Objective. According to common knowledge and retrospective studies, approximately 75-90% of patients with rheumatoid arthritis (RA) will improve during pregnancy. Prospective data on disease activity during pregnancy are limited. Therefore, this study aimed to prospectively determine the disease activity during pregnancy in RA patients treated in an era of new treatment options. Methods. For 84 RA patients (American College of Rheumatology criteria), a Disease Activity Score in 28 joints (DAS28) and medication use were obtained, before conception if possible, at each trimester of pregnancy and at 6, 12, and 26 weeks postpartum. Improvement and deterioration were determined by assessing changes in DAS28 and by applying the DAS28-derived European League Against Rheumatism (EULAR) response criteria. Results. Disease activity decreased with statistical significance (P ‫؍‬ 0.035) during pregnancy and increased postpartum. In patients with at least moderate disease activity in the first trimester (n ‫؍‬ 52), at least 48% had a moderate response during pregnancy according to EULAR-defined response criteria. In patients with low disease activity in the first trimester (n ‫؍‬ 32), disease activity was stable during pregnancy. Thirty-nine percent of patients had at least a moderate flare postpartum according to reversed EULAR response criteria. Less medication was used during pregnancy compared with before conception and compared with postpartum. Conclusion. This study demonstrates that patients achieve remission during pregnancy and deteriorate postpartum, although less frequently than previously described.

In patients with hyperlactatemia on ICU admission, lactate-guided therapy significantly reduced hospital mortality when adjusting for predefined risk factors. As this was consistent with important secondary endpoints, this study suggests that initial lactate monitoring has clinical benefit. Clinical trial registered with www.clinicaltrials.gov (NCT00270673).

IntroductionImprovement of rheumatoid arthritis (RA) during pregnancy has been causatively associated with increased galactosylation of immunoglobulin G (IgG) N-glycans. Since previous studies were small, did not include the postpartum flare and did not study sialylation, these issues were addressed in the present study.MethodsSerum from 148 RA cases and 32 healthy controls was collected at several time points before, during and after pregnancy. Improvement during pregnancy and postpartum flare were determined according to the European League Against Rheumatism (EULAR) response criteria. Galactosylation and sialylation of Immunoglobulin G (IgG) and the presence of bisecting N-acetylglucosamine (GlcNAc) were analyzed by matrix-assisted laser desorption/ionization - time of flight - mass spectrometry (MALDI-TOF-MS).ResultsIgG1 and IgG2 galactosylation of the cases and controls increased during pregnancy with a maximum in the third trimester. Galactosylation decreased directly postpartum. IgG galactosylation of controls was at a higher level than cases (P < 0.001 at all time points) and a similar pattern was observed for sialylation. Moreover, there was a good association between galactosylation and sialylation. The increase in galactosylation was significantly more pronounced for cases with improvement than cases without improvement during pregnancy. The reverse was true for deteriorators and non-deteriorators postpartum. The presence of bisecting GlcNAc was not significantly influenced by pregnancy or postpartum for cases and controls.ConclusionsThis large cohort study demonstrates the association of changes in galactosylation with both pregnancy-induced improvement and postpartum flare in RA-patients, suggesting a role for changes in glycosylation in the pregnancy-induced improvement of RA.

Objective. To determine the outcome of pregnancy in women with rheumatoid arthritis (RA) in relation to disease activity and medication use during the pregnancy.Methods. In a prospective study, pregnant women with RA were evaluated before conception (when possible), during each trimester of the pregnancy, and postpartum. Clinical characteristics, disease activity, medication use, and pregnancy outcome were analyzed. To examine the independent influence of prednisone use and disease activity on birth weight, regression analyses were performed, with adjustments for gestational age of the child at delivery, the sex of the newborn, and the mother's smoking status, education level, parity, and use of an assisted reproduction technique. KaplanMeier curve analyses were performed to examine the association between medication use and gestational age at delivery.Results. Data from 152 Caucasian RA patients with singleton pregnancies were available. Both the mean ؎ SD birth weight (3,379 ؎ 564 gm) and the mean ؎ SD birth weight standard deviation score (SDS; ؉0.1 ؎ 1.1), which is the birth weight adjusted for the gestational age and sex of the newborn, were comparable with those in the general population. On multiple linear regression analyses of birth weight and birth weight SDS, both of which were adjusted for covariates, only disease activity was associated with lower birth weight (P ‫؍‬ 0.025). The gestational age at delivery was significantly lower in women who were taking prednisone (38.8 versus 39.9 weeks; P ‫؍‬ 0.001), and their delivery was more often premature (<37 weeks; P ‫؍‬ 0.004). Conclusion. Pregnancy outcome in women with well-controlled RA is comparable with that in the general population. The effect of prednisone on birth weight is mediated by a lower gestational age at delivery, whereas a higher level of disease activity independently influences birth weight negatively, suggesting an immune-mediated mechanism.

Objective To assess the effectiveness of supervised exercise therapy compared with usual care with respect to recovery, pain, and function in patients with patellofemoral pain syndrome.Design Open label randomised controlled trial.Setting General practice and sport physician practice.Participants Patients with a new episode of patellofemoral pain syndrome recruited by their general practitioner or sport physician.Interventions The intervention group received a standardised exercise programme for 6 weeks tailored to individual performance and supervised by a physical therapist, and were instructed to practise the tailored exercises at home for 3 months. The control group were assigned usual care, which comprised a “wait and see” approach of rest during periods of pain and refraining from pain provoking activities. Both the intervention group and the control group received written information about patellofemoral pain syndrome and general instructions for home exercises.Main outcome measures The primary outcomes were self reported recovery (7 point Likert scale), pain at rest and pain on activity (0-10 point numerical rating scale), and function (0-100 point Kujala patellofemoral score) at 3 months and 12 months follow-up.Results A total of 131 participants were included in the study: 65 in the intervention group and 66 in the control group. After 3 months, the intervention group showed better outcomes than the control group with regard to pain at rest (adjusted difference −1.07, 95% confidence interval −1.92 to −0.22; effect size 0.47), pain on activity (−1.00, −1.91 to −0.08; 0.45), and function (4.92, 0.14 to 9.72; 0.34). At 12 months, the intervention group continued to show better outcomes than the control group with regard to pain (adjusted difference in pain at rest −1.29, −2.16 to −0.42; effect size 0.56; pain on activity −1.19, −2.22 to −0.16; effect size 0.54), but not function (4.52, −0.73 to 9.76). A higher proportion of patients in the exercise group than in the control group reported recovery (41.9% v 35.0% at 3 months and 62.1% v 50.8% at 12 months), although the differences in self reported recovery between the two groups were not statistically significant. Predefined subgroup analyses revealed that patients recruited by sport physicians (n=30) did not benefit from the intervention, whereas those recruited by general practitioners (n=101) showed significant and clinically relevant differences in pain and function in favour of the intervention group.Conclusion Supervised exercise therapy resulted in less pain and better function at short term and long term follow-up compared with usual care in patients with patellofemoral pain syndrome in general practice. Exercise therapy did not produce a significant difference in the rate of self reported recovery.Trial registration ISRCTN83938749.

No abstract

These results suggest that Tai Chi Chuan may not be effective in elderly people at a high risk of falling who live at home.

Rheumatoid arthritis (RA) is known to improve during pregnancy and to flare after delivery. Changes in the glycosylation of immunoglobulin G (IgG)'s fragment crystallizable (Fc) have been suggested to play a role herein. Recent animal studies indicate that not galactosylation but mainly sialylation is important in this respect. We aim to find new associations between IgG-Fc N-glycosylation and improvement of RA during pregnancy and the flare after delivery. Sera of RA patients (n = 251 pregnancies) and healthy controls (n = 32), all participating in a prospective cohort study on RA and pregnancy (PARA study), were collected before conception, during pregnancy, and after delivery. Using a recently developed fast and robust nanoRP-HPLC-sheath-flow-ESI-MS method the glycosylation of IgG Fc-glycopeptides was measured in a subclass specific manner, with relative standard deviations of <4% for the 8 most abundant IgG Fc glycopeptides during the entire measurement period of over 3 weeks. In patients and controls, several glycosylation changes were observed during pregnancy. In depth analysis of the association of these glycosylation changes with disease activity revealed that galactosylation, independent of sialylation, is associated with improvement of RA during pregnancy. Functional studies in human cell systems should be performed to obtain more insight into this matter.