human
***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: Background : Although up to a third of the 10,000 acupuncturists in the United States are medical doctors , little is known about the acupuncture techniques they use or how their practice s compare with those of nonphysician licensed acupuncturists . This is the first study providing descriptive data on physician acupuncture and comparison to nonphysician acupuncture . Purpose : This study describes how a r and om sample of physician acupuncturists in the United States diagnose and treat chronic low back pain and contrasts their practice s with those of nonphysician licensed acupuncturists . Methods : A total of 464 question naires were mailed to physician acupuncturists r and omly sample d from 3 sources : web-based Yellow Pages , American Academy of Medical Acupuncturists ( AAMA ) membership , and Pain Clinics associated with American College of Graduate Medical Education-approved fellowship programs . Responses ( n = 137 , 30 % ) were analyzed using descriptive statistics . The results of this survey were compared with data published from a similar survey of nonphysician licensed acupuncturists in Washington State . Results : Physicians who perform acupuncture use a mixture of styles and emphasize neuroanatomic approaches to needle placement . Most physicians received training in French Energetic acupuncture .  In contrast , most nonphysician licensed acupuncturists use a traditional Chinese medicine approach to needle placement . Despite this apparent difference in their predominant styles of acupuncture  , there was a high correlation between physician and nonphysician licensed acupuncturist acupoint selection to treat low back pain . In addition to acupuncture needling , physicians use other medical treatments , whereas nonphysician licensed acupuncturists ' employ a variety of traditional Chinese medicine adjuncts to needling . Conclusion : This study provides new information about the nature of physician acupuncture practice in the United States and how it compares to acupuncture provided by nonphysician licensed acupuncturists . Further research is necessary to determine if the different types of acupuncture provided by physicians and nonphysician acupuncturists affect treatment outcomes and costs for patients with chronic low back pain BACKGROUND To our knowledge , verum acupuncture has never been directly compared with sham acupuncture and guideline -based conventional therapy in patients with chronic low back pain . METHODS A patient- and observer-blinded r and omized controlled trial conducted in Germany involving 340 outpatient practice s , including 1162 patients aged 18 to 86 years ( mean + /- SD age , 50 + /- 15 years ) with a history of chronic low back pain for a mean of 8 years . Patients underwent ten 30-minute sessions , generally 2 sessions per week , of verum acupuncture ( n = 387 ) according to principles of traditional Chinese medicine ; sham acupuncture ( n = 387 ) consisting of superficial needling at nonacupuncture points ; or conventional therapy , a combination of drugs , physical therapy , and exercise ( n = 388 ) . Five additional sessions were offered to patients who had a partial response to treatment ( 10%-50 % reduction in pain intensity ) . Primary outcome was response after 6 months , defined as 33 % improvement or better on 3 pain-related items on the Von Korff Chronic Pain Grade Scale question naire or 12 % improvement or better on the back-specific Hanover Functional Ability Question naire . Patients who were unblinded or had recourse to other than permitted concomitant therapies during follow-up were classified as nonresponders regardless of symptom improvement . RESULTS At 6 months , response rate was 47.6 % in the verum acupuncture group , 44.2 % in the sham acupuncture group , and 27.4 % in the conventional therapy group . Differences among groups were as follows : verum vs sham , 3.4 % ( 95 % confidence interval , -3.7 % to 10.3 % ; P = .39 ) ; verum vs conventional therapy , 20.2 % ( 95 % confidence interval , 13.4 % to 26.7 % ; P < .001 ) ; and sham vs conventional therapy , 16.8 % ( 95 % confidence interval , 10.1 % to 23.4 % ; P < .001 . CONCLUSIONS Low back pain improved after acupuncture treatment for at least 6 months . Effectiveness of acupuncture , either verum or sham , was almost twice that of conventional therapy OBJECTIVE To determine if acupuncture is an effective , safe adjunctive treatment to st and ard therapy for chronic low back pain ( LBP ) in older patients . METHODS The inclusion criteria for subjects were : ( i ) LBP > or = 12 weeks and ( ii ) age > or = 60 yr ; the exclusion criteria were ( i ) spinal tumour , infection or fracture and ( ii ) associated neurological symptoms . The subjects were r and omized to two groups . The control group of subjects continued their usual care as directed by their physicians , i.e. NSAIDs , muscle relaxants , paracetamol and back exercises . Subjects in the acupuncture group in addition received biweekly acupuncture with electrical stimulation for 5 weeks . Outcome was measured by the modified Rol and Disability Question naire ( RDQ ) at weeks 0 , 2 , 6 and 9 . The primary outcome measure was change in RDQ score between weeks 0 and 6 . RESULTS Fifty-five patients were enrolled , with eight drop-outs . Twenty-four subjects were r and omized to the acupuncture group and 23 were r and omized to the control group . Acupuncture subjects had a significant decrease in RDQ score of 4.1 + /- 3.9 at week 6 , compared with a mean decrease of 0.7 + /- 2.8 in the control group ( P = 0.001 ) . This effect was maintained for up to 4 weeks after treatment at week 9 , with a decrease in RDQ of 3.5 + /- 4.4 from baseline , compared with 0.43 + /- 2.7 in the control group ( P = 0.007 ) . The mean global transition score was higher in the acupuncture group , 3.7 + /- 1.2 , indicating greater improvement , compared with the score in the control group , 2.5 + /- 0.9 ( P < 0.001 ) . Fewer acupuncture subjects had medication-related side-effects compared with the control group . CONCLUSIONS Acupuncture is an effective , safe adjunctive treatment for chronic LBP in older patients Abstract  Variability  in patients ' response to interventions in pain and other clinical setting s is large . Many explanations such as trial methods , environment or culture have been proposed , but this paper sets out to show that the main cause of the variability may be r and om chance , and that if trials are small their estimate of magnitude of effect may be incorrect , simply because of the r and om play of chance . This is highly relevant to the questions of ‘ How large do trials have to be for statistical accuracy ? ’ and ‘ How large do trials have to be for their results to be clinical ly valid ? ’ The true underlying control event rate ( CER ) and experimental event rate ( EER ) were determined from single‐dose acute pain analgesic trials in over 5000 patients . Trial group size required to obtain statistically significant and clinical ly relevant ( 0.95 probability of number‐needed‐to‐treat within ±0.5 of its true value ) results were computed using these values . Ten thous and trials using these CER and EER values were simulated using varying group sizes to investigate the variation due to r and om chance alone . Most common analgesics have EERs in the range 0.4–0.6 and CER of about 0.19 . With such efficacy , to have a 90 % chance of obtaining a statistically significant result in the correct direction requires group sizes in the range 30–60 . For clinical relevance nearly 500 patients are required in each group . Only with an extremely effective drug ( EER>0.8 ) will we be reasonably sure of obtaining a clinical ly relevant NNT with commonly used group sizes of around 40 patients per treatment arm . The simulated trials showed substantial variation in CER and EER , with the probability of obtaining the correct values improving as group size increased . We contend that much of the variability in control and experimental event rates is due to r and om chance alone . Single small trials are unlikely to be correct . If we want to be sure of getting correct ( clinical ly relevant ) results in clinical trials we must study more patients . Credible estimates of clinical efficacy are only likely to come from large trials or from pooling multiple trials of conventional ( small ) size Study Design . A r and omized controlled clinical trial was conducted . Objective . To compare medication , needle acupuncture , and spinal manipulation for managing chronic ( > 13 weeks duration ) spinal pain because the value of medicinal and popular forms of alternative care for chronic spinal pain syndromes is uncertain . Summary of Background Data . Between February 1999 and October 2001 , 115 patients without contraindication for the three treatment regimens were enrolled at the public hospital ’s multidisciplinary spinal pain unit . Methods . One of three separate intervention protocol s was used : medication , needle acupuncture , or chiropractic spinal manipulation . Patients were assessed before treatment by a sports medical physician for exclusion criteria and by a research assistant using the Oswestry Back Pain Disability Index ( Oswestry ) , the Neck Disability Index ( NDI ) , the Short-Form-36 Health Survey question naire ( SF-36 ) , visual analog scales ( VAS ) of pain intensity and ranges of movement . These instruments were administered again at 2 , 5 , and 9 weeks after the beginning of treatment . Results . R and omization proved to be successful . The highest proportion of early ( asymptomatic status ) recovery was found for manipulation ( 27.3 % ) , followed by acupuncture ( 9.4 % ) and medication ( 5 % ) . Manipulation achieved the best overall results , with improvements of 50 % ( P = 0.01 ) on the Oswestry scale , 38 % ( P = 0.08 ) on the NDI , 47 % ( P < 0.001 ) on the SF-36 , and 50 % ( P < 0.01 ) on the VAS for back pain , 38 % ( P < 0.001 ) for lumbar st and ing flexion , 20 % ( P < 0.001 ) for lumbar sitting flexion , 25 % ( P = 0.1 ) for cervical sitting flexion , and 18 % ( P = 0.02 ) for cervical sitting extension . However , on the VAS for neck pain , acupuncture showed a better result than manipulation ( 50%vs 42 % ) . Conclusions . The consistency of the results provides , despite some discussed shortcomings of this study , evidence that in patients with chronic spinal pain , manipulation , if not contraindicated , results in greater short-term improvement than acupuncture or medication . However , the data do not strongly support the use of only manipulation , only acupuncture , or only nonsteroidal antiinflammatory drugs for the treatment of chronic spinal pain . The results from this exploratory study need confirmation from future larger studies The paper describes the type and frequency of adverse events and transient reactions following consultations with  professional acupuncturists .  In a postal survey , involving 1848 professional acupuncturists , all of whom were members of the British Acupuncture Council and practising in the UK , details of adverse events and transient reactions following treatment were recorded on st and ardised self-report forms . A sample size of 30,000 treatments was sought , and piloting indicated that a four-week period was required . Practitioners also provided information on themselves , including age , sex , length of training and years of practice . A total of 574 practitioners responded , 31 % of the total population . These practitioners reported on  adverse events and transient reactions associated with 34,407 treatments . No serious adverse events were reported , where these were defined as requiring hospital admission , prolonging hospital stays , permanently disabling , or result ing in death ( 95 % CI : 0 to 1.1 per 10,000 treatments ) . A total of 43 significant minor adverse events were reported , a rate of 1.3 per 1,000 treatments ( 95 % CI : 0.9 to 1.7 ) . These included severe nausea and actual fainting ( 12 ) , unexpected , severe and prolonged aggravation of symptoms ( 7 ) , prolonged and unacceptable pain and bruising ( 5 ) and psychological and emotional reactions ( 4 ) . There were three avoidable events : two patients had needles left in by mistake , and one patient had moxa burns to the skin , also caused by practitioner error . The acupuncturists also recorded 10,920 mild transient reactions occurring in 5136 treatments , 15 % ( 95 % CI : 14.6 to 15.3 ) of the 34,407 total . In terms of local reactions , there were reports of mild bruising ( 1.7 % ) , pain ( 1.2 % ) and bleeding ( 0.4 % ) . Practitioners reported that patients experienced an aggravation of existing symptoms after 2.8 % of treatments . The most common mild transient reactions to treatment were feeling relaxed ( 11.9 % ) and feeling energised ( 6.6 % ) . In this prospect i ve survey of 34,407 treatments , practitioners reported no serious adverse events . This conclusion was based on data collected from one in three members of the British Acupuncture Council . Given that the whole membership delivers between one and a half and two million treatments a year , this is important evidence on public health and safety . When compared with medication routinely prescribed in primary care , the results suggest that ac 
    Output:
    
agent
***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: Background : Although up to a third of the 10,000 acupuncturists in the United States are medical doctors , little is known about the acupuncture techniques they use or how their practice s compare with those of nonphysician licensed acupuncturists . This is the first study providing descriptive data on physician acupuncture and comparison to nonphysician acupuncture . Purpose : This study describes how a r and om sample of physician acupuncturists in the United States diagnose and treat chronic low back pain and contrasts their practice s with those of nonphysician licensed acupuncturists . Methods : A total of 464 question naires were mailed to physician acupuncturists r and omly sample d from 3 sources : web-based Yellow Pages , American Academy of Medical Acupuncturists ( AAMA ) membership , and Pain Clinics associated with American College of Graduate Medical Education-approved fellowship programs . Responses ( n = 137 , 30 % ) were analyzed using descriptive statistics . The results of this survey were compared with data published from a similar survey of nonphysician licensed acupuncturists in Washington State . Results : Physicians who perform acupuncture use a mixture of styles and emphasize neuroanatomic approaches to needle placement . Most physicians received training in French Energetic acupuncture .  In contrast , most nonphysician licensed acupuncturists use a traditional Chinese medicine approach to needle placement . Despite this apparent difference in their predominant styles of acupuncture  , there was a high correlation between physician and nonphysician licensed acupuncturist acupoint selection to treat low back pain . In addition to acupuncture needling , physicians use other medical treatments , whereas nonphysician licensed acupuncturists ' employ a variety of traditional Chinese medicine adjuncts to needling . Conclusion : This study provides new information about the nature of physician acupuncture practice in the United States and how it compares to acupuncture provided by nonphysician licensed acupuncturists . Further research is necessary to determine if the different types of acupuncture provided by physicians and nonphysician acupuncturists affect treatment outcomes and costs for patients with chronic low back pain BACKGROUND To our knowledge , verum acupuncture has never been directly compared with sham acupuncture and guideline -based conventional therapy in patients with chronic low back pain . METHODS A patient- and observer-blinded r and omized controlled trial conducted in Germany involving 340 outpatient practice s , including 1162 patients aged 18 to 86 years ( mean + /- SD age , 50 + /- 15 years ) with a history of chronic low back pain for a mean of 8 years . Patients underwent ten 30-minute sessions , generally 2 sessions per week , of verum acupuncture ( n = 387 ) according to principles of traditional Chinese medicine ; sham acupuncture ( n = 387 ) consisting of superficial needling at nonacupuncture points ; or conventional therapy , a combination of drugs , physical therapy , and exercise ( n = 388 ) . Five additional sessions were offered to patients who had a partial response to treatment ( 10%-50 % reduction in pain intensity ) . Primary outcome was response after 6 months , defined as 33 % improvement or better on 3 pain-related items on the Von Korff Chronic Pain Grade Scale question naire or 12 % improvement or better on the back-specific Hanover Functional Ability Question naire . Patients who were unblinded or had recourse to other than permitted concomitant therapies during follow-up were classified as nonresponders regardless of symptom improvement . RESULTS At 6 months , response rate was 47.6 % in the verum acupuncture group , 44.2 % in the sham acupuncture group , and 27.4 % in the conventional therapy group . Differences among groups were as follows : verum vs sham , 3.4 % ( 95 % confidence interval , -3.7 % to 10.3 % ; P = .39 ) ; verum vs conventional therapy , 20.2 % ( 95 % confidence interval , 13.4 % to 26.7 % ; P < .001 ) ; and sham vs conventional therapy , 16.8 % ( 95 % confidence interval , 10.1 % to 23.4 % ; P < .001 . CONCLUSIONS Low back pain improved after acupuncture treatment for at least 6 months . Effectiveness of acupuncture , either verum or sham , was almost twice that of conventional therapy OBJECTIVE To determine if acupuncture is an effective , safe adjunctive treatment to st and ard therapy for chronic low back pain ( LBP ) in older patients . METHODS The inclusion criteria for subjects were : ( i ) LBP > or = 12 weeks and ( ii ) age > or = 60 yr ; the exclusion criteria were ( i ) spinal tumour , infection or fracture and ( ii ) associated neurological symptoms . The subjects were r and omized to two groups . The control group of subjects continued their usual care as directed by their physicians , i.e. NSAIDs , muscle relaxants , paracetamol and back exercises . Subjects in the acupuncture group in addition received biweekly acupuncture with electrical stimulation for 5 weeks . Outcome was measured by the modified Rol and Disability Question naire ( RDQ ) at weeks 0 , 2 , 6 and 9 . The primary outcome measure was change in RDQ score between weeks 0 and 6 . RESULTS Fifty-five patients were enrolled , with eight drop-outs . Twenty-four subjects were r and omized to the acupuncture group and 23 were r and omized to the control group . Acupuncture subjects had a significant decrease in RDQ score of 4.1 + /- 3.9 at week 6 , compared with a mean decrease of 0.7 + /- 2.8 in the control group ( P = 0.001 ) . This effect was maintained for up to 4 weeks after treatment at week 9 , with a decrease in RDQ of 3.5 + /- 4.4 from baseline , compared with 0.43 + /- 2.7 in the control group ( P = 0.007 ) . The mean global transition score was higher in the acupuncture group , 3.7 + /- 1.2 , indicating greater improvement , compared with the score in the control group , 2.5 + /- 0.9 ( P < 0.001 ) . Fewer acupuncture subjects had medication-related side-effects compared with the control group . CONCLUSIONS Acupuncture is an effective , safe adjunctive treatment for chronic LBP in older patients Abstract  Variability  in patients ' response to interventions in pain and other clinical setting s is large . Many explanations such as trial methods , environment or culture have been proposed , but this paper sets out to show that the main cause of the variability may be r and om chance , and that if trials are small their estimate of magnitude of effect may be incorrect , simply because of the r and om play of chance . This is highly relevant to the questions of ‘ How large do trials have to be for statistical accuracy ? ’ and ‘ How large do trials have to be for their results to be clinical ly valid ? ’ The true underlying control event rate ( CER ) and experimental event rate ( EER ) were determined from single‐dose acute pain analgesic trials in over 5000 patients . Trial group size required to obtain statistically significant and clinical ly relevant ( 0.95 probability of number‐needed‐to‐treat within ±0.5 of its true value ) results were computed using these values . Ten thous and trials using these CER and EER values were simulated using varying group sizes to investigate the variation due to r and om chance alone . Most common analgesics have EERs in the range 0.4–0.6 and CER of about 0.19 . With such efficacy , to have a 90 % chance of obtaining a statistically significant result in the correct direction requires group sizes in the range 30–60 . For clinical relevance nearly 500 patients are required in each group . Only with an extremely effective drug ( EER>0.8 ) will we be reasonably sure of obtaining a clinical ly relevant NNT with commonly used group sizes of around 40 patients per treatment arm . The simulated trials showed substantial variation in CER and EER , with the probability of obtaining the correct values improving as group size increased . We contend that much of the variability in control and experimental event rates is due to r and om chance alone . Single small trials are unlikely to be correct . If we want to be sure of getting correct ( clinical ly relevant ) results in clinical trials we must study more patients . Credible estimates of clinical efficacy are only likely to come from large trials or from pooling multiple trials of conventional ( small ) size Study Design . A r and omized controlled clinical trial was conducted . Objective . To compare medication , needle acupuncture , and spinal manipulation for managing chronic ( > 13 weeks duration ) spinal pain because the value of medicinal and popular forms of alternative care for chronic spinal pain syndromes is uncertain . Summary of Background Data . Between February 1999 and October 2001 , 115 patients without contraindication for the three treatment regimens were enrolled at the public hospital ’s multidisciplinary spinal pain unit . Methods . One of three separate intervention protocol s was used : medication , needle acupuncture , or chiropractic spinal manipulation . Patients were assessed before treatment by a sports medical physician for exclusion criteria and by a research assistant using the Oswestry Back Pain Disability Index ( Oswestry ) , the Neck Disability Index ( NDI ) , the Short-Form-36 Health Survey question naire ( SF-36 ) , visual analog scales ( VAS ) of pain intensity and ranges of movement . These instruments were administered again at 2 , 5 , and 9 weeks after the beginning of treatment . Results . R and omization proved to be successful . The highest proportion of early ( asymptomatic status ) recovery was found for manipulation ( 27.3 % ) , followed by acupuncture ( 9.4 % ) and medication ( 5 % ) . Manipulation achieved the best overall results , with improvements of 50 % ( P = 0.01 ) on the Oswestry scale , 38 % ( P = 0.08 ) on the NDI , 47 % ( P < 0.001 ) on the SF-36 , and 50 % ( P < 0.01 ) on the VAS for back pain , 38 % ( P < 0.001 ) for lumbar st and ing flexion , 20 % ( P < 0.001 ) for lumbar sitting flexion , 25 % ( P = 0.1 ) for cervical sitting flexion , and 18 % ( P = 0.02 ) for cervical sitting extension . However , on the VAS for neck pain , acupuncture showed a better result than manipulation ( 50%vs 42 % ) . Conclusions . The consistency of the results provides , despite some discussed shortcomings of this study , evidence that in patients with chronic spinal pain , manipulation , if not contraindicated , results in greater short-term improvement than acupuncture or medication . However , the data do not strongly support the use of only manipulation , only acupuncture , or only nonsteroidal antiinflammatory drugs for the treatment of chronic spinal pain . The results from this exploratory study need confirmation from future larger studies The paper describes the type and frequency of adverse events and transient reactions following consultations with  professional acupuncturists .  In a postal survey , involving 1848 professional acupuncturists , all of whom were members of the British Acupuncture Council and practising in the UK , details of adverse events and transient reactions following treatment were recorded on st and ardised self-report forms . A sample size of 30,000 treatments was sought , and piloting indicated that a four-week period was required . Practitioners also provided information on themselves , including age , sex , length of training and years of practice . A total of 574 practitioners responded , 31 % of the total population . These practitioners reported on  adverse events and transient reactions associated with 34,407 treatments . No serious adverse events were reported , where these were defined as requiring hospital admission , prolonging hospital stays , permanently disabling , or result ing in death ( 95 % CI : 0 to 1.1 per 10,000 treatments ) . A total of 43 significant minor adverse events were reported , a rate of 1.3 per 1,000 treatments ( 95 % CI : 0.9 to 1.7 ) . These included severe nausea and actual fainting ( 12 ) , unexpected , severe and prolonged aggravation of symptoms ( 7 ) , prolonged and unacceptable pain and bruising ( 5 ) and psychological and emotional reactions ( 4 ) . There were three avoidable events : two patients had needles left in by mistake , and one patient had moxa burns to the skin , also caused by practitioner error . The acupuncturists also recorded 10,920 mild transient reactions occurring in 5136 treatments , 15 % ( 95 % CI : 14.6 to 15.3 ) of the 34,407 total . In terms of local reactions , there were reports of mild bruising ( 1.7 % ) , pain ( 1.2 % ) and bleeding ( 0.4 % ) . Practitioners reported that patients experienced an aggravation of existing symptoms after 2.8 % of treatments . The most common mild transient reactions to treatment were feeling relaxed ( 11.9 % ) and feeling energised ( 6.6 % ) . In this prospect i ve survey of 34,407 treatments , practitioners reported no serious adverse events . This conclusion was based on data collected from one in three members of the British Acupuncture Council . Given that the whole membership delivers between one and a half and two million treatments a year , this is important evidence on public health and safety . When compared with medication routinely prescribed in primary care , the results suggest that ac 
    Output:
    