Development, implementation and impact of an immunoglobulin stewardship programme in Saskatchewan, Canada.

BACKGROUND AND OBJECTIVES: Intravenous immunoglobulin (IVIG) is one of the most costly and limited-supply blood products. Judicious use of this therapy is important to ensure a continued supply is available for patients in need. The Saskatchewan IG Stewardship Program was initiated to monitor and reduce inappropriate IG use. MATERIALS AND METHODS: The Program was developed and implemented through the collaborative efforts of a multidisciplinary, inter-organizational team. Funding was provided from provincial organizations to create new positions within the Program and to support stakeholder engagement throughout the process of implementation. Data were collected from local and national databases regarding the amount of IVIG used and appropriateness of orders based on published criteria. RESULTS: Over 20 months, the Program helped to reduce unnecessary IVIG use from pre-intervention levels by more than 20%. Interventions from nurse navigators alone reduced inappropriate IVIG use by 2.6%. During the 20-month period following Program initiation, more than 4 million CAD less was spent on IVIG compared with the previous 20 months. CONCLUSION: The Saskatchewan IG Stewardship Program has led to more appropriate IVIG use across the province, more effective preservation of this limited healthcare resource, and cost savings that more than cover the cost of administering the Program.

Determining the validity of non-invasive spot-check hemoglobin co-oximetry testing to detect anemia in postpartum women at a tertiary care centre, a prospective cohort study.

BACKGROUND: Spot-check hemoglobin co-oximetry analyzers measure hemoglobin transcutaneously and offer the benefit of a hemoglobin measurement without phlebotomy. The objective of this study was to determine the validity of non-invasive spot-check hemoglobin co-oximetry testing for the detection of postpartum anemia (hemoglobin < 10 g/dL). METHODS: Five hundred eighty-four women aged 18 and over were recruited on postpartum day one following a singleton delivery. Two non-invasive spot-check hemoglobin co-oximetry monitors, Masimo Pronto Pulse CO-Oximeter (Pronto) and Masimo Rad-67 Pulse CO-Oximeter (Rad-67), were evaluated and compared to the postpartum phlebotomy hemoglobin value. RESULTS: Of 584 participants, 31% (181) had postpartum anemia by phlebotomy hemoglobin measurement. Bland-Altman plots determined a bias of + 2.4 (± 1.2) g/dL with the Pronto and + 2.2 (± 1.1) g/dL with the Rad-67. Low sensitivity was observed: 15% for the Pronto and 16% for the Rad-67. Adjusting for the fixed bias, the Pronto demonstrated a sensitivity of 68% and specificity of 84%, while the Rad-67 demonstrated a sensitivity of 78% and specificity of 88%. CONCLUSION: A consistent overestimation of hemoglobin by the non-invasive spot-check hemoglobin co-oximetry monitors compared to phlebotomy hemoglobin result was observed. Even after adjusting for the fixed bias, the sensitivity for detecting postpartum anemia was low. Detection of postpartum anemia should not be based on these devices alone.

Duration of peripheral intravenous catheter patency in children.

OBJECTIVE: This study aimed to compare the impact of saline lock to running a slow continuous infusion to-keep-vein-open (TKVO) on the total time a peripheral intravenous (PIV) catheter remained patent. METHOD: A retrospective chart review of all children admitted to the paediatric ward of a regional hospital in Saskatchewan December 1, 2013 through February 28, 2014. Characteristics of patients with PIV catheters were abstracted from the health records, including patient size, catheter size and site, and total time each PIV catheter spent (i) infusing therapeutic fluids or medications, (ii) running a TKVO infusion, or (iii) saline locked. The duration of catheter patency was compared with the proportion of time that TKVO infusions were run, as well as patient gender and age. RESULTS: During 375 admissions, there were 189 PIVs which met inclusion criteria. The proportion of nontherapeutic time a PIV catheter spent TKVO compared to saline locked did not affect the total time the PIV catheter was patent (P=0.33). Gender had no influence, but older age, a nonmodifiable factor, was associated with increased time a PIV catheter remained patent (P=0.028). DISCUSSION: Peripheral intravenous (PIV) catheter insertion can be a painful and traumatic procedure. On the paediatric ward of a regional hospital, TKVO infusions were not superior to saline lock for prolonging PIV catheter patency.

Examination of a Canadian provincial prenatal HIV screening program: 2010 to 2014.

OBJECTIVES: Universal prenatal screening in the Canadian province of Alberta employs an 'opt-out' HIV screening strategy. We examined all women giving birth in the province and determined the frequency and characteristics of women having and not having HIV screening. METHODS: All livebirths in Alberta from January 1, 2010 to December 31, 2014 were compiled from the Vital Statistics database and linked to HIV screening data to determine maternal demographic and prenatal care characteristics. Correlates associated with prenatal HIV screening, opting out of HIV screening, and not having any prenatal communicable disease screening were determined by multivariable statistics. RESULTS: Of the 256,280 live births, 94.2% had prenatal HIV screening, 1.9% declined prenatal HIV screening, and 3.9% had no record of any prenatal communicable disease testing. Compared with those who had HIV screening, those who opted out of prenatal HIV screening were more likely to be over 40 years of age (adjusted odds ratio (AOR), 2.83 [2.12-3.78]) and less likely to be single (AOR, 0.67 [0.62-0.73]) and First Nations (AOR, 0.67 [0.56-0.82]). Those who received no prenatal communicable disease screening were less likely to be over 40 years of age (AOR, 0.81 [0.69-0.95]) and more likely to be single (AOR, 1.27 [1.21-1.33]) and have received no prenatal care (AOR, 6.78 [6.40-7.19]). Both the HIV decliners and prenatal non-testers were more likely to have used a midwife (AOR, 4.52 [3.83-5.35] and AOR, 2.44 [2.03-2.92], respectively). CONCLUSION: Demographic and prenatal care characteristics differ by a pregnant woman's prenatal screening status. Policies to improve HIV screening coverage should take these variations into account.

Long-Term Impact of Bariatric Surgery on Renal Outcomes at a Community-Based Publicly Funded Bariatric Program: The Regina Bariatric Study.

BACKGROUND: Obesity is recognized as an independent risk factor for chronic kidney disease through multiple direct and indirect biological pathways. Bariatric surgery is a proven, effective method for sustained weight loss. However, there is a relative paucity of data on the impact of bariatric surgery on renal outcomes. OBJECTIVE: The primary objective was to evaluate the change in urine albumin/creatinine ratio (ACR) in patients undergoing bariatric surgery, at 12 months after the procedure. Secondary objectives were to determine the changes in ACR at (6 and 24 months), estimated glomerular filtration rate (eGFR; 6, 12, and 24 months), and hemoglobin A1c (HbA1c); 12 and 24 months) after the procedure. DESIGN: This observational retrospective cohort study included consecutive obese patients who underwent bariatric surgery. SETTING: Provincial Bariatric Surgery Clinic at the Regina General Hospital, Saskatchewan. PATIENTS: This study includes 471 consecutive obese adult patients who underwent bariatric surgery between 2008 and 2015. MEASUREMENTS: We studied the impact of bariatric surgery on body mass index (BMI), renal outcomes (urine ACR and eGFR) and metabolic outcomes (fasting glucose, total cholesterol, low-density lipoprotein, triglycerides, and HbA1c) in 471 patients. METHODS: Patients were followed for 2 years postsurgery in the bariatric clinic. Mixed linear models that accounted for the repeated nature of the data were used to access changes in outcomes over time. RESULTS: Patients were predominantly female (81%) with a mean age (±SD) of 46 ± 10 years. Most patients (87%) had a BMI > 40 kg/m2 and 81% of the patients underwent Roux-en-Y gastric bypass. The mean BMI decreased from 47.7 ± 7.8 kg/m2 at baseline to 37.1 ± 7.9 kg/m2 at 6 months and 34.8 ± 8.8 kg/m2 at 12 months. In a subcohort of patients with microalbuminuria, ACR showed an improvement from a median [interquartile] value of 5.1 [3.7-7.5] mg/mmol at baseline to 2.3 [1.2-3.6] mg/mmol at 6 months (P = .007), to 1.4 [0.9-3.7] mg/mmol at 2-year follow-up (P < .001). Similarly, eGFR increased in patients with microalbuminuria from 109 ± 10 mL/min/1.73 m2 at baseline to 120 ± 36 mL/min/1.73 m2 at 2-year follow-up (P = .013). There were statistically significant reductions in triglycerides, fasting glucose, and HbA1c. LIMITATIONS: This was a retrospective chart review, with the lack of a control group. Patients with eGFR less than 60 mL/min/1.73 m2 were not considered for surgery, and we had to measure renal outcomes predominantly on the presence of proteinuria. CONCLUSIONS: Our results suggest bariatric surgery significantly decreased weight and consequently improved renal and metabolic outcomes (eGFR, ACR, fasting glucose, cholesterol, and triglycerides) in patients with elevated BMI.

CONTEXTE: L'obésité est reconnue comme un facteur de risque indépendant d'insuffisance rénale chronique (IRC) via de multiples voies biologiques directes et indirectes. La chirurgie bariatrique est une méthode efficace et éprouvée pour perdre du poids de façon durable. Or, il existe peu de données mesurant l'impact de cette intervention sur les issues rénales. OBJECTIFS: L'objectif principal était de mesurer la variation du rapport albumine/créatinine (RAC) urinaire chez des patients subissant une chirurgie bariatrique, 12 mois après l'intervention. On souhaitait aussi mesurer le RAC (6 mois et 24 mois), le débit de filtration glomérulaire estimé (DFGe) (6, 12 et 24 mois) et le taux d'hémoglobine glyquée (HbA1c) (12 et 24 mois) à intervalles réguliers après l'intervention. TYPE D'ÉTUDE: Étude de cohorte rétrospective observationnelle portant sur des patients obèses ayant subi une chirurgie bariatrique. CADRE: La clinique provinciale de chirurgie bariatrique du Regina General Hospital (Saskatchewan). SUJETS: Un total de 471 patients consécutifs ayant subi une chirurgie bariatrique entre 2008 et 2015. MESURES: Nous avons étudié l'impact de la chirurgie bariatrique sur l'indice de masse corporelle (IMC), les issues rénales (RAC, DFGe) et les résultats métaboliques (glycémie à jeun, cholestérol total) de 471 patients. MÉTHODOLOGIE: Les patients ont été suivis dans une clinique bariatrique jusqu'à deux ans après l'intervention. Des modèles mixtes linéaires tenant compte de la nature répétitive des données ont été employés pour évaluer les variations dans les résultats au fil du temps. RÉSULTATS: La cohorte était majoritairement féminine (81%) et l'âge moyen (±SD) se situait à 46 ± 10 ans. La majorité des sujets (87%) présentait un IMC supérieur à 40 kg/m2 et 81% des patients avaient subi une dérivation gastrique de type Roux-en-Y. L'IMC moyen est passé de 47,7 ± 7,8 kg/m2 (initial) à 37,1 ± 7,9 kg/m2 après 6 mois, et à 34,8 ± 8,8 kg/m2 après 12 mois. Dans une sous-cohorte de patients atteints de microalbuminurie, le RAC est passé d'une valeur médiane (EIQ) initiale de 5,1 [3,7-7,5] mg/mmol à 2,3 [1,2-3,6] mg/mmol après 6 mois (P = 0,007), et à 1,4 [0,9-3,7] mg/mmol après deux ans de suivi (P < 0,001). Parallèlement, dans cette même sous-cohorte, le DFGe est passé de 109 ± 10 mL/min/1,73 m2 (initial) à 120 ± 36 mL/min/1,73 m2 après deux ans de suivi (P = 0,013). Des réductions statistiquement significatives ont également été observées pour les triglycérides, la glycémie à jeun et l'HbA1c. LIMITES: Il s'agit d'une analyze de dossiers rétrospective sans groupe contrôle. Les patients avec un DFGe inférieur à 60 mL/min/1,73 m2 n'ont pas été pris en compte pour l'intervention et nous avons dû mesurer les issues rénales principalement en fonction de la présence d'une protéinurie. CONCLUSION: Nos résultats suggèrent que la chirurgie bariatrique entraîne une perte significative de poids et, conséquemment, une amélioration des issues rénales et métaboliques (DFGe, RAC, glycémie à jeun, taux de cholestérol et de triglycérides) chez les patients présentant un IMC élevé.

Central Blood Pressure and Pulse Wave Velocity Changes Post Renal Denervation in Patients With Stages 3 and 4 Chronic Kidney Disease: The Regina RDN Study.

BACKGROUND: Central aortic blood pressures and arterial stiffness are better indicators of cardiovascular outcomes than brachial blood pressures. However, their response to renal denervation (RDN) in patients with Stage 3 and Stage 4 chronic kidney disease (CKD) has not yet been examined. OBJECTIVE: To evaluate the impact of RDN on central blood pressures (CBP), brachial (office and ambulatory) blood pressures, arterial stiffness, glomerular filtration rate (GFR), 24-hour urine protein, and selective cardiac parameters observed on echocardiograms. DESIGN: Single-center, single-arm with pre-/post-RDN follow-up. SETTING: Patients were recruited from the multidisciplinary CKD clinic, Regina General Hospital, Canada. PATIENTS: About 25 consecutive patients with Stage 3 or Stage 4 CKD and resistant hypertension, with no radiological or laboratory evidence of secondary causes of hypertension. MEASUREMENTS: The key measurements were CBP, pulse wave velocity, ambulatory 24-hour blood pressure, office blood pressures on BP Tru, GFR, 24-hour urine protein and sodium, dose and number of blood pressure medication and doses. METHODS: The primary outcome measure was the change in CBP from baseline to 6 months post-RDN. Secondary outcome measures included changes in CBP, office blood pressure, 24-hour ambulatory pressures, pulse wave velocity, kidney function (eGFR and 24-hour protein excretion), and the change in the number and dose of medications during the 2-year follow-up period. The primary outcome and the secondary outcomes were evaluated using a Friedman's analysis of variance (ANOVA) and Wilcoxon signed-rank test for changes from post RDN procedure. Bonferroni correction was used to adjust P values for multiple testing. A two-sided alpha of .05 was used. RESULTS: Median central blood pressures (mm Hg) were 127/75 at baseline versus 118/70 at 6 months and 118/67 at 24 months (P = .13). Median office blood pressures (mm Hg) were 148/76 at baseline versus 135/75 at 6 months and 133/75 at 24 months (P ≤ .001). Median ambulatory 24-hour day (mm Hg) was 148/64 at baseline and 146/68 at 6 months and 152/67 at 24 months (P = .60). Median pulse wave velocity (m/s) at baseline was 13.8 at baseline versus 13.3 m/s at 6 months and 12.3 at 12 months' time (P = .62). Estimated glomerular filtration rate (mL/min/1.73m2) at baseline was 37, at 6 months was 36 and 34 at 24 months (P = .33). LIMITATIONS: Single-center study, with no sham arm. CONCLUSIONS: Our study demonstrates that there was a significant improvement in office blood pressures from baseline to 6 months, maintained to 24 months. There was a numerical improvement in central pressures, and pulse wave velocity at 6 and 24 months, with no sustained changes noted in 24-hour blood pressure. Kidney function remained at or near baseline throughout the 24 months of observation. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01832233).

CONTEXTE: La pression aortique centrale (PAC) et la rigidité artérielle sont de meilleurs indicateurs de maladies cardiovasculaires que la pression artérielle brachiale. Cependant, leur réponse à la dénervation rénale (DNR) chez les patients atteints d'insuffisance rénale chronique (IRC) de stade 3 et 4 n'avait pas encore été examinée. OBJECTIF: Évaluer les effets de la DNR sur la PAC, la pression brachiale (en cabinet et ambulatoire), la rigidité artérielle, le débit de filtration glomérulaire estimé (DFGe), la protéinurie sur 24 heures et les paramètres cardiaques sélectifs observés sur les électrocardiogrammes. TYPE D'ÉTUDE: Une étude monocentrique à un seul bras avec suivi pré/post-DNR. CADRE: Les patients ont été recrutés à la clinique multidisciplinaire d'IRC du Regina General Hospital (Canada). SUJETS: L'étude porte sur 25 patients consécutifs atteints d'IRC de stade 3 ou 4 et d'hypertension résistante, sans indications biologiques ou radiologiques des causes secondaires de l'hypertension. MESURES: La PAC, la vélocité de l'onde de pouls (VOP), la pression artérielle sur 24 heures (ambulatoire), la pression artérielle sur BP Tru en cabinet, le DFGe, la protéinurie et les taux de sodium sérique sur 24 heures, de même que le nombre et les doses de médicaments prescrits contre l'hypertension. MÉTHODOLOGIE: La principale mesure attendue était une variation de la PAC six mois post-DNR par rapport à la mesure initiale. Les résultats secondaires incluaient une variation de la PAC, de la pression artérielle en cabinet, des mesures ambulatoires sur 24 heures, de la VOP, de la fonction rénale (DFGe et protéinurie sur 24 heures) et des changements dans le nombre ou les doses de médicaments prescrits contre l'hypertension dans les 24 mois post-DNR. Tous les résultats, primaires ou secondaires, ont été évalués avec les tests ANOVA de Friedman et de rang de Wilcoxon pour déceler les variations post-DNR. Une correction de Bonferroni a été utilisée pour ajuster les valeurs p pour les tests multiples. Un alpha bilatéral de 0,05 a été employé. RÉSULTATS: Les PAC médianes (mm Hg) étaient de 127/75 à l'inclusion c. 118/70 après 6 mois post-DNR et 118/67 après 24 mois (P = 0,13). Les pressions médianes en cabinet (mm Hg) étaient de 148/76 à l'inclusion c. 135/75 après 6 mois et 133/75 après 24 mois (P ≤ 0,001). La pression ambulatoire médiane sur 24 heures (mm Hg) était de 148/64 à l'inclusion et 146/68 après 6 mois et 152/67 après 24 mois (P = 0,60). La médiane de VOP (m/s) à l'inclusion était de 13,8 c. 13,3 après 6 mois et 12,3 après 12 mois (P = 0,62). Le DFGe (mL/min/1,73 m2) était de 37 à l'inclusion, de 36 après 6 mois et de 34 après 24 mois (P = 0,33). LIMITES: L'étude est monocentrique et non contrôlée. CONCLUSION: L'étude démontre une amélioration significative de la pression artérielle mesurée en cabinet, de l'inclusion des patients à six mois post-DNR, amélioration qui s'est maintenue pendant tout le suivi. On a également constaté une amélioration des valeurs de PAC et de la VOP à 6 et à 24 mois, sans changement durable des mesures ambulatoires sur 24 heures. La fonction rénale est demeurée inchangée ou très similaire à ce qu'elle était à l'inclusion pour la durée du suivi.

Successful Use of Renal Denervation in Patients With Loin Pain Hematuria Syndrome-The Regina Loin Pain Hematuria Syndrome Study.

INTRODUCTION: Loin pain hematuria syndrome (LPHS) is characterized by severe unilateral or bilateral loin pain that suggests a renal origin but occurs in the absence of identifiable or relevant urinary tract disease. Hematuria can either be microscopic or macroscopic, but the renal abnormalities responsible for the hematuria are unexplained. Debilitating pain refractory to conventional pain medications is the main cause of morbidity. METHODS: We conducted a single-arm, single-center study. Twelve patients between the ages of 21 and 62 years (11 female, 1 male) with LPHS underwent endovascular ablation of the renal nerves between July 2015 and November 2016, using the Vessix renal denervation system. The primary objective was to achieve 30% reduction in self-reported pain with the McGill Pain Questionnaire (MPQ) at 6 months. The secondary objectives were to measure changes in disability (Oswestry Disability Index [ODI]), mood (Geriatric Depression Scale [GDS]), and quality of life (EuroQol-5D [EQ-5D] and the MOS 36-Item Short Form Survey [SF-36]) scores from baseline to 6 months postprocedure. RESULTS: Ten of 12 patients at 3 months and 11 of 12 patients at 6 months reported a >30% reduction in pain based on the MPQ at 3 and 6 months. We found consistent improvements in MPQ, ODI, GDS, EQ-5D, and SF-36 scores from baseline to 6 months postprocedure. CONCLUSION: We conclude that renal denervation is associated with a considerable improvement in pain, disability, quality of life, and mood. Our results suggest that percutaneous catheter-based delivery of radiofrequency energy is a safe, rapid treatment option that should be considered in all patients with LPHS.