Immunoglobulin-A Vasculitis With Renal Involvement in a Patient With COVID-19: A Case Report and Review of Acute Kidney Injury Related to SARS-CoV-2.

RATIONALE: Acute kidney injury is a common complication of COVID-19 and is associated with significantly increased mortality. The most frequent renal biopsy finding with SARS-CoV-2 infection is acute tubular injury; however, new onset glomerular diseases have been reported. The development of persistent urinary abnormalities in patients with COVID-19 should prompt consideration for renal biopsy to rule out glomerulonephritis. PRESENTING CONCERNS: A 30-year-old man with no prior medical history presented to the emergency department with symptoms of COVID-19 and new onset painful purpuric rash, arthralgia, and abdominal pain. SARS-CoV-2 infection was confirmed with nucleic acid testing and laboratory investigations revealed preserved renal function with dysmorphic hematuria and nephrotic range proteinuria. DIAGNOSIS: A skin biopsy of the purpuric rash was performed, which demonstrated leukocytoclastic vasculitis. Renal biopsy revealed focally crescentic and segmentally necrotizing IgA nephropathy. Overall, given the clinical syndrome of glomerulonephritis with purpuric rash, arthralgia, and abdominal pain, the presentation is most in keeping with a diagnosis of IgA vasculitis in the setting of COVID-19. INTERVENTIONS: The patient was treated conservatively for COVID-19 in the community. A 7-day course of prednisone was started for the vasculitic rash. IgA nephropathy was managed conservatively with blood pressure control and RAAS blockade with losartan. OUTCOMES: With conservative management, the patient's COVID-19 symptoms resolved completely and he did not require hospital admission. Following prednisone therapy, the patient's rash, arthralgia, and abdominal pain improved. However, despite resolution of COVID-19, hematuria and proteinuria persisted. With the initiation of RAAS blockade, renal function remained stable and proteinuria improved dramatically at 6 weeks. NOVEL FINDINGS: De novo glomerulonephritis is a renal manifestation of SARS-CoV-2 infection beyond acute tubular injury. IgA vasculitis appears to be a rare complication of COVID-19.

Description of a Multi-faceted COVID-19 Pandemic Physician Workforce Plan at a Multi-site Academic Health System.

BACKGROUND: The evolving COVID-19 pandemic has and continues to present a threat to health system capacity. Rapidly expanding an existing acute care physician workforce is critical to pandemic response planning in large urban academic health systems. INTERVENTION: The Medical Emergency-Pandemic Operations Command (MEOC)-a multi-specialty team of physicians, operational leaders, and support staff within an academic Department of Medicine in Calgary, Canada-partnered with its provincial health system to rapidly develop a comprehensive, scalable pandemic physician workforce plan for non-ventilated inpatients with COVID-19 across multiple hospitals. The MEOC Pandemic Plan comprised seven components, each with unique structure and processes. METHODS: In this manuscript, we describe MEOC's Pandemic Plan that was designed and implemented from March to May 2020 and re-escalated in October 2020. We report on the plan's structure and process, early implementation outcomes, and unforeseen challenges. Data sources included MEOC documents, health system, public health, and physician engagement implementation data. KEY RESULTS: From March 5 to October 26, 2020, 427 patients were admitted to COVID-19 units in Calgary hospitals. In the initial implementation period (March-May 2020), MEOC communications reached over 2500 physicians, leading to 1446 physicians volunteering to provide care on COVID-19 units. Of these, 234 physicians signed up for hospital shifts, and 227 physicians received in-person personal protective equipment simulation training. Ninety-three physicians were deployed on COVID-19 units at four large acute care hospitals. The resurgence of cases in September 2020 has prompted re-escalation including re-activation of COVID-19 units. CONCLUSIONS: MEOC leveraged an academic health system partnership to rapidly design, implement, and refine a comprehensive, scalable COVID-19 acute care physician workforce plan whose components are readily applicable across jurisdictions or healthcare crises. This description may guide other institutions responding to COVID-19 and future health emergencies.

Evaluation of the Cost of a High-Dose Intravenous Iron Protocol in a Regional Hemodialysis Program: Research Letter.

BACKGROUND: Intravenous (IV) iron and erythropoietin stimulating agents (ESAs) are standard treatments for anemia in patients receiving maintenance hemodialysis. These medications are associated with significant costs to hemodialysis programs and patients. Recent trial evidence demonstrated that a high-dose IV iron protocol reduces ESA usage and improves cardiovascular outcomes. The cost of implementing a high-dose iron protocol within the Canadian public healthcare context remains unknown. OBJECTIVE: Our primary aim was to estimate the costs of a high-dose IV iron protocol in a large Canadian hemodialysis program that currently uses a low-dose and reactive IV iron strategy. Our secondary aim was to estimate the reduction in ESA use required to maintain cost neutrality with a high-dose IV iron protocol. DESIGN: In this modeling study of IV iron and ESA utilization from a regional hemodialysis program, changes in medication utilization were calculated based on observed effects from published trial data. Using data from a quality improvement audit of regional anemia management and medication utilization, we estimated potential cost differences under various modeling conditions. SETTING: Four adult hospital-based and 9 community in-center hemodialysis units in the Alberta Kidney Care-South renal program during the observation period of September 1, 2018, to November 30, 2018. PATIENTS: In total, data from 826 patients were included. MEASUREMENTS: Mean monthly IV iron and ESA doses were obtained from routine audit data captured within an electronic medical record. Costs were determined from provincially negotiated medication prices. METHODS: Current IV iron and erythropoietin dosages were aggregated at the hemodialysis unit level. We used the results from the PIVOTAL trial to estimate the expected increase in IV iron dose and reduction in ESA dose with a high-dose IV iron protocol. We assumed the split between various manufactures of IV iron and ESA were maintained in our cost model. Total medication costs were aggregated by hemodialysis unit, and the mean costs in each unit were used to estimate per-patient costs. Sensitivity analyses included models that assumed 100% IV iron sucrose usage, as well as models where community hemodialysis units and hospital-based hemodialysis units were examined separately. Finally, we calculated a break-even point for ESA dose reduction required to maintain cost neutrality. RESULTS: Actual baseline IV iron and ESA dose utilization across 13 adult HD units were 118 mg/patient/month (95% confidence interval [CI]: 102-134 mg) and 20,764 IU/pt./mo. (95% CI: 18,104-23,424 IU), respectively. The mean combined cost of ESA and IV iron was $315/pt./mo. (95% CI: $274-$355). In comparison, using the results of the PIVOTAL trial and assuming a high-dose IV iron scenario, we estimated mean IV iron use of 215 mg/pt./mo. (95% CI: 187-243 mg/pt./mo.) and a reduction in mean ESA use to 15,923 IU/pt./mo. (95% CI: 13,883-17,962 IU/pt./mo.). This resulted in an estimated cost savings of $38/pt./mo. (95% CI: $33-$42/pt./mo.) and a total program savings of $370,000 per year (95% CI: $325,000-$420,000). Sensitivity analyses under various alternate conditions also showed potential cost savings. We estimated that a dose reduction of ESA of 10% would be required for cost neutrality with a high-dose IV iron protocol. LIMITATIONS: Our study is limited in its use of data from a single randomized controlled trial (RCT) to estimate cost savings rather than actualized utilization. Our models do not take into consideration anticipated reductions in transfusions and hospitalizations that could be realized from a high-dose IV iron protocol. CONCLUSIONS: Based on cost modeling, a high-dose IV iron protocol could be integrated in large Canadian regional hemodialysis program in a cost saving manner. Programs implementing such a protocol should monitor IV iron and EPO use prospectively to determine if the trial protocol as applied in a real-world setting translates into cost savings.

CONTEXTE: Le traitement habituel pour soigner l'anémie chez les patients sous hémodialyse d'entretien consiste en l'administration d'un supplément de fer par voie intraveineuse (IV) et d'agents de stimulation de l'érythropoïétine (ASE); des médicaments coûteux pour les programs d'hémodialyse et les patients. Des études récentes ont démontré qu'un protocole de fer IV à dose élevée réduisait l'utilization des ASE et améliorait les résultats cardiovasculaires. On ignore toutefois les coûts associés à la mise en œuvre d'un tel protocole dans le système public canadien. OBJECTIFS: Notre principal objectif était d'estimer les coûts d'un protocole de fer IV à dose élevée dans un program majeur d'hémodialyse canadien utilisant une stratégie d'administration de fer IV à faible dose et réactive. Nous souhaitions également estimer le taux de réduction de l'utilization des ASE permettant de maintenir la neutralité des coûts avec un protocole de fer IV à dose élevée. CONCEPTION: Dans cette étude de modélisation, où l'administration de fer IV et d'ASE a été examinée dans le cadre d'un program régional d'hémodialyse, les changements dans l'utilization des médicaments ont été calculés en fonction des effets observés à partir des données publiées. Les potentielles différences de coûts ont été estimées dans diverses conditions de modélisation à l'aide des données d'un audit mesurant l'amélioration de la qualité de la gestion de l'anémie et l'utilization des médicaments au niveau régional. CADRE: Quatre unités d'hémodialyse pour adultes en milieu hospitalier et neuf centers d'hémodialyse communautaires du program Alberta Kidney Care ­ South Renal entre le 1er septembre 2018 et le 30 novembre 2018. SUJETS: Les données de 826 patients ont été incluses. MESURES: Les doses moyennes mensuelles de fer IV et d'ASE ont été obtenues avec les données d'un audit courant tirées d'un dossier médical électronique. Les coûts ont été évalués avec les prix négociés par la province pour ces médicaments. MÉTHODOLOGIE: Les posologies actuelles de fer IV et d'érythropoïétine ont été agrégées au niveau de l'unité d'hémodialyse. Les résultats de l'essai PIVOTAL ont servi à estimer l'augmentation prévue de la dose de fer IV et la réduction prévue de la dose d'ASE avec un protocole de fer IV à dose élevée. Nous avons supposé que la division entre les divers fabricants de fer IV et d'ASE était maintenue dans notre modèle de coûts. Les coûts totaux des médicaments ont été agrégés par unité d'hémodialyse, et les coûts moyens pour chaque unité ont été employés pour estimer les coûts par patient. Les analyses de sensibilité ont inclus des modèles qui supposaient une utilization à 100 % du fer saccharose IV et des modèles où les unités d'hémodialyse communautaires et hospitalières ont été examinées séparément. Enfin, nous avons calculé un seuil de rentabilité pour la réduction d'ASE nécessaire au maintien de la neutralité des coûts. RÉSULTATS: L'utilization réelle initiale de fer IV et d'ASE dans les 13 unités d'HD pour adultes était respectivement de 118 mg/patient/mois (IC 95 % : 102 mg à 134 mg) et de 20 764 UI/pt/mois (IC 95 % : 18 104 à 23 424 UI). Le coût combiné moyen du fer IV et des ASE était de 315 $/pt/mois (IC 95 % : 274 à 355 $). En comparaison, en utilisant les résultats de l'essai PIVOTAL et en supposant un scénario de fer IV à dose élevée, nous avons estimé une utilization moyenne de fer IV à 215 mg/pt/mois (IC 95 % : 187 à 243 mg/pt/mois) et une réduction de l'utilization moyenne d'ASE de 15 923 UI/pt/mois (IC 95 % : 13 883 à 17 962 UI/pt/mois); ce qui entraînerait une possible économie de 38 $/pt/mois (IC 95 % : 33 à 42 $/pt/mois) et une économie totale de 370 000 $ par année pour le program (IC 95 % : 325 000 à 420 000 $). Les analyses de sensibilité dans diverses conditions ont également montré des économies potentielles. Nous avons estimé qu'une réduction de 10 % de la dose d'ASE serait nécessaire pour maintenir la neutralité des coûts avec un protocole de fer IV à dose élevée. LIMITES: Notre étude utilize les données d'un seul essai clinique randomisé pour estimer les économies de coûts plutôt que l'utilization actualisée. Nos modèles ne prennent pas en compte les réductions dans les nombres de transfusions et d'hospitalisations qui pourraient découler d'un protocole de fer IV à dose élevée. CONCLUSION: Selon la modélisation des coûts, un protocole de fer IV à dose élevée pourrait être intégré à un program majeur d'hémodialyse régional canadien et réduire les coûts. Les programs qui mettent en œuvre un tel protocole devraient surveiller l'administration de fer IV et d'EPO de façon prospective pour déterminer si le protocole de l'essai, lorsqu'il est appliqué dans un contexte réel, se traduit par une réduction des coûts.

Controversies in vascular access.

PURPOSE OF REVIEW: There is renewed interest in vascular access research, fueled by new perspectives and a critical re-examination of traditional thinking. This review summarizes important developments in vascular access from the past year, highlight areas of controversy, and makes recommendations for future research. RECENT FINDINGS: Recent studies provide an innovative and critical look at the assumptions underlying the promotion of fistulas as the preferred form of vascular access and highlight the need for a randomized comparison of different forms of access. Promising work that will help determine predictors of fistula maturation and potentially improve patient selection is ongoing. The role of early cannulation grafts continues to generate interest, and new approaches to reducing the risk of catheter-related bacteremia show promise. SUMMARY: The scientific community should capitalize on this opportunity to critically re-examine fundamental questions that have gone unanswered to date. High-quality randomized trials are needed to quantify the magnitude of benefit of different vascular access strategies, gather information about the risks, benefits, and cost-effectiveness of different approaches, and to get a clear view of the patient experience and how it is impacted by choice of vascular access.

Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial.

BACKGROUND: Recent warnings from Health Canada regarding codeine for children have led to increased use of nonsteroidal anti-inflammatory drugs and morphine for common injuries such as fractures. Our objective was to determine whether morphine administered orally has superior efficacy to ibuprofen in fracture-related pain. METHODS: We used a parallel group, randomized, blinded superiority design. Children who presented to the emergency department with an uncomplicated extremity fracture were randomly assigned to receive either morphine (0.5 mg/kg orally) or ibuprofen (10 mg/kg) for 24 hours after discharge. Our primary outcome was the change in pain score using the Faces Pain Scale - Revised (FPS-R). Participants were asked to record pain scores immediately before and 30 minutes after receiving each dose. RESULTS: We analyzed data from 66 participants in the morphine group and 68 participants in the ibuprofen group. For both morphine and ibuprofen, we found a reduction in pain scores (mean pre-post difference ± standard deviation for dose 1: morphine 1.5 ± 1.2, ibuprofen 1.3 ± 1.0, between-group difference [δ] 0.2 [95% confidence interval (CI) -0.2 to 0.6]; dose 2: morphine 1.3 ± 1.3, ibuprofen 1.3 ± 0.9, δ 0 [95% CI -0.4 to 0.4]; dose 3: morphine 1.3 ± 1.4, ibuprofen 1.4 ± 1.1, δ -0.1 [95% CI -0.7 to 0.4]; and dose 4: morphine 1.5 ± 1.4, ibuprofen 1.1 ± 1.2, δ 0.4 [95% CI -0.2 to 1.1]). We found no significant differences in the change in pain scores between morphine and ibuprofen between groups at any of the 4 time points (p = 0.6). Participants in the morphine group had significantly more adverse effects than those in the ibuprofen group (56.1% v. 30.9%, p < 0.01). INTERPRETATION: We found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen. However, morphine was associated with a significantly greater number of adverse effects. Our results suggest that ibuprofen remains safe and effective for outpatient pain management in children with uncomplicated fractures. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT01690780.