COBRA combination therapy is well known and has uncontested efficacy in the treatment of rheumatoid arthritis (RA). However, it is infrequently applied in Dutch clinical practice. Based on qualitative research on opinions of physicians and patients towards COBRA therapy, our study describes the development and pilot testing of an implementation package to facilitate prescription and use of COBRA therapy in early RA.
The implementation package was developed to address specific barriers towards prescription of COBRA therapy and comprised informational handouts (an information booklet and leaflet for patients), preprinted prescription orders, and background information on COBRA therapy for the rheumatologists. Twenty-two rheumatologists agreed to participate, including the arthritis nurse where available. Rheumatologists, nurses, and patients were asked to record their experience. All Dutch arthritis nurses were invited to an educational session on COBRA therapy.
Sixteen rheumatologists accompanied by 10 arthritis nurses used the material to prescribe COBRA therapy to a total of 27 patients. Rheumatologists and nurses both gave high marks to the supplied materials. Eighty-eight percent of rheumatologists reported that the material sped up the prescription process, and 65% indicated they would prescribe COBRA therapy more frequently if these materials were available routinely. Patients expressed great satisfaction with the information handouts, rating it 2.8 (standard deviation 0.5) on a scale of -3 (very negative) to +3 (very positive). Most patients (89%) planned to keep the information booklet as a reference and 70% used it as a tool to remember the correct intake of medication. The attitude and perceived capability of nurses towards the guidance of patients with RA receiving COBRA therapy was improved through a brief educational intervention.
Rheumatologists, patients, and arthritis nurses all highly appreciated the implementation package and indicated that its availability would increase uptake of COBRA therapy.
"The main studies, which have informed practice, are discussed by Horton, Walsh, and Emery in Chapter 5. There are now data for combination conventional therapy   and biologic therapy commenced in early RA as being more effective in achieving rapid disease remission  . In Chapter 8, Thalayasingam and Isaacs discuss the relative merits of individual tumour necrosis factor alpha inhibitor (TNFi) therapies while Leandro and Becera-Fernandez discuss specific aspects of B-cell depletion therapy in Chapter 7. Another key question in the conventional DMARD and biologics era is to establish when it is safest for therapies to be stepped up or stepped down and which parameters should be used to decide on such changes. "
[Show abstract][Hide abstract] ABSTRACT: Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting synovial tissue in multiple joints. In recent years, there have been several advances which have influenced the management of established RA. Not only has there been the advent of additional serological tests to improve diagnostic accuracy, as exemplified by the antibodies to citrullinated peptide antigen (ACPA) test, but this has also translated into new revised American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria for the diagnosis of RA published in 2010 . Coupled with advances in diagnostic criteria, we now have evidence for the treatment of RA with disease-modifying anti-rheumatic drugs (DMARDs), be they conventional DMARDs used in combination or biologic agents, which can achieve clinical and radiographic remission. However, it must be appreciated that patients with established RA remain at risk of long-term co-morbidities including cardiovascular disease, osteoporosis, infection and malignancy. In addition, the impact of chronic disease on daily function should not be underestimated and patients should be routinely screened for risk factors such as smoking and depression, and changes implemented as necessary so that the aims of targeted therapy can be maintained to achieve disease remission in the long-term. RA is the most-researched and best-understood rheumatic disease. As a consequence, its diagnosis and management are refined and sophisticated. This short book will bring you up-to-date with regard to all facets of our current appreciation of pathogenesis, diagnosis and management, in 12 chapters written by internationally acclaimed researchers.
Best practice & research. Clinical rheumatology 08/2011; 25(4):435-46. DOI:10.1016/j.berh.2011.10.011 · 2.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: As the dimensions of MOSFETs scale into deep sub-0.1 μm, a clear understanding of both the effects of scattering and quantum interference is needed. In this work, the quantum transport simulator "Schrodinger Equation Monte Carlo" (SEMC) (L.F. Register, in Quantum-Based Electronic Devices and Systems, M. Dutta and M.A. Stroscio, eds., World Scientific, Singapore, p. 251, 1998) is used to examine the effects of scattering and quantum interference along the channel. The simulation results suggest that not only does scattering, and the modeling thereof, remain critical even for 10 nm devices, but the detailed nature of the scattering - elastic, inelastic, etc. - remains important.
Device Research Conference, 2002. 60th DRC. Conference Digest; 02/2002
[Show abstract][Hide abstract] ABSTRACT: Although the evidence is clear and most rheumatologists agree that RA should be treated early and intensively, it obviously remains a challenge to put this paradigm into practice. Patient- as well as physician-related factors determine the delay before the disease is recognized and treated appropriately. There is still a need for education in this context. Optimal treatment allocation depends on the determination of prognostic factors, but should also take into account the patient's perspective to be effective. Patients' perceptions about the disease and its medical management need to be adjusted as soon as possible. Initiation of intensive or complex treatment regimens is most feasible in a clinical setting, where rheumatologists work together with other health-care professionals, such as nurse specialists. Until now there does not seem to have been a difference in terms of efficacy between intensive RA treatment strategies based on a combination of classical DMARDs with glucocorticoids or with TNF-blocking agents, but given the costs biologicals cannot be considered first-line therapy. More scientific work is needed to identify individuals that could benefit from biologicals early in the disease. Given the long-term benefits of rapid disease control, health authorities should consider investing in a better implementation of intensive treatment regimens based on combinations of classical DMARDs and glucocorticoids.
Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.