Educational program for physicians to reduce use of non-steroidal anti-inflammatory drugs among community-dwelling elderly persons: a randomized controlled trial

CONTEXT

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed drugs for patients 65 years of age or older, primarily for musculoskeletal symptoms of osteoarthritis. Because NSAIDs frequently cause serious gastrointestinal (GI) and other complications among elderly patients, expert guidelines for osteoarthritis recommend acetaminophen-based regimens, which are safer and often as effective as NSAIDs.

OBJECTIVE

Evaluate a physician education program that communicated guidelines for management of osteoarthritis in elderly patients that emphasized avoidance of NSAIDs when possible. The program reviewed NSAID risks and benefits and recommended: re-evaluating continuous NSAID users, considering substitution of up to 4 g/d of acetaminophen for the NSAID, and trying topical agents and nonpharmacologic measures.

DESIGN AND SETTING

Randomized controlled trial among community-dwelling Tennessee Medicaid enrollees.

SUBJECTS

Study physicians had 5 or more patients who: were community-dwelling Medicaid enrollees 65 years of age or older; had used NSAIDs regularly for at least 180 days; had had no medical care encounters during this period suggesting an indication other than osteoarthritis; and had 1 year of baseline and follow-up data. The study thus included 209 physicians (103 intervention/106 control) with 1,566 qualifying regular NSAID users (768/798).

INTERVENTIONS

Face-to-face visit to study physicians by another physician, and reminder placements in the charts of patients eligible to have NSAID use reevaluated.

OUTCOMES

Change between baseline and follow-up years in: days of prescribed NSAIDs, acetaminophen, other drugs for musculoskeletal disorders, and GI drugs; outpatient visits and inpatient days of stay; SF36 measures of general health, physical function, and bodily pain (from 40% random patient sample); and over-the-counter NSAIDs (from the sample).

RESULTS

Intervention-attributable reduction of 7% (95% CI, 3% to 11%) in days of prescribed NSAIDs use with concomitant increase in acetaminophen use. No significant changes in other study endpoints. The intervention effect was greater among 75 physicians with a completed study visit, whose 564 patients had a 10% (95% CI, 6% to 14%) attributable reduction in NSAID use.

CONCLUSIONS

The educational program modestly reduced NSAID exposure in community-dwelling elderly patients without undesirable substitution of other medications or detectable worsening of musculoskeletal symptoms.

Semiautomated image registration for digital subtraction radiography

OBJECTIVE

The purpose of this study was to evaluate the semiautomatic alignment and correction of affine geometric discrepancies for digital subtraction radiography.

STUDY DESIGN

Algorithms were tested in vitro to determine their ability to semiautomatically select reference points on a second image based on points selected on a first (reference) image. A preserved human mandible was imaged with and without bone-equivalent material chips at varying degrees of angulation. Each chip had a mass of less than 10 mg and was no more than 0.3 mm thick. High levels of specificity and sensitivity for chip detection were achieved with 6 degrees of angular discrepancy or less. The algorithms were then applied to radiographs from six human subjects through use of the bone-chip validation model.

RESULTS

Sensitivity was 89% and 100% for the three-point and four-point affine warp algorithms, respectively. Specificity for both algorithms was 100%.

CONCLUSIONS

The data indicate that semiautomated alignment algorithms may enhance the efficacy of digital subtraction radiography while maintaining diagnostic efficacy in clinical trials.

Expression and functional expansion of fibroblast growth factor receptor T cells in rheumatoid synovium and peripheral blood of patients with rheumatoid arthritis

OBJECTIVE

Rheumatoid arthritis (RA) is an inflammatory disorder of the diarthroidial joints, characterized by fibroblast proliferation, angiogenesis, and perivascular CD4+ T cell infiltration. The present study examined the interactions between fibroblast growth factor-1 (FGF-1) and T cells.

METHODS

Synovial tissues from patients with RA or noninflammatory arthritis were examined for the expression of FGF-1 and its receptor, FGFR-1, by immunohistology and reverse transcriptase-polymerase chain reaction. Functional assays were used to detect enrichment of FGF-1-responsive peripheral CD4+ T cells in RA.

RESULTS

FGF-1 is abundantly expressed by rheumatoid synovium. Enhanced expression of its receptor, FGFR-1, was found in perivascular CD4+ T cells. In addition, T cells that are activated by FGF-1 are increased in the peripheral blood of patients with RA, as compared with other inflammatory conditions.

CONCLUSION

The increased frequency of peripheral T cells that respond to FGF-1 in RA is consistent with expansion of FGFR-1-expressing T cells in the rheumatoid synovium.