Systematic Review of Tofacitinib: A New Drug for the Management of Rheumatoid Arthritis

Purpose

The goal of this study was to review and summarize the efficacy and safety of use of tofacitinib for treating rheumatoid arthritis (RA).

Methods

A systematic literature review was conducted to identify English-language articles published through May 2013 within PubMed, ClinicalTrials.gov, and Cochrane Library reporting results from Phase II and Phase III tofacitinib randomized clinical trials. Tofacitinib must have been used as monotherapy or in combination therapy with disease-modifying antirheumatic drugs (DMARDs) in the treatment of RA. Study outcomes had to include at least 1 of the following: American College of Rheumatology (ACR) 20%, 50%, or 70% response rates; tender/swollen joint count; health assessment questionnaire of disability; radiographic outcomes; and drug persistence.

Findings

Eight studies (4 Phase II and 4 Phase III trials) were included in the review. Patients with active RA and who were nonresponders to a biologic agent or the nonbiologic DMARD methotrexate were included in these studies. The results of the Phase II trials show that tofacitinib at doses ≥3 mg BID was efficacious among the nonresponders. The results of the Phase III trials, comparing tofacitinib 5 and 10 mg with placebo, show that tofacitinib led to a significant improvement in ACR20 response (P < 0.0001), Health Assessment Questionnaire–Disability Index (P < 0.0001) scores, and ACR50 response (P < 0.0001) after 3 months. The efficacy of tofacitinib was numerically similar to adalimumab. The most common adverse events were infections, infestations, increases in LDL-C and HDL-C levels, and a decrease in neutrophil counts.

Implications

Tofacitinib is an efficacious drug for the management of moderate to severe RA among patients with an inadequate response to methotrexate and tumor necrosis factor inhibitors. Long-term studies can help in understanding the risk/benefit profile of tofacitinib.     

Taiwanese nursing students' knowledge, application and confidence with standard and additional precautions in infection control

Aim. This study reports on nursing students’ current capacity to handle standard and additional infection‐control precautions in terms of their knowledge, application skills and confidence. Background. These precautions are recommended as the guidelines for preventing infections and ensuring occupational safety. As nursing students undertake patient care during clinical practice, their knowledge of and ability to apply these precautions with confidence should be examined before they enter the clinical field. Method. A specific tool, the Infection Control Evaluation, was developed and distributed. Design. A cross‐sectional survey involving a sample of preservice nursing students was conducted in southern Taiwan. Results. The results were based on an 88% response rate and indicated that the level of knowledge concerning standard and additional precautions was low among Taiwanese nursing students. Their ability in applying these precautions in clinical practice also appeared to be inadequate. Conclusions. Such findings indicate that Taiwanese preservice nursing students require a comprehensive foundation course in infection‐control precautions before they enter the clinical environment. This will help to ensure their protection and that of their patients. Relevance to clinical practice. As the findings highlight the importance of providing such education for students before they undertake any clinical work, the information provided here can help nursing educators and academics to develop a specific program.     

手术室护士的职业危害分析及对策

目的:分析手术室护士的职业危害及对策。方法:对我院28名手术室护士采用问卷及谈话的方式调查工作中可能出现的职业危害,并提出相应的解决策略。结果:血源性感染、物理性感染和化学性感染是危害手术室护士的三大有害因素,针对具体情况采取相应措施进行防范。结论:手术室护士是一种高风险的职业,应对风险内容作具体了解并采取相应的防范措施,才能将手术室危害降到最低。     

Intravascular device-related infection

Intravascular device-related infection is one of the most important nosocomial infections. More than 200,000 cases with blood stream infection occur each year and most of them are related to the use of an intravascular device in United States. The microorganisms most frequently involved are Staphylococcus epidermidis, Staphylococcus aureus and Candida spp. It is very important to prevent and treat the catheter-related infections. Many researches have been done to develop methods for preventing and treating intravascular device-related infection. They include diagnosis of catheter-infections, appropriate barrier precautions during catheter insertion, intervals for replacement of catheters, catheter-site care, site of catheter insertion and type of catheter material. Furthermore novel approaches are needed for prevention and treatment of the intravascular device-related infection.     

Antimicrobials: classifications and uses in critical care

Patients in the critical care setting are at high risk for infection because their normal host defenses are compromised. Critical care patients frequently have complicated, multisystem, mixed infections that can be life threatening. Optimal patient outcomes are the result of (1) early identification of signs and symptoms of infection; (2) nursing knowledge about common antimicrobials and their side effects and adverse reactions; (3) obtaining cultures before starting empiric therapy with antimicrobials; (4) consulting as needed with the infection control team; (5) practicing basic measures of infection control, such as hand washing; and (6) using special isolation precautions when the patient's condition warrants special care. The nurse also needs to be vigilant to the signs of toxicity from antimicrobial therapy. These interventions can save the critical care patient's life, prevent others from becoming infected, and save the hospital precious fiscal resources.     

Infection control precautions for visitors to healthcare facilities

Infection transmission in healthcare facilities is a growing concern. Visitation to healthcare facilities is very common, though the potential role of visitors in the transmission of infection is unknown. Although transmission-based precautions are generally used to prevent the spread of organisms in healthcare settings by healthcare staff, the applicability of these precautions to visitors is unclear. Decisions regarding whether to implement transmission-based precautions among visitors should take into account the organism of concern and means of transmission as well as factors pertaining to the visitor and the healthcare setting. The role of visitors as vectors for organism transmission in the healthcare setting and the potential benefits and adverse consequences of visitor adherence with transmission-based precautions are important areas for additional research.     

Introduction of Infection Control Measures to Reduce Infection Associated With Implantable Pain Therapy Devices

Introduction: Implantable pain therapy devices for chronic pain include spinal cord stimulators (SCS) and intrathecal drug delivery systems (IDDS). A number of different complications can occur after implantation of these devices, but among the most serious is infection. Based on Centers for Disease Control and Prevention guidelines for prevention of surgical site infection, published literature on infection risk with implantable pain therapy devices, and recommendations from groups within our own our institution, we introduced infection control measures for all patients receiving either SCS or IDDS. Methods: After approval from the Institutional Review Board, we performed a retrospective review of patients undergoing primary implantation of SCS or IDDS before and after introduction at our institution of safety measures designed to reduce device‐related infection. We compared infection incidence and compliance to infection precautions before and after introduction of these measures. Results: Thirty‐four SCS or IDDS were implanted before implementation of the infection control measures and 58 were placed after. Five device‐related infections occurred. Adherence to most infection precautions improved during the study period, but 100% compliance was seen only with venue used for implantation. Infection incidence declined after introduction of the safety measures, but the reduction was not statistically significant. Conclusions: Introduction of infection control measures for implantable pain therapy devices improved adherence to most infection precautions in our practice. Lack of specific documentation could have hindered practice surveillance within our group. A tool to document performance of infection control measures would be useful not only as a marker of compliance but could also serve as a reminder to perform certain safety measures.     

Malaria and children: the risks, precautions, and the nurse's role

Malaria is a life-threatening illness which can be particularly risk in children. This paper guides nurses who offer travel advice on the best approaches to take with parents. It is best to avoid travelling to areas affected by the disease at all. However, if people do travel, they should take prophylactic medication as well as other precautions to avoid being bitten by mosquitoes.     

Hepatitis A infection during pregnancy

Question Many of my patients are from Southeast Asia, where hepatitis A virus (HAV) infection is quite common. What precautions can I suggest my pregnant patients take before traveling to these areas and what is the risk of contracting HAV during pregnancy?Answer Hepatitis A virus is a water-borne pathogen transmitted by the fecal-oral route. To reduce the risk of contracting HAV while traveling to endemic areas, it is important to maintain hygienic practices such as hand washing with safe water, particularly before handling food, avoiding drinking water or using ice cubes of unknown purity, and avoiding eating unpeeled fruits and vegetables. An HAV vaccine is available and can be administered before traveling to endemic countries. Hepatitis A virus infection has a largely favourable expected outcome even during pregnancy. Infection occurring in the second or third trimester has been reported to be associated with preterm labour.     

Biologic therapy and screening for tuberculosis in a new service

Plaque psoriasis is a common skin condition that can greatly affect quality of life. Biologic therapy is an effective treatment, but it poses risks to patients, particularly concerning latent infections such as tuberculosis (TB), which may be reactivated. Medical practitioners therefore need to screen patients before commencing a biologic therapy. There are a number of screening tools for TB infection, which vary in efficacy depending on the patient being screened, and some tests can give a false-negative result for TB infection. It is important to screen for TB and to take a good clinical and lifestyle history before commencing biologic treatment. This article discusses the above in the context of setting up a dedicated clinic to monitor patients on biologic therapy for plaque psoriasis.     

Common variable immunodeficiency: the disorder and treatment

A case of common variable immunodeficiency, a relatively rare disorder, is presented. This case was complicated by the presence of an anti-IgA antibody in the patient's serum and a history of a possible anaphylactic reaction to a prior intravenous infusion of gamma-globulin. Common variable immunodeficiency is actually a heterogeneous group of demonstrable immunoglobulin deficiencies that have in common low levels of most immunoglobulin isotypes, the inability to form antibodies to antigen, an absence of gross defects in cell-mediated immunity, and the presence of recurrent bacterial infections. The history of immunoglobulin deficiency and its treatment is reviewed. Although the primary therapy for common variable immunodeficiency is gamma-globulin replacement, ancillary measures such as early treatment of infections with antibiotics are also important. Intravenous gamma-globulin replacement therapy is preferred to intramuscular replacement therapy in these patients because intramuscular doses must be limited in volume to minimize local pain and take 2 to 14 days to achieve maximal blood levels, during which time in situ degradation of up to 50% of the administered dose can occur. Five intravenous gamma-globulin preparations are currently available in the United States. The potential adverse effects of intravenous gamma-globulin infusion and the precautions currently taken to ensure safety during administration of this product are discussed.     

Tigecycline: A new antibiotic

Tigecycline is a novel antimicrobial agent recently licensed in the United Kingdom (UK), United States and Europe. It is a broad spectrum glycylcycline antibiotic which has structural similarities to the tetracyclines but is more potent against tetracycline-resistant organisms. It is only available as an intravenous (IV) preparation. This article reviews the clinical efficacy, side effect profile, dosing and administration schedule of tigecycline. The article also discusses the warnings and precautions associated with the use of this drug. Tigecycline may be used for complicated intra-abdominal and complicated skin and soft tissue infections. It is also likely to find a role in the treatment of infections caused by multi-resistant organisms such as Acinetobacter species.     

机械通气时人工气道的护理

对于呼吸衰竭病人,迅速建立人工气道并进行机械通气治疗,可以为抢救成功、原发病治疗、健康恢复赢得时间.人工气道的有效护理是保证机械通气治疗成功的关键.本文根据近年来国内外护理研究进展和临床护理经验,从人工气道的妥善固定、保持气道通畅、预防和控制YAP的发生等方面来阐述人工气道的护理进展.     

The hazards of fine-needle aspiration biopsy

Review of the literature and the results of the hospital survey substantiate the widely held belief that fine-needle aspiration biopsy is a very safe procedure. However, serious and even fatal complications, although rare, can and do occur and it is important to be aware of the possibility and to take all the appropriate precautions in order to reduce their incidence.     

VN Profile

Prevention is better than cure, whether we are talking about physical or psychological health. Under the Animal Welfare Act (2006), owners have a responsibility to take all reasonable precautions to ensure animals in their care, of any species, are free from fear and distress and are able to perform normal behaviour.     

54例先心病体外循环术围手术期护理

总结了54例先心病体外循环术患者的临床护理经验.对54例在体外循环下行房间隔、室间隔缺损修补、法络四联征矫正术病人术前做好心理护理,加强深呼吸训练,指导病人练习有效咳嗽和排痰方法;术后严密观察病情加强呼吸道管道、胸腔引流管护理及循环系统监测,预防可能出现的并发症.本组术后2例发生快速室上性心率失常,全部病例于术后10～15 d痊愈出院.术前、术后严密的护理是预防术后并发症,促进病人康复的基础.     

急诊救治老年人大面积脑梗死患者66例死因再认识

目的:分析老年脑梗死患者的死亡因素和探讨急救方案。方法:研究对象为66例脑梗死患者,年龄60岁以上,经CT证实均为大面积脑梗死。结果:死亡因素依次为多器官功能衰竭25例(37％)、脑疝并肺部感染15例(22％)、脑疝11例(16％)和肺部感染7例(10％)等。结论:多器官功能衰竭、脑疝或合并肺部感染是老年大面积脑梗死患者死亡的主要因素,溶栓、抗凝、改善脑血液循环等早期治疗是提高成活率的关键。     

Transmission and epidemiology of MRSA: current perspectives

Staphylococcus aureus is a gram-positive bacterium that developed resistance to the penicillin derivative methicillin. Subsequently, methicillin-resistant S. aureus (MRSA) emerged as a bacterium that became less susceptible to the actions of methicillin and thus developed the ability to colonize and cause life-threatening infections. Globally, MRSA continues to cause hospital-acquired infections which are becoming difficult to treat owing to increasing glycopeptide resistance and the increasing development of community-associated MRSA. Nurses caring for patients in both hospital and community settings should be able to acknowledge the importance of MRSA, the difficulties of treating the bacterium and the need to comprehend and adhere to universal precautions that are important in the prevention of transmission of MRSA.