OBJECTIVES:Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used, but have potentially serious adverse effects. We investigated the knowledge of patients with inflammatory arthritis with regards to risks associated with the combination of prescribed and over-the-counter (OTC) NSAIDs, of differences in side effects between acetaminophen and NSAIDs, and from which sources patients received information about side effects. METHODS:Data from 170 questionnaires provided to consecutive patients with inflammatory arthritis at a rheumatologic outpatient clinic were collected through questionnaires (response rate 75%). RESULTS:Eighty-seven percent of patients had taken prescribed NSAIDs or OTC analgesics during the previous 2 weeks, 36% being NSAIDs, and 36% used analgesics regularly. Fifty-four percent would increase the dose of drugs in a bad period, and they were more likely to over-use the OTC drugs than the prescribed drugs (P = 0.002, Mann-Whitney). Factors recognized to increase the risk of side effects were: higher dose (81% of patients), long-term treatment (68%), previous side effects (57%), combination of NSAIDs (49%), and old age (31%). Twenty-three percent assumed that acetaminophen increased the risk of side effects. Information was obtained from package inserts (84%), the rheumatologist (80%), and the general practitioner (50%). They had greatest confidence in the rheumatologist, package leaflets, and the general practitioner. CONCLUSION:Incomplete knowledge and misconceptions of some patients suggests that more information on risk factors and side effects to NSAID treatment is needed to improve patient safety. This is especially true about the combination of prescribed and OTC drugs.

A consecutive group of 169 patients with acute hepatitis found negative for hepatitis B surface antigen (HBsAg) and negative for IgM antibody against hepatitis A (anti-HAV IgM) was studied for presence of IgM antibody against hepatitis B core antigen (anti-HBc IgM) by ELISA. Anti-HBc IgM was found in a total of 34 of 60 patients with detectable total anti-HBc. One hundred and nine patients had no detectable anti-HBc IgM and no total anti-HBc and were thus considered as having acute non-A, non-B hepatitis. Among the 34 patients with anti-HBc IgM in their first serum sample, 23 were anti-HBs negative and all had high and steadily decreasing ratio unit (RU) values for anti-HBc IgM (mean RU value 17.1). Twelve of the 23 patients showed seroconversion to anti-HBs during the follow-up, indicating an actual hepatitis B virus infection. Eleven of the 34 anti-HBc IgM positive patients had anti-HBs in their first serum sample. In this group, the RU values for anti-HBc IgM were high and steadily declining and the initial values were significantly lower (mean RU value 9.9) (p less than 0.05) than in the anti-HBs negative group. Evidence is provided that anti-HBc IgM in serum from patients with HBsAg negative hepatitis with or without anti-HBs indicates an actual hepatitis B virus infection. According to generally accepted criteria, the demonstration of anti-HBc IgM identified 20% of the 169 patients with acute non-A, non-B hepatitis as having an actual hepatitis B infection.

STUDY DESIGN A 15-year follow-up study. OBJECTIVE To find risk indicators for self-reported sick-listing because of low back trouble and to evaluate which variables were the most important indicators of work incapacity resulting from low back trouble during the follow-up period of 15 years. SUMMARY OF BACKGROUND DATA The initial data were obtained from a health survey conducted in a general population from the Municipality of Glostrup, Denmark. The follow-up data included information from the Central Person Register, the Early Retirement Pension Register, and a postal questionnaire regarding self-reported sick-listing because of low back trouble. METHODS An epidemiologic study, in which logistic regression analyses were used for evaluation of the data. The model used consisted of the variable in question, age, gender, and previous experience of low back trouble, along with interactions. RESULTS It was found that 22 of 37 variables were risk indicators for later self-reported sick-listing because of low back trouble during the preceding year or the 7 years before the date of follow-up evaluation. In analyzing the most significant variables simultaneously, it was found that information from the initial investigation about sick-listing in general during the previous 10 years, sciatic pain, use of analgesics for low back trouble, previous sick-listing because of low back trouble, and occupation were the most important risk indicators for self-reported work incapacity resulting from low back trouble during the follow-up period of 15 years. CONCLUSION Findings showed that the strongest prognostic indicators of later sick-listing because of low back trouble involve information from the person about previous sick-listing behavior in general and previous experience of low back trouble episodes, especially if these had been accompanied by sciatic pain, use of analgesics, or previous low back trouble sick-listing.

One thousand and fifty-eight conscripts participating in an investigation of back problems among conscripts in 1979-80 were re-examined 12 years later with an identical questionnaire concerning back problems. The questionnaire was answered by seven hundred and eighty-four persons (74%). The lifetime prevalence for low-back trouble was 73%, the one-year prevalence 53% and the point prevalence 26%. At the time of follow-up the incidence of low-back trouble depended on ever having had back pains and on having an X-ray made because of back problems. The probability for sick leave from work caused by lowback trouble was increased when back troubles had been reported at the time of the initial investigation. A significant amount of the conscripts that had been rejected due to back problems (60%) had been unfit for work because of low-back trouble in the follow-up period, and 95% of them had had low-back trouble in the year before follow-up, compared to 51% of the other conscripts. Previous back trouble increases the risk of getting back trouble once again. The risk of sick leave from work caused by low-back trouble increases with the incidence of back trouble up to the investigation in 1979-80. Rejection from service due to back problems increases the risk of later low-back trouble and sick leave from work caused by low-back troubles.

OBJECTIVE:To identify risk indicators for granting of disability pension (DP) during a period of 15 years.DESIGN:Follow-up study. The initial data were obtained from a health survey in a general population 1977/78. Variables were initially collected through questionnaires and objective measurements. Information about the end-point for the follow-up, granting of DP, was obtained from the Registry for Early Retirement Pension in 1992/93. Data analyses were performed by logistic regression and Cox analyses.SETTING:The Glostrup Population Studies, Glostrup University Hospital and The Danish Committee for the Assessment of Substandard Lives.POPULATION:General population of 892 persons, born in 1918, 1928, 1938, and 1948, and living in the municipality of Glostrup, Denmark. Eighty-four were granted DP during the 15 years follow-up.RESULTS:Ninety-six variables from the initial study were analysed, age and 18 variables were found to be risk indicators for DP. These were general health variables, including dyspnoea, colic, nervousness, previous hospitalizations and operations, self-reported poor general health the last year, and low general health risk-score by the doctor. Objective measurements included high Body Mass Index, low peak flow and isometric endurance of the back muscles. Among the occupational variables unemployment and sick leave were found to be risk indicators. In addition, low physical activity in leisure time, self-reported worse physical condition than those at the same age and smoking were also identified as risk indicators.CONCLUSION:The main indicators for granting of DP can be covered by the heading poor physical condition and general health.

OBJECTIVES:To compare the clinical effectiveness of an intensive three-month training programme with a less intensive programme on females suffering from chronic neck/shoulder pain. STUDY DESIGN:A prospective observer-blinded clinical trial including 12-month pretreatment follow-up. SETTING:Patients were referred to the Departments of Rheumatology and Physical Medicine at Hvidovre Hospital by their general practitioners. Training was undertaken at a satellite clinic for physiotherapy of Hvidovre Hospital. SUBJECTS:Female patients aged 18-65 years suffering from chronic neck/shoulder pain for a minimum of six months. INTERVENTION:Patients were examined by a physician in order to exclude serious diseases. They were then randomized to either an intensive neck/shoulder training programme or a programme of lesser intensity but of similar duration. MAIN OUTCOME MEASURES:Scales measuring pain and activities of daily living (ADL) were used, and strength and endurance measurements of the cervical and shoulder muscles were carried out at baseline and completion of the study. Follow-up measurements were carried out by postal questionnaire at 6 and 12 months after inclusion, and included pain, ADL and treatment satisfaction measurements. RESULTS:Seventy-seven patients were included in the trial, of whom 27 (69%) completed the intensive programme and 25 (61%) the lighter programme. Forty-one (>80%) completed the follow-up questionnaires. The patients in the two groups did not differ with regard to age, pain, ADL scores and physical measurements prior to training. Patients in both groups that completed the trial demonstrated statistically significant improvements in nearly all of the outcome measurements at completion. ADL scores maintained statistical significance at 12 months in both groups, but pain scores were only significantly improved in the intensive group at 12 months follow-up. There was no statistically significant difference between groups regarding pain or ADL, but overall 50% of all patients showed improvement. CONCLUSIONS:The type of low-tech dynamic training used in either of our two programmes resulted in both subjective and objective improvements in patients suffering from chronic neck/shoulder pain, but there were no statistically significant differences in outcome between the two approaches. The subjective improvements were maintained throughout the follow-up period.

Different training models are effective for the treatment of chronic low back pain, but no consensus has been found. Earlier studies have emphasized training of spinal mobility and back strength. To evaluate if other physiological parameters, such as coordination, are of equal importance, we performed a randomized trial on 40 consecutive patients with chronic low back pain. Two training models were compared: 1) intensive training of muscle endurance and 2) muscle training, including coordination. In both groups, training was performed 1 hour twice a week for 3 months. Pain score, disability score, and spinal mobility improved in both training groups without differences between the two groups. Only intensive training of muscle endurance improved isokinetic back muscle strength. At study entry, we found a significant correlation between spinal mobility and dysfunction, but after the training, no correlation was found between improvement of spinal mobility or isokinetic back extension strength and improvement of function or pain level. We conclude that coordination training for patients with chronic low back pain is as equally effective as endurance training.

The changes in MR-determined synovial membrane volume, early synovial enhancement, and cartilage and bone erosions after osmic acid knee synovectomy were studied. Gadolinium-DTPA enhanced magnetic resonance imaging (MRI) of 18 knees with persistent arthritis was performed before and 1 month after treatment. The synovial membrane volume was significantly reduced (median -52%) in all 9 patients brought into clinical remission (p<0.01), while no significant change was found in patients with clinical relapse. The early synovial enhancement was not significantly changed. MRI revealed progressive erosive changes in 2 patients. The lime of relapse was correlated to a MR-erosion score, but not to early synovial enhancement or volumes of synovium or effusion (Spearman tests). MRI-deternined synovial membrane volumes and early synovial enhancement may be objective quantitative markers of inflammation. MR-scores of cartilage and bone erosions are sensitive to progressive changes occurring within a month.

In a chronic inflammatory disease as rheumatoid arthritis, the local processes in the affected tissues lead to destruction of the joint. When estimating the inflammatory activity in rheumatic joint diseases, a major problem is the rather unspecific and indirect character of the biochemical and the crude character of the clinical measures used.

OBJECTIVE:We performed a randomised trial to evaluate if intensive supervised training of the back should be offered to all patients after a first lumbar diskectomy.METHODS:Forty consecutive patients were, after a first lumbar diskectomy, randomly allocated to 2 groups undergoing "supervised training" twice a week for 3 months in an outpatient clinic or "home training" after 2 hours of instruction.RESULTS:The two rehabilitation models both showed a significant effect on spinal mobility, isokinetic trunk flexion strength, isokinetic trunk extension strength and daily function. These improvements were unchanged at follow up 3 months later. The pain score remained unchanged, however, throughout the trial in both groups. No differences in effect between the two rehabilitation models could be found for any of the assessed parameters. Thirteen patients did not complete the trial, including 9 from the supervised endurance trained group, mainly because of increased pain and reprolaps (n = 4). Four patients dropped out of the home trained group, only one because of increased pain. The differences in drop-out rate and training side effects were, however, not statistically significant.CONCLUSION:We conclude that it is not worthwhile to implement 3 months of supervised intensive endurance training as opposed to home training in all cases of first lumbar diskectomy, although a beneficial effect and better compliance might be found for a selected group of such patients.

The incidence, severity and potential disability of low back pain are related, in particular, to previous back complaints, heavy lifting and the general psychosocial environment and to the physical constitution of the individual, viz the endurance of his back muscles. Recommendations for approach to the problem in future are discussed.

OBJECTIVES--To compare the effects of hydroxychloroquine and sulphasalazine alone and in combination in rheumatoid arthritis. METHODS--A six month randomised, multicentre, double blind trial with three parallel groups was performed. Ninety one outpatients with active rheumatoid arthritis were included. Monthly assessments of erythrocyte sedimentation rate, morning stiffness, number of swollen joints, a pain score, and global assessments were carried out. Radiographs of hands and wrists were taken before and after the trial. RESULTS--Sixty two patients completed the study. The 29 withdrawals caused no evident bias, and there was no difference in side effects among the three groups. All variables improved significantly with time. Patients treated with a combination of hydroxychloroquine and sulphasalazine responded better and faster than those treated with hydroxychloroquine alone, but there was no statistically significant difference between the combination treatment and single drug treatment with sulphasalazine or between treatment with hydroxychloroquine and sulphasalazine given alone. CONCLUSION--The present results do not support a recommendation to use a combination of hydroxychloroquine and sulphasalazine in the treatment of rheumatoid arthritis.

Forty-seven women with osteoporotic fractures of the spine were examined consecutively. The age range was 64-91 years with a median of 77 years. Risk factors for osteoporosis such as induced menopause or gastric resection were not present. Four patients had had rheumatoid arthritis. 19% had been treated with glucocorticoid. Only one patient had received long-term oestrogen treatment. The patients had been physically very active at a younger age and 91% had been occupationally employed. The symptoms frequently commenced with a fall or strain by lifting at home. The average period of hospitalization was 22 days. Thirty-four patients were followed-up after 6-12 months. All of them experienced pain and 74% still took analgesics. Fifteen out of the 19 patients who had been fitted with a supportive corset still employed this.

OBJECTIVE:To assess whether monthly treatment with intravenous methylprednisolone enhances or accelerates the effect of disease modifying drugs in patients with rheumatoid arthritis.DESIGN:A 12 month double blind, placebo controlled, multicentre trial in which patients with active rheumatoid arthritis were randomly allocated to receive pulses of either methylprednisolone or saline every four weeks for six months. At the start of the pulse treatment all patients were started on penicillamine or azathioprine.SETTING:Four rheumatology departments in Denmark.PATIENTS:97 Patients (71 women, 26 men) aged 23-84 (mean 60) who had active rheumatoid arthritis of at least four weeks' duration despite treatment with non-steroidal anti-inflammatory drugs.MAIN OUTCOME MEASURES:Monthly clinical recording of morning stiffness, number of tender and swollen joints, blinded observers' evaluation of therapeutic effect, and patients' self assessed condition. Concomitant laboratory measurements of erythrocyte sedimentation rate and concentrations of C reactive protein and haemoglobin. Radiography to determine the number of erosions at the start of treatment and after 12 months.RESULTS:57 Patients completed the trial, taking the same disease modifying drug throughout. Evaluation four weeks after each pulse treatment and at 12 month follow up showed no significant differences between the methylprednisolone and placebo groups in any of the clinical or laboratory variables. Radiography showed the same degree of progression of erosions in both groups. Evaluation of the total data on 97 patients and on the 57 who completed the trial showed the same lack of significance between the treatment groups.CONCLUSIONS:Intravenous pulse treatment with steroids can be recommended only for rapid temporary relief of flares of disease in patients with rheumatoid arthritis. The response is short lived. Repeated pulses of methylprednisolone at four week intervals do not improve the results of treatment with drugs that induce remission such as penicillamine and azathioprine.

Reactivation of hepatitis B virus replication was investigated in an unselected group of 44 HBV DNA negative, anti-HBe positive chronic HBsAg carriers. Twenty-five patients (54%) were intravenous drug addicts and 7 (16%) were male homosexuals. Sixteen patients had evidence of delta infection and five of the seven male homosexuals had human immunodeficiency virus infection. The patients were followed for 1 to 180 months (median, 24 months) while HBV DNA negative, anti-HBe positive. Reactivation, defined as reappearance of HBV DNA or HBeAg, or both, was detected in six patients corresponding to an annual reactivation rate of 5%. Reactivation in four patients was detected by reversion to HBV DNA positivity only, whereas HBeAg/anti-HBe status remained unchanged. Two patients became both HBV DNA and HBeAg positive. None of the patients developed hepatitis-like symptoms and transaminase elevation was only observed in two patients. Reactivation in two patients was ascribed to human immunodeficiency virus infection and in one patient to chronic lymphatic leukaemia. It is concluded that HBV DNA seems to be superior to HBeAg in the detection of reactivation of HBV replication and that reactivation associated with clinical symptoms leading to progression in chronic liver disease is a rare event in the population studied.

An anonymous questionnaire investigation involving 393 rheumatological patients showed that 185 patients (47%) had tried alternative treatment (52% of the women and 33% of the men). The three forms of treatment most commonly employed were chiropractor treatment, zone therapy and acupuncture. The 185 patients had, on an average, tried 2.2 types of treatment and 30% had tried more than two forms of treatment. One third of the patients had tried alternative treatment before or simultaneously with medical treatment while the remaining 2/3 had received medical treatment from weeks up to several years. The sources of information about alternative treatment were, most frequently, friends and relatives (70%) while in 16%, the general practitioner was the source. Only 58% replied to the question about the effect of the alternative treatment. Out of these, 56% had experienced improvement, 41% stated that there was no effect and 2% stated that deterioration had occurred. On an average, the patients had employed 2,444 Danish crows (approximately 200 pounds) for the alternative treatment. In addition, 6% stated that had spent more than 10,000 Danish crowns (approximately 833 pounds). It is concluded that alternative treatment frequently constitutes a considerable economical stress for the patients. Greater frankness and a increased level of information about the alternative forms of treatment are necessary.