Optimising gout treatment: insights from a nurse-led cohort study.

OBJECTIVES: Currently, gout management, particularly urate-lowering therapy (ULT), is often suboptimal. Nurses successfully manage various diseases including gout. As gout prevalence is rising, and rheumatologists and general practitioners face shortages, a new approach is imperative. This real-life prospective cohort study evaluated the effectiveness of nurse-led care employing a treat-to-target strategy for gout management over a 2-year period. METHODS: All consecutively confirmed gout patients were included. The nurse-led clinic provided a structured treatment plan with consultations, patient leaflets, telephone contacts and laboratory monitoring. After a year of nurse-led care, patients transitioned to continued care in general practice. Follow-up data were complete through registries. The primary outcome was achieving target p-urate levels (<0.36 mmol/L) at 2 years after diagnosis. Secondary outcomes included treatment continuation and achievement of target p-urate levels in specific subgroups. The results were compared with patients diagnosed in the same clinic but followed up in 'usual care'. RESULTS: In the nurse-led group (n=114), 83% achieved target p-urate levels and ULT was continued by 98%. This trend persisted across various patient subgroups. Only 44% of patients in usual care achieved target p-urate and with insufficient doses of allopurinol . Nurse-led care involved an average of two visits and three telephone contacts over 336 days. The 2-year mortality rate was 15%. CONCLUSIONS: Nurse-led gout care, employing a targeted approach, was associated with a very high uptake of and adherence to ULT. The encouraging results were not achieved in usual care although a direct comparison might be influenced by selection bias.

[Severe tophaceous gouty arthritis can be treated but is still overlooked in healthcare].

This is a case report of a 68-year-old male with severe tophaceous gouty arthritis, diabetes, kidney impairment and ischaemic heart disease. The patient had repeated attacks of acute gout during a 20-year period and excessive tophaceous depositions. Walking was severely hampered by feet deformity and pain. No urate-lowering therapy was initiated despite contacts to several medical specialties. After the diagnosis was established, the patient was finally treated with allopurinol with an obvious beneficial effect on his symptoms and the size of the tophaceous depositions.

Patients with severe gout treated in mixed settings.

INTRODUCTION We aimed to investigate whether patients with a definite gout diagnosis who were treated in mixed real-life settings (various hospital departments or general practice) followed treatment recommendations. METHODS We included all patients in the hospital's uptake area in 2015-2017 who had been diagnosed with gout after microscopy findings of urate crystals. Data regarding comorbidities and indications for urate-lowering therapy (ULT) were collected. The criteria for treatment success were a p-urate level less-than 6 mg/dl (less-than 0.36 mmol/l) or less-than 5 mg/dl (less-than 0.30 mmol/l) if tophi were present. All patients were followed up for 24 months. RESULTS The study included 100 patients with a median age of 70 years, and 82% of patients were males. An indication for ULT was present in 99 patients and initiated in 79 patients. Fourteen of these 99 patients died within one year. For the remaining 85 patients, p-urate was measured, and the target was reached by 22 (26%) patients, not reached by 33 (39%) patients and not measured in 30 (35%) patients. Treatment success was positively associated with a written treatment plan in the rheumatology record after microscopy, initiation of ULT in the clinic, provision of a gout leaflet, a higher number of outpatient visits and non-smoking status. CONCLUSIONS Many patients with crystal-proven gout did not receive ULT as recommended. Even if ULT was initiated, the p-urate level was monitored infrequently and the dose of ULT was not escalated when necessary. The best outcomes were associated with continued care in a rheumatology clinic. FUNDING none. TRIAL REGISTRATION The study was assessed by the Ethics Committee, which decided it was a quality assurance project and the study was subsequently approved by the Regions data protection office service with ID 2018-62.

Management practices and honey characteristics of Melipona eburnea in the Peruvian Amazon / Práticas de manejo e características do mel de Melipona eburnea Friese na Amazônia peruana

ABSTRACT: Meliponiculture and associated honey production are activities with a great potential for general use and commercialization in the Peruvian Amazon. Lack of management techniques and limited knowledge of honey quality are two factors which may hinder the implementation of meliponiculture. The present study was conducted in three communities in the Peruvian Amazon where the production and physicochemical and microbiological characteristics of honey from Melipona eburnea were evaluated at 90 days following transfer from natural to rational hives. Honey from M. eburnea was also compared with the 90-day-old honey from Melipona grandis, Melipona illota, and Melipona titania. In addition, 180-day-old honey from M. eburnea was sampled and compared with the younger 90-day-old honey. The production of honey varied from 900 to 1400 mL/colony/3 months for M. eburnea. When moisture and total sugars among the different species of Melipona were compared, no significant differences were observed. Neither were there significant differences between the M. eburnea honey at 90 and 180 days of maturation. Microbiological analyses for both treatments had values <0.3/g most probable number (MPN) of coliforms and organisms of fecal origin. Stingless bee honey can therefore be harvested after 3 months, by which time its physicochemical characteristics are stable and it is microbiologically suitable for human consumption.

RESUMO: A meliponicultura e a produção associada de mel é uma atividade com grande potencial de uso e comercialização na Amazônia peruana, contudo, as poucas técnicas de manejo e o pouco conhecimento da qualidade do mel oferecido limitam seu desenvolvimento. O presente estudo foi realizado em três comunidades da Amazônia peruana, onde a produção e as características físico-químicas e microbiológicas do mel de Melipona eburnea foram avaliadas 90 dias após a instalação em colmeias racionais. O mel de M. eburnea também foi comparado ao mel de 90 dias de M. grandis, M. illota e M. titania. Além disso, o mel de M. eburnea foi amostrado aos 180 dias. A produção de mel variou de 900 a 1400 ml/colônia/três meses para M. eburnea. Quando a umidade e os açúcares totais foram comparados entre as diferentes espécies, não foram encontradas diferenças significativas. Também não foram encontradas diferenças significativas para o mel de M. eburnea aos 90 e 180 dias de maturação. As análises microbiológicas para os dois tratamentos apresentaram valores <0,3 / g MPN (número mais provável) de coliformes e organismos de origem fecal. O mel de abelha sem ferrão pode, portanto, ser colhido após três meses, pois mantém suas características físico-químicas e é microbiologicamente adequado para consumo humano.

Rheumatoid arthritis patients' oral health and disease activity.

AIM: Rheumatoid arthritis (RA) and periodontal diseases (PD) are common chronic, inflammatory, destructive and progressive diseases that may have similar pathophysiological mechanisms and risk factors. RA affects more than 1.5% of the world's population, with a higher percentage of females than males. PD is present in around 20% of the population and has multifactorial etiology. The purpose of this study is to describe patients' self-reported oral health and the association with RA disease activity. METHOD: Three hundred patients under treatment for RA from the Division of Rheumatology, Clinical Medicine, North Jutland Region Hospital, Hjørring, Denmark and were eligible for the study. Questionnaires were emailed to the patients and 164 completed answers were received. RESULTS: The mean age of the group of 164 patients (61% female) was 65 ± 11 years. The average value of Disease Activity Score of 28 joints was 2.31 ± 0.83. Only 12% of responders were active smokers. Patients estimated their status of their teeth and gingiva respectively as poor in 13% and 11% of cases, good, in 46% and 49%, and excellent, both as 40%. Spontaneous and/or provoked gingival bleeding were experienced by 15% and 49% of patients. Only 14% of patients declared feelings of loose or movable teeth and 10% declared difficulties in biting or chewing. CONCLUSIONS: The status of oral cavity reported by Danish patients indicates a significant proportion with symptoms of gingival/periodontal disease, which may negatively influence RA activity and disease management. Cooperation between rheumatologists and dentists is important in oral health management in periodontal inflammation.

A new species of Andinopanurgus (Hymenoptera: Andrenidae) from high elevations in southern Peru / Una especie nueva de Andinopanurgus (Hymenoptera: Andrenidae) de las grandes alturas del sur de Perú

We describe and figure a distinctive new species of the bee genus Andinopanurgus Gonzalez and Engel (Andrenidae, Protandrenini) from Apurímac and Cusco in southern Peru. Andinopanurgus vargasllosai Gonzalez and Alvarado, n. sp., occurs at elevations above 4000 m in the Central Andes and is the second species of this genus in Peru. The new species possesses terga with semi-translucent distal margins, a unique feature among Andinopanurgus, and it combines morphological features of the two species groups previously recognized in the genus. To facilitate its recognition, we provide an updated key to species of Andinopanurgus.

Describimos e ilustramos una especie nueva del género Andinopanurgus Gonzalez y Engel (Andrenidae, Protandrenini) procedentes de Apurímac y Cusco, al sur de Perú. Andinopanurgus vargasllosai Gonzalez y Alvarado, n. sp., se encuentra en alturas superiores a los 4000 m en los Andes centrales y es la segunda especie del género registrada para el Perú. La especie nueva posee tergos metasomales con las márgenes distales semi-translúcidas, una característica única dentro de Andinopanurgus, y combina características morfológicas de los dos grupos de especies hasta ahora reconocidos en el género. Con el fin de facilitar la identificación, presentamos una clave actualizada para las especies de Andinopanurgus.

Impact of tobacco smoking on response to tumour necrosis factor-alpha inhibitor treatment in patients with ankylosing spondylitis: results from the Danish nationwide DANBIO registry.

OBJECTIVES: To investigate the association between tobacco smoking and disease activity, treatment adherence and treatment responses in patients with AS treated with their first tumour necrosis factor-alpha inhibitor (TNFi) therapy in routine care. METHODS: Observational cohort study based on the Danish nationwide DANBIO registry. Kaplan-Meier plots, Cox and logistic regression analyses by smoking status (current/never/previous) were calculated for treatment adherence and BASDAI 50%/20 mm-response. Additional stratified analyses were performed for gender and TNFi-type. RESULTS: Of 1576 AS patients included in the study, 1425(90%) had known smoking status (current/never/previous: 43%/41%/16%). The median follow-up time was 2.02 years (IQR 0.69-5.01). At baseline, current smokers compared with never smokers had longer disease duration (4 years (1-12)/2 years (0-10)), higher BASDAI (61 mm (47-73)/58 mm (44-70)), BASFI (53 mm (35-69)/46 mm (31-66)) and BASMI (40 mm (20-60)/30 mm (10-50)) scores (all P < 0.01). Current and previous smokers had shorter treatment adherence than never smokers (current: 2.30 years (1.81-2.79) (median (95% CI)); previous: 2.48 years (1.56-3.40), never: 4.12 years (3.29-4.95)), P < 0.0001). Similar results were found in multivariate analyses (current versus never smokers, HR 1.41 (95% CI 1.21-1.65), P < 0.001), most pronounced among men. Current smokers had poorer 6 months' BASDAI50%/20 mm-response rate than never smokers (42%/58%, P < 0.001). In multivariate analyses, current smokers had lower odds of achieving BASDAI50%/20 mm-response than never smokers, both overall (OR 0.48 (95% CI 0.35-0.65), P < 0.0001) and for the different TNFi-types (adalimumab 0.45 (0.27-0.76)/etanercept 0.24 (0.10-0.61)/infliximab 0.57 (0.34-0.95)). CONCLUSION: In this study of TNFi-treated AS patients in clinical practice, current and previous smokers had significantly poorer patient-reported outcomes at baseline, shorter treatment adherence and poorer treatment response compared with never smokers.

[Dual-energy computer tomography can be used for gout diagnostics]. / Dual-energy computertomografi kan anvendes tildiagnosticering af arthritis urica

Gout is a potentially destructive inflammatory disorder occurring in the setting of hyperuricaemia and urate crystal deposition in tissue. It is often overlooked or treated insufficiently. Early diagnosis is important to prevent joint destruction and to prevent the systemic effects of inflammatory disease. This is a case report of a 48-year-old male with intermittent swellings of both wrists where polarized microscopy was unable to confirm the diagnosis. Dual-energy computed tomography showed urate crystals in both wrists, and urate lowering therapy normalised the plasma urate levels. The patient was without joint swellings or pain.

Discordance of Global Assessments by Patient and Physician Is Higher in Female than in Male Patients Regardless of the Physician's Sex: Data on Patients with Rheumatoid Arthritis, Axial Spondyloarthritis, and Psoriatic Arthritis from the DANBIO Registry.

OBJECTIVE: To assess the frequency of discordance in patient's (PtGA) and physician's (PGA) global assessment, and to investigate whether higher discordance in female patients compared with male patients is associated with the physician's sex in patients with rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), and psoriatic arthritis (PsA). METHODS: PtGA, PGA, and other patient-related variables were retrieved from the Danish DANBIO registry, used nationwide to monitor patients with RA, axSpA, and PsA. A questionnaire was sent to all physicians registering in DANBIO (n = 265) regarding individual physician characteristics including sex and age. Discordance was defined as PtGA > 20 mm higher (or lower) than PGA. First encounters between patients and physicians were analyzed using descriptive statistics and mixed model regression analysis. RESULTS: Ninety physicians (34%) returned the questionnaire and were pairwise matched with 10,282 first patient encounters (8300 patients with RA, 524 axSpA, and 1458 PsA). The frequency of discordant (PtGA > PGA) encounters (not including PGA > PtGA seen in < 2%) in RA, axSpA, and PsA was 49.0%, 48.3%, and 56.5%, respectively. Discordance was more common in female patients with high scores on functional disability, pain, and fatigue across the 3 diseases, whereas it was independent of the physician's sex. CONCLUSION: In this study on Danish patients with RA, axSpA, and PsA, the PtGA was > 20 mm higher than the PGA in about half of the encounters, and more common in female patients of both female and male physicians. This finding highlights one of the challenges in shared decision making.

Impact of different infliximab dose regimens on treatment response and drug survival in 462 patients with psoriatic arthritis: results from the nationwide registries DANBIO and ICEBIO.

OBJECTIVE: The aim of this study was to describe dose regimens, dose escalation and clinical outcomes in TNF-α inhibitor (TNFi)-naive patients with PsA treated with infliximab in routine rheumatology care. METHODS: We conducted an observational cohort study based on the nationwide Danish Rheumatologic Database (DANBIO) and Center for Rheumatology Research (ICEBIO) registries. Stratified by country, characteristics of patients treated with ≤3 mg infliximab/kg body weight, 3-5 mg/kg or ≥5 mg/kg every 8 weeks were described. Outcomes were evaluated by ACR 20%, 50% and 70% (ACR20/50/70) responses and European League Against Rheumatism good response after 6 months, disease activity after 12 months, Kaplan-Meier plots and regression analyses. RESULTS: Four hundred and sixty-two patients (376 Danish, 86 Icelandic) received treatment with infliximab. In Danish patients, the starting dose was ≤3 mg/kg in 110 patients (29%), 3-5 mg/kg in 157 (42%), ≥5 mg/kg in 38 (10%) and unregistered in 71 (19%). In Icelandic patients, corresponding numbers were 64 (74%), 17 (27%), 0 (0%) and 5 (6%). Patients with a higher body weight received lower doses per kilogram. Danish patients received higher doses than Icelandic patients at baseline [median 3.1 (interquartile range 3.0-3.8) vs 2.3 (2.1-2.9) mg/kg, P < 0.05] and after 12 months [3.3 (3.0-4.5) vs 2.9 (2.2-3.5) mg/kg, P < 0.0001]. After 12 months, 58% of Danish and 66% of Icelandic patients maintained treatment. Danish patients had shorter drug survival than Icelandic patients (1183 vs 483 days). In univariate analyses stratified by country, time until dose escalation, response rates, drug survival and 1-year's disease activity were independent of starting dose. Drug survival was shorter among patients not receiving concomitant MTX. CONCLUSION: In clinical practice, > 70% of Icelandic and Danish PsA patients treated with infliximab received sustained doses below the 5 mg/kg every 8 weeks recommended in international guidelines. Lower starting doses did not affect drug survival or response.

Incidences of overall and site specific cancers in TNFα inhibitor treated patients with rheumatoid arthritis and other arthritides - a follow-up study from the DANBIO Registry.

OBJECTIVES: To investigate the incidence of cancer in arthritis patients treated with or without TNFα inhibitors (TNF-I). METHODS: Arthritis patients from the DANBIO database were followed-up for cancer in the Danish Cancer Registry during 2000-2008. RESULTS: Hazard ratio for cancer overall was 1.02 (95% confidence interval (CI) 0.80-1.30) in 3347 TNF-I-treated RA patients compared to non-treated. Excess among TNF-I-treated was found for colon cancer (HR 3.52 (95%CI 1.11-11.15), whereas 6 and 0 ovarian cancer cases were observed in treated and non-treated patients, respectively. Compared to the general population, TNF-I-treated RA patients had increased risk for cancer overall, cancer in lymphatic-haematopoietic tissue and non-melanoma skin cancer, while non-RA patients had no increase in overall cancer risk. CONCLUSIONS: Our results suggest that TNF-I therapy in routine care is not associated with an overall excess of cancer in arthritis patients, but observed increased risks of colon and ovarian cancer need further investigation.

Clinical response, drug survival and predictors thereof in 432 ankylosing spondylitis patients after switching tumour necrosis factor α inhibitor therapy: results from the Danish nationwide DANBIO registry.

OBJECTIVE: To investigate frequencies and reasons for switching, treatment responses and drug survival in patients with ankylosing spondylitis (AS) switching tumour-necrosis-factor-α inhibitor (TNFi) treatment in routine clinical care. METHODS: AS patients were identified in the Danish nationwide DANBIO registry. Disease activity, treatment responses (50% or 20 mm reduction in Bath AS Disease Activity Index (BASDAI)), duration and rates of drug survival and predictors thereof were studied in patients receiving ≥2 different biological drugs. RESULTS: Of 1436 AS patients starting TNFi treatment, 432 patients (30%) switched to a second and 137 (10%) to a third biological drug. Compared with non-switchers, switchers were more frequently women (33%/22%), had shorter disease duration (3 years/5 years) and higher BASDAI (62(52-76) mm/56(43-69) mm (median(interquartile-range))), Bath AS Functional Index (BASFI) (54(39-71) mm/47(31-65) mm) and visual-analogue-scale (VAS) global, pain and fatigue scores when they started the first TNFi (all p<0.01). Main reason for switching was lack of response (56%). During the first, second and third treatment BAS- and VAS scores had decreased after 6 months' treatment (all p<0.05). Median drug survivals were 3.1, 1.6 and 1.8 years respectively (p<0.001). After 2 years of treatment 52% of switchers and 63% of non-switchers had achieved response (number needed to treat 1.9 and 1.6, respectively, p=0.01). Drug survivals were similar regardless of the reason for switching. Male gender and low BASFI predicted drug survival of the second TNFi. CONCLUSIONS: Nearly one-third of AS patients in clinical practice switched biological treatment. Response rates and drug survivals were lower among switchers, however, half of switchers achieved treatment response.

Properties of honey from ten species of Peruvian stingless bees.

Honey produced by ten stingless bee species (Melipona crinita, M. eburnea, M. grandis, M. illota, Nannotrigona melanocera, Partamona epiphytophila, Ptilotrigona lurida, Scaptotrigona polystica, Scaura latitarsis, and Tetragonisca angustula) from Peru has been characterized according to traditional physicochemical standards (color and moisture), biochemical components (flavonoids, polyphenols, nitrites, proteins), and bioactive properties (antibacterial activity, antioxidant capacity). Analytical data are also provided for a sample of Apis mellifera and an artificial honey control. For stingless bees, honey color varied between 26 and 150 mm Pfund. M. illota produced the lightest honey, while N. melanocera and T. angustula were the darkest. Moisture varied between 20.8 and 45.8 g water/100 g, confirming higher moisture for stingless bee honey than the A. mellifera honey standard of 20 g water/100 g. Flavonoids varied from 2.6 to 31.0 mg quercetin equivalents/100g, nitrites from 0.30 to 2.88 micromoles nitrites/100 g, polyphenols from 99.7 to 464.9 mg gallic acid equivalents/100g, proteins from 0.75 to 2.86 g/100 g, and the antioxidant capacity from 93.8 to 569.6 micromoles Trolox equivalents/100 g. The minimal inhibitory concentration (MIC) was slightly lower against Staphylococcus aureus (12.5 -50 g/100 mL) than Escherichia coli (50 g/100 mL).

[Costs of biological treatment of rheumatoid arthritis]. / Omkostninger til biologisk behandling af leddegigt.

INTRODUCTION: Biological drugs are used for the treatment of severe rheumatoid arthritis (RA). The high costs of such treatment have drawn attention to the economic appropriateness of the use of biological drugs. There are no Danish studies of the real costs of present clinical practice. The purpose of this study was to compare the actual costs of RA treatment for the three most commonly used biological drugs. MATERIAL AND METHODS: Data were collected from three Danish hospitals. The study is a cost analysis designed as a retrospective cohort study using data from medical records (n = 198). RESULTS: The costs of infliximab varied due to dose escalation from 78,660 DKK at one hospital to 120,657 DKK at another hospital. Treatment with either etanercept or adalimumab will tend to cost the same as or less than treatment with infliximab, when infliximab doses exceed the standard dose (3 mg/kg), and treatment breaks amount to at least 10%. At one hospital treatment breaks reduced the consumption of etanercept and adalimumab by 20%. CONCLUSION: Actual medicine expenses for treatment of RA with infliximab, etanercept and adalimumab tend to be equal. Consequently, there is no economic rationale for basing the choice of drug on costs calculated on the basis of standard dosage. Instead, the choice should be based on considerations of efficacy, safety, patient needs and the treatment feasibility.

Diversity and abundance of orchid bees (Hymenoptera: Apidae, Euglossini) in a tropical rainforest succession / Composicion de abejas euglossinas (Hymenoptera: Apidae, Euglossini) en una sucesión de selva tropical

Euglossine bee males are easily lured to chemical baits imitating natural fragrances gathered by bees, providing a widely applied measure for estimating the diversity and abundance of euglossines. In here, I report the composition of euglossine bees in three lowland rainforest habitats of Peru, a primary old forest, a reforested and managed forest, and a very disturbed forest. A total of 2,072 males of euglossine were collected, belonging to 33 species and four genera. Although a comparable diversity relative to other studies from the Amazonian region was found, no significant differences among the sampled areas were detected. Perhaps, the short time and low intensity surveys here used (< 3 months) were not good enough indicators of forest disturbance without additional data. Compared to other major studies on the euglossine bee fauna, Loreto is most similar to the species assemblage reported from lowland rainforest in Brazil (Manaus), central Peru (Panguana) and southern Peru (Tambopata).

Las abejas euglossinas macho, son fácilmente atraídas por los cebos químicos que imitan las fragancias naturales recolectadas por las abejas, proporcionando así una medida de la diversidad y abundancia extensamente aplicada para estas abejas. En este estudio documento la composicion de las abejas euglossinas en tres hábitats de la selva baja del Perú (Loreto), tales como un bosque primario, un bosque reforestado y manejado, y un bosque muy deforestado. A partir de 2.072 abejas capturadas perteneciendo a 33 especies y cuatro géneros, encontré una diversidad comparable a otros estudios de la región Amazónica, pero no encontré ninguna diferencia significativa entre los hábitats muestreados. Quizás por que los muestreos de las abejas euglossinas de corta duración (< 3 meses), tal como este caso, no son buenos indicadores del estado del bosque sin datos adicionales. Comparado a otros estudios de la fauna de las abejas euglossinas, Loreto es el más similar en especies a las especies reportadas de Brasil (Manaus), de Perú central (Panguana) y luego de Perú meridional (Tambopata).

Chronic cystamine treatment inhibits small artery remodelling in rats.

BACKGROUND/AIMS: We investigated whether the tissue transglutaminase inhibitor cystamine is able to inhibit remodelling of small arteries in vivo, a possibility suggested by recent in vitro experiments. METHODS: Using osmotic minipumps, phenylephrine, cystamine and/or amlodipine were infused for 1-2 weeks into 9-week-old Wistar rats. Small arteries were then removed for pressure myograph investigation. RESULTS: Phenylephrine infusion caused inward remodelling of the small arteries compared to vehicle infusion. The remodelling was abolished by concomitant infusion with cystamine; blood pressure was unaffected. Second, we investigated whether cystamine was able to inhibit outward remodelling. Rats were first infused with phenylephrine for 1 week, and some were infused for a further week with amlodipine with or without cystamine. Amlodipine caused 24% outward remodelling compared to vessels from rats at completion of the phenylephrine infusion. The outward remodelling was attenuated 86% by concomitant cystamine infusion. A series of in vitro experiments supported the inhibitory action of cystamine on tissue transglutaminase. CONCLUSION: The ability of cystamine to inhibit inward remodelling independent of blood pressure is consistent with a role of tissue transgluaminase in this process. It remains to be determined if the ability of cystamine to inhibit outward remodelling also involves inhibition of tissue transglutaminase.

Rates of lumbar disc surgery before and after implementation of multidisciplinary nonsurgical spine clinics.

STUDY DESIGN: Correlation study. OBJECTIVES: To assess the rates of lumbar disc surgery in North Jutland County, Denmark, before and after implementation of two nonsurgical spine clinics, and to compare the observed rates with those for the rest of Denmark in the same time periods. SUMMARY OF BACKGROUND DATA: Few studies have addressed initiatives to reduce high rates of lumbar disc surgery by improving nonsurgical care offered to patients with sciatica and low back pain. METHODS: The study was conducted in North Jutland County, Denmark with 500,000 inhabitants (10% of the Danish population). In 1997, two nonsurgical spine clinics were established, along with an educational program for general practitioners. The clinics targeted patients with sciatica of 1 to 3 months' duration, with or without low back pain. Data on rates of lumbar disc surgery were obtained from the National Registry of Patients. RESULTS: The annual rate of lumbar disc operations for patients in North Jutland County decreased from approximately 60 to 80 per 100,000 before 1997 to 40 per 100,000 in 2001 (P = 0.00), and the rate of elective, first-time disc surgeries decreased by approximately two thirds (P = 0.00). In contrast, the annual rate of lumbar disc operations for patients in the rest of Denmark remained unchanged during the same period. CONCLUSIONS: The implementation of multidisciplinary, nonsurgical spine clinics coincided closely with a significant reduction in the rate of lumbar disc surgery. The observed reduction seems most likely to be causally associated with educational activities and improved patient care provided by the clinics.