Reducing waiting times from 65 to under 40 days for children and adolescents receiving mental health services using a new scheduling policy.

The aim of this study is to conduct an intervention that tests whether a new scheduling policy designed to reduce waiting times actually will lead to a reduction in waiting times. The new scheduling policy was developed using mixed methods. Qualitative data was gathered to fully understand current planning processes, while quantitative methods were used to model and predict future waiting times. If current planning practices are continued, waiting times will only increase. Additionally, the findings show that simulation modeling can be used to predict the capacity needed for intakes (first appointment) to reduce and maintain target waiting times over time. In our study, this meant a slight increase in capacity for intakes. This new scheduling policy led to a reduction in waiting times from 65 days in 2016, to under 40 days post-intervention in 2017. Waiting times have been held under 40 days since implementation of the new policy, 2017-2020. Our study shows that setting appropriate (weekly) intake goals, will lead to maintaining acceptable levels of variation in waiting times. This theory was tested and proven to be effective.

Factors Associated With Time to Pregnancy in Women With Axial Spondyloarthritis: A Registry-Based Multicenter Study.

OBJECTIVE: The present study was undertaken to study time to pregnancy (TTP) and factors associated with TTP in women with axial spondyloarthritis (SpA) compared to women with rheumatoid arthritis (RA). METHODS: We included 274 women with axial SpA and 317 women with RA from the Norwegian nationwide registry RevNatus. For all the women, we had retrospectively collected data on TTP, and a subgroup also had prospectively collected data. We compared TTP in women with axial SpA to women with RA using Kaplan-Meier plots and a log rank test. To identify factors associated with TTP, we used Cox proportional hazards regression. RESULTS: TTP exceeded 12 months in 21% of women with axial SpA. In the subgroup followed prospectively, 32% had TTP that exceeded 12 months. Longer TTP was associated with older age, nulliparity, and longer disease duration, with hazard ratios of 0.97 (95% confidence interval [95% CI] 0.94-1.00), 0.66 (95% CI 0.50-0.88), and 0.94 (95% CI 0.91-0.98), respectively. Disease activity, medication, and self-reported health-related quality of life were not associated with TTP. We found no statistically significant differences between axial SpA and RA in regard to TTP. CONCLUSION: In women with axial SpA, longer TTP was associated with older age, nulliparity, and longer disease duration.

Psoriatic Arthritis Disease Activity During and After Pregnancy: A Prospective Multicenter Study.

OBJECTIVE: To study disease activity in women with peripheral psoriatic arthritis (PsA) during and after pregnancy. Previous knowledge on this topic is sparse. METHODS: The study included 108 pregnancies in 103 women with PsA from a Norwegian nationwide register. Disease activity was assessed prospectively at 7 time points before, throughout, and after pregnancy with the 3-variable Disease Activity Score in 28 joints (DAS28) using C-reactive protein levels and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Scores assessed at each time point were analyzed in a linear mixed model. We did additional analyses with "tumor necrosis factor inhibitor (TNFi) in pregnancy" as a covariate. The same statistical method was used to study self-reported physical function, pain, and mental health. RESULTS: Approximately 75% of the women were in remission or had low disease activity during and after pregnancy according to the DAS28-CRP score. Although disease activity was altogether stable, we found that it decreased in pregnancy and increased within 6 months postpartum. Disease activity at 6 months postpartum was significantly higher than at 6 weeks postpartum (mean DAS28-CRP score 2.71 versus 2.45; P = 0.016). Women using TNFi in pregnancy had significantly lower disease activity than women not using TNFi (mean DAS28-CRP score at 6 months postpartum 2.22 versus 2.72; P = 0.043). BASDAI scores were also low and stable during pregnancy but significantly higher at 6 months postpartum than at 6 weeks postpartum (mean BASDAI score 3.69 versus 2.95; P = 0.013). CONCLUSION: Studying women with PsA, we found that disease activity was highest at 6 months postpartum but altogether low and stable in the period from planning pregnancy to 1 year after delivery. Women using TNFi in pregnancy had significantly lower disease activity.

Disease Activity of Juvenile Idiopathic Arthritis during and after Pregnancy: A Prospective Multicenter Study.

OBJECTIVE: To study disease activity in women with juvenile idiopathic arthritis (JIA) during and after pregnancy. There is little previous knowledge about this topic. METHODS: Our study included 135 pregnancies in 114 women with JIA. Disease activity was assessed at 7 timepoints before, throughout, and after pregnancy with the Disease Activity Score-28-C-reactive protein 3 (DAS28-CRP3). Scores assessed at each visit were analyzed in a linear mixed model. The same statistical method was used to study self-reported physical function, pain, and mental health. RESULTS: Almost 80% of the women were in remission or had low disease activity during and after pregnancy. Although disease activity was stable throughout the study period, we found that DAS28 6 weeks postpartum increased significantly compared to the first trimester (2.78 vs 2.51, p = 0.005) and third trimester (2.78 vs 2.56, p = 0.011), respectively. DAS28 decreased significantly between 6 weeks and 12 months postpartum (2.78 vs 2.54, p = 0.014). Self-reported mental health was significantly better 6 weeks postpartum than before pregnancy (Medical Outcomes Study Short Form-36 Mental Health subscale 80.7 vs 76.5, p = 0.039). Self-reported pain was stable. Physical function was significantly worse in the third trimester of pregnancy than postpartum (Modified Health Assessment Questionnaire 0.57 vs 0.39, p < 0.001). CONCLUSION: In women with JIA, disease activity was highest 6 weeks postpartum, but altogether low and stable in the period from planning pregnancy to 1 year after delivery.

Reproductive trends in females with inflammatory joint disease.

BACKGROUND: The study assessed birth trends per decade in offspring of females with inflammatory joint diseases (IJD) compared with women without IJD. METHODS: This retrospective cohort study is based on data from the Medical Birth Registry of Norway from 1967 to 2009. We investigated singleton births in females with IJD (n = 7502) and compared with births from the general population (n = 2 437 110). Four periods were examined: 1967-79, 1980-89, 1990-99 and 2000-09. In the logistic regression analysis adjustments were made for maternal age at delivery and birth order. Odds ratios were obtained for the associations between IJD and birth outcome for each period. RESULTS: Females with IJD had in average 65 deliveries / year (0.08 % of all births) in the 1970ies and 274 deliveries / year (0.5 % of all births) from 2000 to 2009. Adjusted Odds ratios (aOR) for newborns small for gestational age were 1.5 (95 % CI 1.2, 1.9) in the earliest and 1.1 (95 % CI 0.9, 1.2) in the last period. Correspondingly, for birth weight < 2500 grams aOR decreased from 1.4 (95 % CI 1.0, 1.9) to 1.1 (95 % CI 0.9, 1.4). For preterm birth aOR was 1.1 (95 % CI 0.8, 1.5) in the first and 1.3 (95 % CI (1.1, 1.5) in the last period. CONCLUSION: An increasing number of births among females with IJD were observed in the study period. Birth weights of newborns of IJD women approached to birth weights in the general population, but preterm birth remained a problem.

Secular trends of pregnancies in women with inflammatory connective tissue disease.

INTRODUCTION: This study examined secular trends in reproductive outcome in women with inflammatory connective tissue disease compared with reference deliveries from the general population. MATERIAL AND METHODS: Historical cohort study based on data registered in the Medical Birth Register of Norway from 1967 to 2009. The study included singleton births in women recorded with connective tissue disease (n = 851) and reference deliveries from the general population (n = 2 437 110). Births were stratified in four periods, 1967-1979, 1980-1989, 1990-1999 and 2000-2009. Associations between connective tissue disease and maternal and perinatal outcomes by decade were assessed in logistic regression analyses and adjusted for maternal age at delivery and parity. RESULTS: In the 1970s, around 2.7 deliveries/year were registered for women with connective tissue disease (0.004% of all deliveries). This increased to 42 deliveries/year (0.07% of all deliveries) after 2000. Adjusted odds ratios (aOR) for cesarean section were 5.0 (95% CI 2.1-11.9) in the first and 1.8 (95% CI 1.4-2.3) in the last period. For preterm delivery the aOR decreased from 4.9 (95% CI 2.1-11.4) to 3.1 (95% CI 2.3-4.2) and the aOR for birthweight <2500 g changed from 7.3 (95% CI 3.3-16.3) to 4.1 (95% CI 3.0-5.6). CONCLUSIONS: An increasing number of births were observed over time among women with connective tissue disease. Adverse pregnancy outcomes were more common among women with connective tissue disease but risks have decreased over time.

Miscarriage and Stillbirth in Women with Rheumatoid Arthritis.

OBJECTIVE: To examine the risk of pregnancy loss in women with rheumatoid arthritis (RA). METHODS: Cumulative numbers of early miscarriages (before gestational Week 12), late miscarriages (weeks 12-22), and stillbirths reported to the Medical Birth Registry of Norway in the period 1999-2009. RESULTS: There were 1578 women with RA and 411,130 reference women included in the study. Relative risks of early and late miscarriage in women with RA versus references were 1.2 (95% CI 1.1-1.3) and 1.4 (95% CI 1.1-1.7), respectively. There was no difference in stillbirth. CONCLUSION: The risk of miscarriage was slightly higher among women with RA than in references.

No excess risks in offspring with paternal preconception exposure to disease-modifying antirheumatic drugs.

OBJECTIVE: To examine pregnancy outcomes in the partners of male patients with inflammatory joint disease who were or were not exposed to disease-modifying antirheumatic drugs (DMARDs) before conception compared with the outcomes in reference subjects from the general population. METHODS: Linkage of data from a longitudinal observational study of patients with inflammatory joint disease (the Norwegian Disease-Modifying Antirheumatic Drug [NOR-DMARD] registry study) and the Medical Birth Registry of Norway (MBRN) enabled a comparison of pregnancy outcomes in the partners of men with inflammatory joint disease. Outcomes of pregnancies in which the father was exposed to DMARDs within 12 weeks of conception and those in which the father was never exposed to DMARDs were analyzed separately and compared with the outcomes in reference subjects. Potential associations between DMARD exposure and adverse pregnancy outcomes were assessed by logistic regression analysis. RESULTS: A total of 1,796 men with inflammatory joint disease were associated with 2,777 births in the MBRN. In 110 of these births, the father had been exposed to DMARDs within 12 weeks before conception, and in 230 births the father had never been exposed to DMARDs before conception. The DMARDs (monotherapy or combination treatment) to which the fathers were exposed most frequently within 12 weeks of conception were methotrexate (n = 49), sulfasalazine (n = 17), and tumor necrosis factor inhibitors (n = 57). Neither adverse pregnancy outcomes nor occurrence of congenital malformations differed between patients and reference subjects in either group. CONCLUSION: Preconception paternal exposure to DMARDs was not associated with an increase in adverse pregnancy outcomes. Importantly, no increased risk of congenital malformations was observed.

Systemic lupus erythematosus and outcomes in first and subsequent births based on data from a national birth registry.

OBJECTIVE: To examine the associations between systemic lupus erythematosus (SLE) and outcomes in first and subsequent births. METHODS: Data from the Medical Birth Registry of Norway during the period December 1, 1998 to December 31, 2009 were used to assess maternal and perinatal outcomes in women diagnosed with SLE compared with the general population. Outcomes of first and subsequent births were analyzed separately. Associations between SLE and pregnancy outcomes were assessed in logistic regression analyses and are shown as adjusted odds ratios (aORs) after adjustment for maternal age, gestational age, smoking habits, and previous cesarean section (CS), when relevant. RESULTS: We analyzed 95 first and 145 subsequent births in patients and compared them with references. The risk of CS was two-fold higher in SLE patients in first and subsequent births. More newborns of patients had a birth weight <2,500 gm (aOR 5.00 [95 % confidence interval (95% CI) 3.02, 8.27] in first births and aOR 4.33 [95% CI 2.64, 7.10] in subsequent births). Additionally, preterm birth was more frequent among SLE patients (aOR 4.04 [95% CI 2.45, 6.56] in first births and aOR 3.13 [95% CI 1.97, 4.98] in subsequent births). Congenital malformations were more prevalent among children of patients than references (aOR 2.71 [95% CI 1.25, 5.86] in first births and aOR 3.13 [95% CI 1.69, 5.79] in subsequent births). Perinatal death was more frequent in first births among patients (aOR 7.34 [95% CI 2.69, 20.03]), but no difference was observed in subsequent births. CONCLUSION: Pregnancy complications were more frequent in SLE patients than references, and the greatest differences between groups were observed in first births.

Long-term effects of a nurse-led group and individual patient education programme for patients with chronic inflammatory polyarthritis - a randomised controlled trial.

AIMS AND OBJECTIVES: To investigate the long-term effect of a nurse-led hospital-based patient education programme combining group and individual education for patients with chronic inflammatory polyarthritis. BACKGROUND: Patient education interventions have shown short-term effects, but few studies have investigated whether the effects are sustained for a longer period. DESIGN: Randomised controlled trial. METHODS: Patients with rheumatoid arthritis, psoriatic arthritis and unspecified polyarthritis were randomised to the intervention group (n = 71) or a waiting list (n = 70). Primary outcomes were as follows: Global Well-Being and the Arthritis Self-Efficacy Other Symptoms Subscale. Secondary outcomes were as follows: patient activation, physical and psychological health status, patients' educational needs and a Disease Activity Score (DAS28-3). RESULTS: The intervention group had a statistically significant higher global well-being than the controls after 12 months, mean change score 8·2 (95% CI, 1·6-14·8; p-value = 0·015), but not in the Arthritis Self-Efficacy Other Symptoms Subscale, mean change score 2·6 (95% CI, -1·8 to 7·1; p-value = 0·245). Within each group, analyses showed a statistically significant improvement in DAS28-3, mean change -0·3 (95% CI, -0·5 to -0·1; p-value = 0·001), in the intervention group from baseline to 12 months, but not in the controls. The controls had a statistically significant deterioration in the Arthritis Self-Efficacy Other Symptoms Subscale, mean change -5·0 (95% CI, -8·6 to -1·3; p-value = 0·008), Arthritis Impact Measurement Scales - 2 Social, mean change 0·3 (95% CI, 0·1-0·5; p-value = 0·008), and Hospital Anxiety and Depression Scale total, mean change 1·4 (95% CI, 0·3-2·5; p-value = 0·013). CONCLUSION: A combination of group and individual patient education has a long-term effect on patients' global well-being. RELEVANCE TO CLINICAL PRACTICE: Nurses should consider whether a combination of group and individual patient education for patients with chronic inflammatory polyarthritis is an alternative in their clinical practice. This combination is less time-consuming for the patients, and it includes the benefit of group learning in addition to focusing on patient's individual educational needs.

Rheumatoid arthritis and outcomes in first and subsequent births based on data from a national birth registry.

OBJECTIVE: To examine associations between rheumatoid arthritis (RA) and pregnancy outcomes in first and subsequent births. DESIGN: Cohort study. SETTING: Study based on data registered in the Medical Birth Registry of Norway from the period 1 December 1998 to 31 December 2009. POPULATION: Singleton births in women recorded with RA (n = 1496) and reference deliveries from the general population (n = 625,642). METHODS: Outcomes of first and subsequent births were analyzed separately. First birth was defined as the first delivery of nulliparous women. Associations between RA and maternal and perinatal outcomes were assessed in logistic regression analyses and adjusted for maternal age at delivery, gestational age, smoking habits and for previous cesarean section when relevant. MAIN OUTCOME MEASURES: Maternal and perinatal outcomes. RESULTS: Vaginal bleeding was observed more often among women with RA both in first pregnancy [adjusted odds ratio (aOR) 1.8, 95% CI 1.3-2.4] and in subsequent pregnancies (aOR 1.4, 95% CI 1.1-1.9). Elective cesarean section was more common among women with RA both in the first birth (aOR 2.0, 95% CI 1.4-2.8) and in subsequent births (aOR 1.5, 95% CI 1.2-2.0). Preterm delivery was more frequent among women with RA than the reference population in first pregnancy (aOR 1.5, 95% CI 1.1-2.0) and in subsequent pregnancies (aOR 1.5, 95% CI 1.1-1.9). CONCLUSION: Complications and poor pregnancy outcomes were more often observed in women with RA and the greatest differences were observed in the first pregnancy.

The effect of an educational programme consisting of group and individual arthritis education for patients with polyarthritis--a randomised controlled trial.

OBJECTIVE: The aim of this study was to investigate the effect of an educational programme for patients with polyarthritis compared to usual care. METHODS: Patients with rheumatoid arthritis, psoriatic arthritis and unspecified polyarthritis were randomised to the intervention (n=71) or usual care (n=70). The intervention consisted of three group educational sessions followed by one individual educational session. The primary outcomes were a patient's global well-being and arthritis self-efficacy. Secondary outcomes were patient activation, physical and psychological health status, educational needs and disease activity. RESULTS: After four months the intervention group had significantly better global well-being, 95% CI (2.3-14.1), p=0.01, and self-efficacy, 95% CI (0.2-8.1), p=0.04, than the control group. There were also trends for improved disease activity, and a statistically significant improvement in patient activation and pain in the intervention group. CONCLUSION: This patient educational programme consisting of group sessions and nurse-delivered individual education has statistically significant benefits for global well-being and maintaining a level of self-efficacy in managing other symptoms in patients with polyarthritis. PRACTICE IMPLICATIONS: This educational programme allows patients to learn from each other in addition to addressing individual educational needs.

Pregnancy and delivery in women with chronic inflammatory arthritides with a specific focus on first birth.

OBJECTIVE: To examine possible associations between chronic inflammatory arthritides and pregnancy outcomes with separate analyses of first and subsequent births before and after diagnosis. METHODS: Linkage of data from a registry of patients with chronic inflammatory arthritides and the Medical Birth Registry of Norway enabled a comparison of pregnancy outcomes in women with chronic inflammatory arthritides and pregnancy outcomes in reference subjects. Outcomes of first birth and subsequent births before and after diagnosis were analyzed separately. Associations between chronic inflammatory arthritides and the women's health during pregnancy and delivery as well as perinatal outcomes were assessed in logistic regression analyses with adjustments for maternal age at delivery and gestational age. RESULTS: We analyzed 128 first births and 151 subsequent births after diagnosis and 286 first births and 262 subsequent births before diagnosis in patients and compared them with first and subsequent births in reference subjects. Firstborn children of women diagnosed as having chronic inflammatory arthritides were more often preterm (odds ratio [OR] 1.85 [95% confidence interval (95% CI) 1.09-3.13]) and small for gestational age (OR 1.60 [95% CI 1.00-2.56]). They also had lower mean birth weight (P=0.01) and higher perinatal mortality (OR 3.26 [95% CI 1.04-10.24]). Birth by caesarean section (all classifications) was more frequent in patients than in reference subjects, and elective caesarean section was 2-fold more frequent in patients, both in first birth (OR 2.60 [95% CI 1.43-4.75]) and in subsequent births (OR 2.18 [95% CI 1.33-3.58]). No excess risks of clinical importance were observed prior to diagnosis of chronic inflammatory arthritides. CONCLUSION: Excess risks were related to first birth in women diagnosed as having chronic inflammatory arthritides, including a higher rate of perinatal mortality. A higher caesarean section rate was related to all patient deliveries. Mainly, pregnancy outcomes before diagnosis did not differ from those in reference subjects.

Fertility in women with chronic inflammatory arthritides.

OBJECTIVE: To compare fertility rates in women with RA, other chronic arthritides (OCAs) and JIA with reference women from the general population. METHODS: Each woman from a Norwegian patient registry was matched by year of birth with 100 reference women randomly selected from the National Population Registry. Data linkage of patients and references with the Medical Birth Registry of Norway (MBRN) identified all offspring in patients and references until October 2007, and indirectly also nulliparous (childless) women. Groups were compared with Mann-Whitney U-test for continuous variables and chi-squared tests for categorical variables. Poisson regression analysis was applied to calculate relative fertility rates in the diagnostic groups vs references. RESULTS: Among 631 patients 849 children were registered in MBRN. Of these, 289 children (34.0%) were born after time of diagnosis vs 44.3% in references. Altogether, 206 of 631 patients (32.6%) were nulliparous vs 26.4% in references (P < 0.001). Among RA patients, 28.4% (96 of 338) were nulliparous vs 24.5% in references (P = 0.09), 30.7% (67 of 218) in OCA patients vs 24.5% in references (P = 0.03) and 57.3% (43 of 75) in JIA patients vs 40.9% in references (P = 0.004). Adjusted relative fertility rates in RA, OCA and JIA after diagnosis were 0.88, 0.84 and 0.84, respectively, compared with references. CONCLUSION: A higher proportion of women with chronic inflammatory arthritides were nulliparous compared with references, and relative fertility rates were reduced in all patient groups.

Drug insight: Anti-tumor necrosis factor therapy for inflammatory arthropathies during reproduction, pregnancy and lactation.

Tumor necrosis factor (TNF) antagonists are widely used to reduce disease activity and joint damage, and to improve health-related quality of life in patients suffering from rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis. To date, no increased risk of embryotoxicity or teratogenicity, or adverse pregnancy outcome (such as birth defects, premature birth, and low birth weight) has been reported in patients with inflammatory arthropathies treated with anti-TNF therapy, compared with the general population. However, the available data are limited, and methotrexate, which is commonly used in combination with anti-TNF drugs, is teratogenic. Until more data are available, no firm conclusions can be reached regarding the safety of anti-TNF therapy in pregnancy. Nevertheless, in selected cases where there is high disease activity, anti-TNF therapy might be recommended, depending on the results of individual risk-benefit analyses. Fully informed consent from the mother is needed in such cases. Anti-TNF agents are not usually used during lactation, although the risk of toxicity is probably negligible.

Stability of the patient acceptable symptomatic state over time in outcome criteria in ankylosing spondylitis.

OBJECTIVE: The Patient Acceptable Symptomatic State (PASS) is the highest level of symptoms beyond which patients consider themselves well. It provides clinically meaningful information to interpret results from scales or questionnaires. Our goal was to determine the PASS in main outcome criteria when assessing patients with ankylosing spondylitis (AS) and to evaluate whether the PASS is stable over time. METHODS: We used data from a randomized controlled trial of 330 patients with AS. The PASS was estimated at weeks 2, 6, and 12 for the following patient-reported outcomes: global pain (measured on a visual analog scale [VAS]), nocturnal pain (VAS), patient's global assessment of disease activity (VAS), disease activity (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]), and functional impairment (Bath Ankylosing Spondylitis Functional Index [BASFI]). We used an anchoring method based on patients answering yes or no to, "Is your current condition satisfactory, when you take your general functioning and your current pain into consideration?" The PASS was defined as the 75th percentile of the score for patients who considered their state satisfactory. All patients were considered together in the analysis. RESULTS: The values (95% confidence interval) of PASS were 33.5 (29.2-38.6) for pain, 28.0 (23.1-34.1) for night pain, 35.7 (31.3-41.1) for patient's global disease assessment, 31.4 (26.9-37.0) for BASFI, and 34.5 (30.9-38.9) for BASDAI. The PASS estimates were stable over time for all criteria during followup. CONCLUSION: This study provides cutoff values for the PASS for the main outcome measures in AS and shows that PASS values are stable over time.

Anti-inflammatory pharmacotherapy during pregnancy.

NSAIDs or cyclooxygenase inhibitors (COX inhibitors), including aspirin, are widely used to treat pain, fever and the articular symptoms of chronic rheumatic diseases. Manifestations of connective tissue or autoimmune diseases are commonly treated with glucocorticosteroids. The effect and side effects of NSAIDs depend on the isoforms of cyclooxygenases that they preferentially or selectively inhibit. The use of COX inhibitors has recently been associated with infertility and miscarriage. The classical nonselective COX inhibitors, including aspirin, do not increase the risk of congenital malformations in humans but administered in the latter part of gestation, they can affect pregnancy and the fetus. The ability of nonselective and selective COX inhibitors to prolong gestation has been used by obstetricians to inhibit premature delivery. The vascular effects of prostaglandin inhibitors can cause constriction of the fetal ductus arteriosus and reduce renal blood flow. These complications have been described for most nonselective COX inhibitors but are increasingly reported also for the selective COX-2 inhibitors. Aspirin, which causes irreversible inhibition of cyclooxygenases, differs from other NSAIDs with regard to indication, effects and side effects. Prematurity, which is increased in pregnancies of women with connective tissue diseases, is an additional risk factor for adverse effects of antenatal exposure to NSAIDs. Therefore, treatment with COX inhibitors should be discontinued at week 32 of gestation. The ability of NSAIDs to compromise reproductive function by inhibition of ovulation and as causative agents for miscarriage is still under debate. Glucocorticosteroids given in early pregnancy are a risk factor for the development of oral clefts. Therefore, the daily dose should be kept to

[Training effects on pain in rheumatoid arthritis]. / Effekt av trening på smerte ved revmatoid artritt.

BACKGROUND: This report considers the relationship between the effect of training on pain and joint manifestations in patients with rheumatoid arthritis. METHODS: A review of randomized controlled trials published from 1997 to February 2001. RESULTS: Six randomized controlled trials confirm results from previous research indicating that exercise leads to unchanged or reduced self-reported pain and unchanged or reduced tender joint counts in patients in ACR functional classes I or II with low to moderate disease activity. This effect may possibly be generalized to patients with higher disease activity. The effect is less clearly demonstrated in patients with serious joint destruction and loss of function. INTERPRETATION: The results indicate that exercise leads to unchanged or reduced self-reported pain and joint tenderness for patients with rheumatoid arthritis. Further studies are needed in order to demonstrate to what extent and how different kinds of exercise influence pain and joint tenderness in rheumatoid arthritis patients.

The recurrence risk of adverse outcome in the second pregnancy in women with rheumatic disease1.

OBJECTIVE: To study recurrence risks of adverse pregnancy outcome in the second pregnancy in women with rheumatic disease. METHODS: In a national population-based cohort study, women with rheumatic disease recorded from 1967 to 1995 in the Medical Birth Registry of Norway were compared with mothers without such diagnoses with regard to recurrence risks of adverse pregnancy outcomes in the second pregnancy. The odds ratios (ORs) of all outcomes were adjusted for maternal age, those of cesarean delivery for time period, and those of preeclampsia for interpregnancy interval. RESULTS: Women with rheumatic disease an dadverse pregnancy outcome in the first pregnancy had a statistically significant higher recurrence risk of the same event in the second pregnancy than women without rheumatic disease (preeclampsia: OR 2.22; 95% confidence interval [CI] 1.18, 4.19) (cesarean delivery: OR 1.52; 95% CI 1.05, 2.21) (preterm birth: OR 1.86; 95% CI 1.12, 3.11). In women with rheumatic disease diagnosed between the first and second births, a significantly increased recurrence risk of low birth weight occurred. Women with rheumatic disease also had a higher occurrence of markers for placental dysfunction (preeclampsia, preterm birth, or small for gestational age) in the second birth after any of these outcomes in the first birth (OR 1.35; 95% CI 1.02, 1.78) (35.1% versus 29.2%). CONCLUSION: The recurrence risk of an adverse outcome in the second pregnancy is increased in any woman, but was even higher in women with a rheumatic disease. These patients should be counseled accordingly, be closely monitored during pregnancy, and have access to appropriate subspecialists.