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Conservative calculations estimate that approximately 107,000 patients are hospitalized annually for nonsteroidal anti-inflammatory drug (NSAID)-related gastrointestinal (GI) complications and at least 16,500 NSAID-related deaths occur each year among arthritis patients alone. The figures for all NSAID users would be overwhelming, yet the scope of this problem is generally under-appreciated. The Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) Post-Marketing Surveillance Program (PMS) has prospectively followed patient status and outcomes, drug side effects, and the economic impact of illness for [is greater than] 11,000 arthritis patients at 8 participating institutions in the United States and Canada. Analysis of these data indicates that: (1) osteoarthritis (OA) and rheumatoid arthritis (RA) patients are 2.5-5.5 times more likely than the general population to be hospitalized for NSAID-related GI events; (2) the absolute risk for serious NSAID-related GI toxicity remains constant and the cumulative risk increases over time; (3) there are no reliable warning signals-[is greater than] 80% of patients with serious GI complications had no prior GI symptoms; (4) independent risk factors for serious GI events were age, prednisone use, NSAID dose, disability level, and previous NSAID-induced GI symptoms; and (5) antacids and [H.sub.2] antagonists do not prevent NSAID-induced gastric ulcers, and high-risk NSAID users who take gastro-protective drugs are more likely to have serious GI complications than patients not taking such medications. Currently, limiting NSAID use is the only way to decrease the risk of NSAID-related GI events. Ongoing ARAMIS research is aimed at developing a simple point-score system for estimating individual risks of developing serious NSAID-related GI complications. Am J Med. 1998;105(1B):31S-38S. [C] 1998 by Excerpta Medica, Inc.

We performed a randomized controlled trial to evaluate the effectiveness of a patient education and health promotion program in the treatment of Parkinson's disease. The health promotion program (PROPATH) was designed to improve health confidence, provide information and support, improve physical function through exercise, and work with the physician to optimize medical treatment and compliance. The intervention was delivered by mail, with disease assessment questionnaires completed by patient or caregiver at 0, 2, 4, and 6 months, with computer-generated reports and individualized recommendation letters returned to patients and reports to physicians. Two hundred ninety patients completed the 6-month trial, 140 patients in the intervention group and 150 in a control group of patients who received only questionnaires. The intervention group had significantly increased exercise, decreased 'time off' and percentage of time off, reduced side effects, and decreased summary Parkinson's scores by approximately 10% (P >0.05). Twelve of 13 variables showed differences favoring the intervention group. The rate of progression of summary scores became essentially flat during the program for the intervention group and continued to rise sharply for controls (P >0.01). Levodopa dose rose for controls and slightly decreased for the intervention group. Doctor visits, hospital days, and sick days were reduced in the intervention group. The quality-of-life assessment demonstrated improvement in patient global, self-efficacy scores, and spouse or caregiver assessments. We conclude that a low-cost patient education program provides a useful adjunct to medical therapy of Parkinson's disease, may reduce costs, and can improve intermediate term outcomes.

* Objective: To determine, by longitudinal study, whether regular vigorous running activity is associated with accelerated, unchanged, or postponed development of disability with increasing age. * Study Design: 8-year prospective, longitudinal study with yearly assessments. * Participants: 451 members of a runners' club and 330 community controls who were initially 50 to 72 years old (also characterized as 'ever-runners' [n = 534] and 'never-runners' [n = 247], respectively). * Measurements: The dependent variable was disability as assessed by the Health Assessment Questionnaire and separately validated in these participant cohorts. Covariates included age, sex, body mass index, comorbid conditions, education level, smoking history, alcohol intake, mean blood pressure, initial disability level, family history of arthritis, and radiologic evidence of osteoarthritis of the knee in a subsample. * Results: initially, the runners were leaner, reported joint symptoms less frequently, took fewer medications, had fewer medical problems, and had fewer instances of and less severity of disability, suggesting either that the average previous 12 years of running had improved health or that self-selection bias was present. After 8 years of longitudinal study, the differences in initial disability levels (0.026 compared with 0.079; P < 0.001) had steadily increased to 0.071 for runners compared with 0.242 for controls (P < 0.001). The difference was consistent for men and women. The rate of development of disability was several times lower in the runners' club members than in community controls; this difference persisted after adjusting for age, sex, body mass, baseline disability, smoking history, history of arthritis, or other comorbid conditions slopes of progression of disability for the years 1984 to 1992, after adjusting for covariates: men in the runners' club, 0.004 [SE, 0.002]; community controls, 0.012 [SE, 0.0021; women in the runners' club, 0.009 [SE, 0.005]; community controls, 0.027 [SE, 0.004]; P < 0.002 for both sets of comparisons). In addition to differences in disability, there were significant differences in mortality between the runners' club members (1.49%) and community controls (7.09%) (P < 0.001). These differences remained significant after adjusting for age, sex, body mass, comorbid conditions, education level, smoking history, alcohol intake, and mean blood pressure (P < 0.002, conditional risk ratio for community controls compared with the runners, 4.27; 95% Cl, 1.78 to 10.26). * Conclusions: Older persons who engage in vigorous running and other aerobic activities have lower mortality and slower development of disability than do members of the general population. This association is probably related to increased aerobic activity, strength, fitness, and increased organ reserve rather than to an effect of postponed osteoarthritis development., Running for exercise may delay musculoskeletal disability in older persons. Among 781 people between 50 and 72 years old at the beginning of an eight-year study, 451 were members of a runners' club and 330 were selected from the community for a comparison group. Researchers also classified the study participants as ever-runners (534) and never-runners (247). Functional disability was assessed annually by means of a questionnaire. Runners' club members and ever-runners showed little increase in disability over the eight years, while nonrunners had a significant increase. These differences remained even when researchers adjusted the data for age, gender, body mass, initial disability, smoking history, and history of arthritis or other illnesses. Both runners and nonrunners had x-ray evidence of similar increases in osteoarthritis. Therefore, the lower disability rate among runners is probably due to improved conditioning and cardiovascular health.

Background: Aspirin therapy has been largely superseded by prescription nonsteroidal anti-inflammatory drug (NSAID) therapy in rheumatoid arthritis, in part because of premarketing studies suggesting lesser toxic effects for NSAIDs than for aspirin. This study evaluates these toxic effects in a postmarketing population of patients with rheumatoid arthritis. Methods: We studied 1521 consecutive courses of aspirin and 4860 courses of NSAIDs in patients with rheumatoid arthritis from eight Arthritis, Rheumatism, and Aging Medical Information System Post-marketing Surveillance Centers. Toxicity index scores were generated from symptoms, laboratory abnormalities, and hospitalizations, weighted for variable severity and severity of side effect. Results: The toxicity index was only 1.37 (SE=0.10) for aspirin and 1.87 to 2.90 for selected nonsalicylate NSAIDs. These differences were consistent across centers and remained after statistical adjustment for differing patient characteristics. There was a different toxicity with different aspirin preparations, with a score for plain aspirin of 1.36 (SE=0.23), for buffered aspirin of 1.10 (0.20), and for enteric-coated aspirin preparations of 0.92 (0.14). Most important, there were strong dose effects, with a score of 0.73 (0.09) for 651 to 2600 mg daily, 1.08 (0.17) for 2601 to 3900 mg, and 1.91 (0.38) for more than 3900 mg. The average aspirin dose taken was only 2665 mg/d, approximately eight 'tablets,' compared with 3600 to 4800 mg/d used in the 16 pivotal premarketing studies reviewed. Average NSAID doses were, on the other hand, lower in premarketing trials (eg, naproxen 500 mg/d vs 773 mg/d in the Arthritis, Rheumatism, and Aging Medical System clinical practices). Conclusions: Aspirin therapy, in doses commonly employed in practice, has an excellent safety profile in rheumatoid arthritis, and it is the least costly NSAID. The safety advantage is explained primarily by a dose effect and secondarily by possible differences between formulations. Newer management strategies for rheumatoid arthritis emphasize NSAID use as symptomatic therapy and use of disease-modifying anti-rheumatic drug therapy for anti-inflammatory objectives. Thus, the original recommendation for 'anti-inflammatory' doses of aspirin now is less easily justified. Aspirin therapy merits reconsideration as adjunctive therapy for the management of rheumatoid arthritis.

A study is conducted to investigate that whether the increased risk of serious gastrointestinal (GI), which is associated to exposure to non-steroidal anti-inflammatory drugs (NSAIDs), is sustained over time. Result shows small decrease in risk over time, which are of negligible clinical importance, while also suggesting that for patients who need long-term treatment, precautionary measures are to be considered to reduce the net probability of serious GI events over the anticipated treatment duration.

John B Wong, MD(*); Jared D Schettler, MS; Dena Ramey, BA and Gurkirpal Singh, MD. Clinical Decision Making, Tufts-New England Medical Center, Boston, MA and Medicine and Biostatistics, Stanford University [...]

The majority of diabetes care is delivered in the primary care setting. Studies reveal large gaps between recommended standards of diabetes care and current practices in these settings. We have [...]