Focused Jurisdictional Scan of Glomerulonephritis Medication Access in Canada: A Program Report

Purpose of Program

Glomerulonephritis (GN) is a group of rare kidney diseases that is increasingly being managed with higher cost immunosuppressive (IS) agents in Canada. Ontario Health's Ontario Renal Network (ORN) oversees the management and delivery of GN services in the province. Stakeholder surveys previously conducted by ORN identified that both clinicians and patients do not perceive access to GN medications as comprehensive or timely. The program conducted a focused jurisdictional scan among 7 provinces to inform ORN initiatives to improve access to GN medications. Specifically, the program examined clinician experience with GN access, public drug coverage criteria, and timelines for public coverage for select IS agents (ie, tacrolimus, cyclosporine, mycophenolate mofetil [MMF], mycophenolate sodium, rituximab, and eculizumab) used to manage GN in adults who live in Canada.

Methods

For the selected IS agents, a focused jurisdictional scan on medication access was conducted by ORN in 2018 and updated in July 2022. Information was obtained by searching the gray literature and/or credible online sources for public funding policies and eligibility criteria. Findings were supplemented by personal communications with provincial drug programs and consulting GN clinical experts from 7 provinces (ie, Alberta, British Columbia, Saskatchewan, Manitoba, Ontario, Nova Scotia, and Quebec).

Key Findings

Clinicians from different provinces prescribe IS agents similarly for GN indications, despite distinctions in public drug funding policies. While patients can obtain public funding for many IS agents, for GN, most provinces rely on case-by-case review processes. In addition, provinces can vary in their funding criteria and which IS agents are listed on the public formulary. For IS agents that require prior authorization or case-by-case review, timelines vary by province with decisions taking a few days to weeks. British Columbia, with a GN-specific drug formulary, had the most integrated and efficient system for patients and prescribers.

Limitations

This scan primarily relied on publicly available information for drug coverage criteria and clinician experience with access in their province. Since this scan was conducted, public drug coverage criteria and/or application processes may have changed.

Implications

While patients in most provinces have similar needs and nephrologists similar prescribing patterns, gaps still exist for publicly funded GN medications. Interprovincial differences in the drugs funded, funding criteria, and application process may affect timely and equitable access to GN medications across Canada. Given the rarity of GN, a pan-Canadian funding approach may be warranted to improve the current state.

Ferric Derisomaltose Evaluation in Patients with Non-Dialysis-Dependent Chronic Kidney Disease or Peritoneal Dialysis

Background

Iron deficiency anemia is common in patients with advanced chronic kidney disease (CKD). Ferric derisomaltose (FDI) enables iron repletion in a single dose, unlike other forms of iron for IV administration, which require multiple doses. Protocols are commonly used with other IV irons, but there are limited Canadian data for FDI, and no protocol exists.

Objectives

To evaluate the efficacy and safety of FDI for patients with CKD and to ascertain information related to its use in Canadian provinces.

Methods

This retrospective cohort study involved patients with non-dialysis-dependent CKD (NDD-CKD) and patients undergoing peritoneal dialysis (PD) who received FDI in a tertiary hospital in Nova Scotia between June 2020 and May 2021. Each patient was followed for a minimum of 6 months. The efficacy outcomes were the changes from baseline in hemoglobin, transferrin saturation (TSAT), and ferritin after the first dose of FDI and at 3 and 6 months. The safety outcomes were the frequency and types of adverse reactions to FDI. Electronic surveys were sent to 33 Canadian renal pharmacists to gather information about FDI use, dosing, administration, monitoring, funding, and safety in their respective organizations.

Results

A total of 52 infusions were administered to 35 patients during the study period. The median times between doses 1 and 2 and between doses 2 and 3 were 19.1 and 6.6 weeks, respectively. The median change from baseline to first post-FDI follow-up blood work was significant for hemoglobin (9.0 g/L, p = 0.023), TSAT (11 percentage points, p < 0.001), and ferritin (271.4 μg/L, p < 0.001). Median darbepoetin doses decreased from baseline to 6 months (p < 0.001). Three adverse reactions occurred. At least 15 (65%) of the 23 survey respondents reported that FDI was funded by their province or was listed on their hospital drug formulary.

Conclusion

This study provides evidence that FDI is an effective and safe treatment for anemia in NDD-CKD and PD patients.

Stereotactic breast biopsy: recumbent biopsy using add-on upright equipment

OBJECTIVE

The purpose of the study was to show that stereotactic breast biopsy can be performed effectively and accurately using add-on stereotactic equipment when it is performed with the patient in a decubitus or recumbent position.

MATERIALS AND METHODS

We retrospectively reviewed the results of 225 stereotactic core breast biopsies performed during a 42-month period. The biopsies were performed using a reclining mammography chair and add-on stereotactic equipment. Procedures were performed with the patient in the right or left lateral decubitus position or upright. Patients with benign biopsy results were followed up mammographically at 6 months initially, then yearly.

RESULTS

Of the 225 lesions biopsied stereotactically, 205 lesions (91%) were biopsied with the patient in the decubitus (right or left) position and 20 (9%) biopsied with the patient upright. Pathology results were classified as abnormal in 45 lesions (20%) and normal in 180 lesions (80%). All but one of the abnormal lesions were followed up with surgical excision. One hundred thirty-four of the 180 benign lesions have been followed up with at least one 6-month mammogram (follow-up range, 6-40 months), and none of the lesions has been subsequently proven malignant.

CONCLUSION

Stereotactic core biopsy can be performed effectively and accurately using standard add-on equipment when it is performed with the patient in the decubitus position. This approach obviates the use of dedicated prone stereotactic equipment.

Attenuation of interleukin-8 production by inhibiting nuclear factor-kappaB translocation using decoy oligonucleotides

Interleukin-8 (IL-8), a monocyte-derived neutrophil chemoattractant factor, is a polymorphonuclear neutrophil chemotaxin that is involved in a number of inflammatory disorders. Transcription of the IL-8 gene is controlled by regulatory proteins, including nuclear factor-kappaB (NF-kappaB), a family of proteins that is important in the transcriptional control of a number of genes. When cells are activated, NF-kappaB translocates from the cytoplasm to the nucleus, where it activates transcription by binding to a specific sequence within the 5' untranslated region of the gene. During translocation, NF-kappaB is potentially susceptible to diversion by oligonucleotides that contain the binding sequence for this protein. In the current study, we produced phosphorothioate-modified oligonucleotides containing the specific DNA sequence that NF-kappaB binds within the IL-8 gene. We then investigated the effects of transfection of monocytes with these oligonucleotides on interleukin-1beta (IL-1beta)-stimulated IL-8 production, IL-8 mRNA expression, and NF-kappaB binding activity. We found that transfection with these oligonucleotides significantly inhibited monocyte IL-8 production. A single-stranded oligonucleotide with two copies of the NF-kappaB-binding sequence was the most potent of those tested. This single-stranded oligonucleotide also inhibited IL-1beta-induced translocation of NF-kappaB to the nucleus and reduced IL-8 mRNA expression. These studies demonstrated that monocyte production of IL-8 can be attenuated using a single-stranded oligonucleotide that binds a transcriptional activating protein before it translocates to the cell nucleus. This approach ultimately may be useful in the control of inflammation involved in a number of diseases.

Malignant mesenchymoma of the pleura

Malignant mesenchymomas are uncommon tumors of soft tissues. Three such tumors involving the pleura have been reported in the literature. We report a case of malignant mesenchymoma of the pleura that had liposarcomatous, rhabdomyosarcomatous, chondrosarcomatous, and osteosarcomatous elements.

An exploration of the relationship between interpersonal problems and psychological health

The relationship between interpersonal distress and psychological health was investigated using a sample of 185 college undergraduates. Subjects completed the Inventory of Interpersonal Problems (a measure of interpersonal distress), the Personal Orientation Inventory (a measure of self-actualization), and the Miller Social Intimacy Scale (a measure of interpersonal closeness). The mean of scores on the Inventory of Interpersonal Problems was compared with the mean of the clinical sample reported in 1988 by Horowitz, et al. The measures of psychological health were correlated with the Inventory of Interpersonal Problems total and with the octant scales of the Inventory of Interpersonal Problems-Circumplex version. The measures were also projected onto the circumplex to summarize their interpersonal connotations.

Three-Phase Fluid Flow Including Gravitational, Viscous and Capillary Forces

Abstract

This paper presents a technique for predicting the flow, of oil, gas and water through a petroleum reservoir. Gravitational, viscous and capillary forces are considered, and all fluids are considered to be slightly compressible. Some theoretical work concerning the fluid flow in one-, two- and three-space dimensions is given along with example performance predictions in one- and two-space dimensions. predictions in one- and two-space dimensions

Introduction

Since the introduction of high speed computing equipment one of the goals of reservoir engineering research has been to develop more accurate methods of describing fluid movement through underground reservoirs. Various mathematical methods have been developed or used by reservoir engineers to predict reservoir performance. The work reported in this paper extends previously published work on three-phase fluid flow (1) by including a rigorous treatment of capillary forces and (2) by showing certain theoretical mathematical results proving that these equations can be approximated by certain numerical techniques and that a unique solution exists.

Discussion

The method of predicting three-phase compressible fluid flow in a reservoir can be summarized briefly by the following steps. 1.The reservoir, or a section of a reservoir, is characterized by a series of mesh points with varying rock and fluid properties simulated at each mesh point. point. 2.Three partial differential equations are written to describe the movement at any point in the reservoir of each of the three compressible fluids. All forces influencing movement are considered in the equations. 3. At each mesh point, the partial differential equations are replaced by a system of analogous difference equations. 4. A numerical technique is used to solve the resulting system of difference equations.

Capillary forces have been included in two-phase flow calculations. The literature, however, does not contain examples of prediction techniques for three-phase flow that include capillary forces. Where capillary Races are considered, each of the three partial differential equations previously discussed has a different dependent variable, namely pressure in one of the three fluid phases. Therefore, pressure in one of the three fluid phases. Therefore, three difference equations must be solved at each point in the reservoir. Where large systems of point in the reservoir. Where large systems of equations must be solved simultaneously, an engineer might question whether a unique solution to this system of equations actually exists and, if so, what numerical techniques may be used to obtain a good approximation to the solution. It is shown in the Appendix that a unique solution to the three-phase flow problem, as formulated, always exists. It is also shown that several methods may be used to obtain a good approximation to the solution. The partial differential equations and difference equations partial differential equations and difference equations used are shown in the Appendix. Matrix notation has been used in developing the mathematical results.

Two sample problems were solved on a CDC 1604. They illustrate the type of problems that can be solved using a three-phase prediction technique.

SAMPLE ONE-DIMENSIONAL RESERVOIR PERFORMANCE PREDICTION

A hypothetical reservoir was studied to provide an example of a one-dimensional problem that can be solved. Of the several techniques available, the direct method A solution as shown in the Appendix was used.

The reservoir section studied was a truncated, wedge-shaped section, 2,400 ft long, with a 6' dip. (A schematic is shown in Fig. 1.) This section was represented by 49 mesh points, uniformly spaced at 50-ft intervals. The upper end of the wedge was 2 ft wide, and the lower end was 6 ft wide.

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