***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: OBJECTIVE We previously reported that monthly telephone contact by lay personnel , to promote self-care for patients with osteoarthritis ( OA ) , was associated with improved joint pain and physical function after 1 year of followup . The present study was a secondary analysis to determine whether improvement was contingent on intensified medical treatment . METHODS We reanalyzed control/treatment group differences in all 40 subjects with radiographically confirmed knee OA who had had no changes in antirheumatic drug therapy or institution of physical therapy during the period of observation . RESULTS Group differences in measured pain remained significant ( effect size [ ES ] = 0.65 SD , P less than 0.01 ) . The same trend was observed for physical function ( ES = 0.53 SD , P not significant ) . CONCLUSION The findings in this re analysis suggest that periodic telephone support interventions are effective enough to be regarded as an adjunctive treatment for OA OBJECTIVE The purpose of this study was to investigate the efficacy of acupuncture as an adjunctive therapy to st and ard care for the relief of pain and dysfunction in elderly patients with osteoarthritis ( OA ) of the knee . METHODS Seventy-three patients with symptomatic OA of the knee were r and omly assigned to treatment ( acupuncture ) or st and ard care ( control ) . Analysis was performed on last score carried forward to account for patients who dropped out before completion . Patients self-scored Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) and Lequesne indices at baseline and at 4 , 8 and 12 weeks . Patients in the control group were offered acupuncture treatment after 12 weeks . The data for these patients are pooled with those from the original acupuncture group for within-group analysis . RESULTS Patients r and omized to acupuncture improved on both WOMAC and Lequesne indices compared to those who received st and ard treatment alone . Significant differences on total WOMAC Scale were seen at 4 and 8 weeks . There appears to be a slight decline in effect at 4 weeks after cessation of treatment ( 12 weeks after first treatment ) . No adverse effects of acupuncture were reported . CONCLUSION These data suggest that acupuncture is an effective and safe adjunctive therapy to conventional care for patients with OA of the knee OBJECTIVE To evaluate the cost-effectiveness of telephone intervention for patients with osteoarthritis . METHODS R and omized , controlled trial . RESULTS The intervention did not significantly increase health care costs . The annual costs for a 1-unit improvement in physical functioning and in pain , as measured by the Arthritis Impact Measurement Scales , were $ 70.86 and $ 31.00 , respectively . CONCLUSION Telephone contact is a potentially cost-effective intervention in osteoarthritis OBJECTIVE The effects of treatment counseling or symptom monitoring telephone intervention strategies on the health outcomes of patients with rheumatoid arthritis ( RA ) or osteoarthritis ( OA ) , compared with usual care , were assessed . METHODS A 3-group , r and omized , controlled 9-month trial was conducted incorporating 405 patients with RA or OA and using the Arthritis Impact Measurement Scales ( AIMS 2 ) as the outcome measure . RESULTS Analyses of covariance showed that the AIMS 2 total health status of the treatment counseling group ( effect size = 33 , P < 0.01 ) , but not the symptom monitoring group ( effect size = 0.21 , P = 0.10 ) , was significantly improved , compared with usual care , for both RA and OA patients . The specific types of benefits differed significantly between RA and OA patients . The mean number of medical visits by OA patients in the treatment counseling group was also significantly reduced ( P < 0.01 ) . CONCLUSION Telephone contact using the treatment counseling strategy produced significant , but different , health status benefits for RA and OA patients . The symptom monitoring strategy produced modest benefits Approximately 14 million patients in the United States regularly take nonsteroidal anti-inflammatory drugs(NSAIDs ) for various types of arthritis [ 1 ] for relief of pain , stiffness , and other symptoms . However , these benefits are obtained at a price . Use of NSAIDs is associated with various gastrointestinal side effects . Minor side effects such as nausea , dyspepsia , anorexia , abdominal pain , flatulence , and diarrhea may affect 10 % to 60 % of patients [ 2 ] . Symptomatic ulcers and potentially life-threatening ulcer complications such as upper gastrointestinal bleeding , perforation , and gastric outlet obstruction are reported in 2 % to 4 % of patients who take NSAIDs for a year [ 3 ] . The chance of hospitalization or death from a gastrointestinal adverse event is 1.3 % to 1.6 % per year in patients with rheumatoid arthritis [ 4 ] . These infrequent but potentially serious gastrointestinal side effects of NSAIDs have become a major health care problem because of the many patients at risk [ 5 ] . General physicians and rheumatologists caring for patients with symptoms of chronic arthritis may be reluctant to ab and on using NSAIDs , which help most of these patients , in order to protect the few who may develop serious complications from use of these drugs . On the other h and , gastroenterologists see fewer patients for arthritis but many with serious gastrointestinal complications . Life-threatening events such as perforation or serious hemorrhage from NSAID-induced ulcers , which often develop with little or no warning [ 6 ] , are a real problem because of the many patients at risk . Various agents have been used in attempts to reduce the incidence of NSAID-induced gastrointestinal lesions . In one endoscopic study , cimetidine at a dose of 300 mg four times a day showed no benefit in healing NSAID-related lesions compared with placebo , and 400 mg at bedtime provided no benefit in preventing these lesions compared with placebo [ 7 ] . Antacids ( magnesium-aluminum hydroxide , 10 to 20 mL as needed to a dose as high as 60 mL daily ) and sucralfate have recently been reported to reduce dyspeptic symptoms in arthritic patients receiving NSAIDs in whom gastropathic lesions ( but not ulcers ) were shown endoscopically [ 8 , 9 ] . The surface-active antiulcer drug sucralfate was ineffective in preventing ulcers in persons receiving NSAIDs [ 10 , 11 ] , and the histamine-2-receptor antagonist ranitidine did not prevent gastric ulcers but did reduce the frequency of duodenal ulcers [ 12 , 13 ] . Results of preliminary studies indicate that the effects of omeprazole parallel those of ranitidine [ 14 ] . A recent study [ 15 ] in achlorhydric patients showed that NSAID-induced ulcers develop in the absence of gastric acid . In contrast , several clinical trials have shown that the incidence of endoscopically visible erosions and ulcers associated with NSAID use can be reduced by cotherapy with the synthetic prostagl and in misoprostol [ 16 - 19 ] . However , it was not proved that preventing endoscopic lesions would prevent clinical ly serious complications of NSAID-induced gastrointestinal ulcers [ 20 ] . Our objective was to determine whether concurrent therapy with misoprostol reduces the incidence of serious upper gastrointestinal complications in older patients with chronic rheumatoid arthritis who are taking NSAIDs .  Because most patients taking NSAIDs do not routinely have endoscopy , we investigated the incidence of these complications during clinical care as actually practice d. A second goal was to better define which patients were at increased risk for development of serious NSAID-induced upper gastrointestinal complications . Methods Patients Ambulatory patients at least 52 years of age who had chronic rheumatoid arthritis , defined by American College of Rheumatology criteria [ 21 ] , and who were expected to be taking 1 of 10 specified NSAIDs at predefined minimum doses for 6 months were sought from practice s of family medicine , internal medicine , or rheumatology . Of these practice s , 661 in the United States and 3 in Canada enrolled at least one patient between July 1991 and August 1993 . For all patients , a medical history was elicited , a physical examination was done , and a modified Health Assessment Question naire that included eight items on activities of daily living was administered [ 22 ] . Patients were excluded if they had had active peptic ulcer disease within 30 days of study enrollment ; were taking or expected to need antiulcer medication ( histamine-2 blockers , sucralfate , omeprazole ) or any experimental medication during the study ; had the Zollinger-Ellison syndrome , pyloric or duodenal obstruction , previous gastric resection or vagotomy , gastroesophageal reflux disease , varices , or cirrhosis ; had a history of inflammatory bowel disease , upper gastrointestinal tract malignancies , hepatitis , alcoholism , or bleeding diathesis ; were estimated to have a life expectancy of less than 8 months or had do-not-resuscitate status ; were women of child-bearing potential ; or could not tolerate misoprostol or any prostagl and in . The following were the minimum NSAID doses ( mg/d ) allowed : aspirin , 2000 ; diclofenac , 100 ; flurbiprofen , 200 ; ibuprofen , 1200 ; indomethacin , 75 ; ketoprofen , 150 ; naproxen , 750 ; piroxicam , 20 ; sulindac , 200 ; or tolmetin , 1200 . Patients were allowed to receive more than one NSAID . Intervention Eligible patients were r and omly assigned to receive either misoprostol or placebo in the form of 200- micrograms tablets from coded bottles supplied by the manufacturer . Patients were r and omly assigned in blocks of four , so that in each block , half the patients would receive misoprostol and half would receive placebo . Because blocks were assigned to investigators , patients were r and omly assigned within the individual centers . Investigators were not informed about the r and omization procedure but were told only that the study was r and omized and double-blind . Patients were instructed to begin taking half a tablet with meals and at bedtime each day for 10 days and then , if the drug was tolerated , to increase the dose to a whole tablet four times a day for the rest of the study . If the drug was not tolerated , the patients were instructed to reduce the dose back to half a tablet four times a day . Patients could continue therapy with arthritis disease-modifying agents ( such as gold or corticosteroids ) and were allowed to take antacids that did not contain magnesium . Patients purchased their own arthritis medications or antacids and reported their consumption when seen monthly for examination and counts of study medication tablets . Physicians were instructed to watch closely for clinical signs of gastrointestinal bleeding or other possible gastrointestinal complications , to inquire about symptoms , and to investigate suspicious episodes by appropriate clinical procedures . Outcome Measures All suspicious events , regardless of presumed cause , were to be reported , along with all available patient data , to the study medical officer ( HWD ) and then to an external review committee . This committee consisted of a gastroenterologist ( FS ) , a rheumatologist ( Kenneth Br and t , MD , Indiana University ) , and an epidemiologist ( Marie Griffin , MD , MPH , V and erbilt University ) . The committee determined , without unblinding the r and omization code , whether the patient had upper gastrointestinal bleeding ; other ulcer complications ; or a problem such as hemorrhoids , diverticulitis , colon polyps , or cancer . It developed definitions of what were considered to be complications related to NSAID use and categories of such complications . The committee reached consensus and assigned such events to one of the following categories of definite upper gastrointestinal complications : 1 . perforated ulcer , proved at surgery ; 2 . gastric outlet obstruction caused by proven ulceration and stricture , proved by endoscopy ; 3 . hematemesis , with endoscopically proven gastric or duodenal ulceration or erosion ; 4 . active or recent visualized bleeding from endoscopically proven ulceration or erosion ; 5 . melena , with endoscopically proven ulceration or erosion ; 6 . heme-positive stool , with endoscopically proven ulceration or erosion , plus either a ) a decrease in hematocrit of at least 0.05 or b ) orthostatic change in the pulse rate ( from sitting to st and ing ) of at least 20 beats per minute or decrease in  systolic blood pressure of at least 20 mm Hg and a decrease in diastolic blood pressure of 10 mm Hg ; 7 . hematemesis  , without endoscopically proven ulceration or erosion  ; and 8 . melena , with heme-positive stool and without endoscopically proven ulceration or erosion . The committee also defined categories of events not involving clinical ly significant bleeding : 9 . report of melena with no other data ; 10 . heme-positive stools , with endoscopically proven ulceration or erosion and without active bleeding ; and 11 . report of melena and heme-negative stools when the stools were tested . Sample Size Calculation and Statistical Methods The placebo group was expected to have an incidence of serious NSAID-induced upper gastrointestinal complications of about 2 % per 
    Output:
    
Furthermore , the risk for a catastrophic gastrointestinal event in elderly patients taking NSAIDs  is dose dependent ( 18 ) .
Celecoxib has been found to be more effective than placebo and as effective as naproxen for symptoms in patients with hip or knee osteoarthritis ( 27 - 29 ) .
Rofecoxib has also been found to be more effective than placebo and is comparable in efficacy to both ibuprofen and diclofenac in patients with hip or knee osteoarthritis ( 30 , 31 ) .
A further advantage of COX-2specific inhibitors with respect to upper gastrointestinal bleeding is that celecoxib and rofecoxib do not have a clinical ly significant effect on platelet aggregation or bleeding time .
In addition , at doses recommended for treatment of osteoarthritis , these drugs appear to be better tolerated than comparator nonselective NSAIDs , with a lower incidence of dyspepsia and other gastrointestinal side effects .
As with nonselective NSAIDs , however , COX-2specific inhibitors can cause renal toxicity .
Histamine-2 blockers in usual doses , however , have not been found to be as effective as misoprostol ( 36 ) , whereas omeprazole ( 20 mg/d or 40 mg/d ) was as effective as misoprostol ( 200 g twice daily ) in treatment of existing ulcers and was better tolerated and associated with a lower rate of relapse ( 37 ) .