients . Serum or plasma specimens were obtained from the patients at baseline , 4 weeks , and 24 weeks and stored at 80C until analysis . Radiographs of h and s and feet were obtained at baseline and 24 weeks or at study discontinuation . The primary end point was a 20 % improvement at 24 weeks , as defined by ACR criteria ( ACR 20 ) ( 23 ) . To meet criteria , a patient must have 20 % or greater improvement in both tender and swollen joints ( 68 tender and 66 swollen joints were assessed ) and 20 % or greater improvement in 3 or more of the following : the physician 's or patient 's assessment of global health status , the patient 's assessment of pain on a visual analogue scale , the patient 's assessment of function ( using a modified version of the Health Assessment Question naire [ HAQ ] ) , and the serum CRP level . Secondary end points included the efficacy of TwHF in achieving ACR 50 and ACR 70 responses at 24 weeks , the improvement in the European League Against Rheumatism Disease Activity Score 28 ( DAS 28 ) measure , and a change in the Sharpvan der Heijde score of the h and and foot radiographs ( 24 ) . Radiographs were obtained at baseline and at the end of the study and were scored by 2 independent readers who were blinded to the r and omization schedule and the radiograph sequence . Drug adherence was assessed by using a daily diary and by pill counts . Body weight , blood pressure , and serum glucose level were measured at each visit . Laboratory assessment s included ESR ( Westergren method ) ; high-sensitivity CRP with normal levels up to 38.1 nmol/L ( 0.4 mg/dL ) , which was analyzed in a central laboratory ; and interleukin-6 levels , which were measured at baseline , 4 weeks , and 24 weeks by using high-sensitivity enzyme-linked immunosorbent assay ( R&D Systems , Minneapolis , Minnesota ) . Rheumatoid factor was measured by immunonephelometry with a BNII analyzer ( Siemens Medical Solutions Diagnostics , Newark , Delaware ) , cortisol and adrenocorticotropic hormone levels by immunochemiluminescence methods with an Immulite 2500 ( Siemens Medical Solutions Diagnostics , Los Angeles , California ) , and plasma lipids by Synchron LX-20 automated analyzers ( Beckman Coulter , Brea , California ) . Safety assessment s consisted of all patients marking adverse events in their drug diaries , which were review ed on each visit . Vital signs and safety laboratory measures , including a complete blood count and a chemistry profile ( electrolyte and liver and kidney function tests ) , were recorded at each visit . Adverse events were grade d by severity according to the National Cancer Institute Common Toxicity Criteria guidelines . An electrocardiogram ( ECG ) was obtained from all patients at baseline , 2 weeks , and the end of study . After 24 weeks , no follow-up was conducted . Statistical Analysis We design ed our study to detect differences in the primary end point with greater than 90 % power at a 2-sided level of significance of 0.05 . To properly account for missing end point data due to dropouts , we used mixed-effects analyses to predict each patient 's ACR response at the end of study visit and to properly account for uncertainty in that prediction . The response was categorized according to the ACR 20 , ACR 50 , and ACR 70 criteria . In a similar manner , we compared changes in DAS 28 from baseline visit between treatment groups . We modeled the treatment group , visit number ( 2 r and om-effect terms for visit number and visit OBJECTIVE To explore the efficacy and safety of ethyl acetate ( EA ) extracts of the Chinese herbal remedy Tripterygium wilfordii Hook F ( TWHF ) for treatment of patients with a variety of inflammatory and autoimmune diseases including rheumatoid arthritis ( RA ) . METHODS The roots of TWHF were extracted sequentially by ethyl alcohol and ethyl acetate and the content of the extract documented . An open label , dose escalation Phase I study was performed in 1993 in 13 patients with established RA . Clinical manifestations and laboratory findings were examined before and every 4 weeks after starting treatment with the EA extract . 
    Output:
    
Conclusions Our data suggest that TwHF is effective and safe in the treatment of RA and has better clinical efficacy in terms of ACR 20 and 50 than existing conventional synthetic DMARDs .