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Purpose It is currently unclear how the shift towards virtual care during the 2019 novel coronavirus (COVID-19) pandemic may have impacted chronic disease management at a population level. The goals of our study were to provide a description of the levels of use of virtual care services relative to in-person care in patients with chronic disease across Ontario, Canada and to describe levels of healthcare utilization in low versus high virtual care users. Methods We used linked health administrative data to conduct a population-based, repeated cross-sectional study of all ambulatory patient visits in Ontario, Canada (January 1, 2018 to January 16, 2021). Further stratifications were also completed to examine patients with COPD, heart failure, asthma, hypertension, diabetes, mental illness, and angina. Patients were classified as low (max 1 virtual care visit) vs. high virtual care users. A time-series analysis was done using interventional autoregressive integrated moving average (ARIMA) modelling on weekly hospitalizations, outpatient visits, and diagnostic tests. Results The use of virtual care increased across all chronic disease patient populations. Virtual care constituted at least half of the total care in all conditions. Both low and high virtual care user groups experienced a statistically significant reduction in hospitalizations and laboratory testing at the start of the pandemic. Hospitalization volumes increased again only among the high users, while testing increased in both groups. Outpatient visits among high users remained unaffected by the pandemic but dropped in low users. Conclusion The decrease of in-person care during the pandemic was accompanied by an increase in virtual care, which ultimately allowed patients with chronic disease to return to the same visit rate as they had before the onset of the pandemic. Virtual care was adopted across various chronic conditions, but the relative adoption of virtual care varied by condition with highest rates seen in mental health.

The gonadal arteries are paired vessels that usually originate from the abdominal aorta at the level of second lumbar vertebra. In 5-20% of cases, the gonadal artery has a high origin (superior to L2) and in 5-6% of cases it originates from the main or accessory renal artery. The latter is referred to here as an aberrant gonadal artery. Ninety-eight kidneys of 50 healthy potential renal transplant donors were prospectively studied by conventional angiography. The renal artery, either main or accessory, was detected and individually injected to highlight their perihilar divisions and possible extrarenal branches. The gonadal arteries were recorded if they originated from the renal arteries. We found that 39% (n = 38) of kidneys had at least one accessory renal artery. In 14 sides (14% of kidneys), the gonadal artery (11 right and 3 left) originated from the renal artery, either main (n = 5) or accessory (n = 9). Ten out of 14 kidneys with an aberrant gonadal artery had an associated accessory renal artery. In nine cases, the gonadal artery originated from the accessory renal artery, and in one case, although it originated from the main renal artery, the same kidney had an accessory arterial supply. The results of this study demonstrate that aberrant gonadal arteries tend to originate from kidneys that possess an accessory arterial supply. We hypothesize that aberrancies of the gonadal artery are a part of a common embryologic error resulting in the persistence of the future accessory renal arteries. We believe that this study is the first to hypothesize and study such an association with these arterial anomalies of the renal pedicle.

IMPORTANCE Use of stimulants continues to increase among older adults for a variety of indications. An association between stimulant use and increased risk of cardiovascular (CV) events has been established among children and young adults, but few studies have explored the risk of CV events among older patients, a group with increased baseline risk.OBJECTIVE To evaluate the association between stimulant use and risk of CV events among older adults.

The variations of renal arteries are considered critical issues that surgeons should have thorough envision and appreciation of the condition. Variations of these vessels may influences urological, renal transplantation and laparoscopic surgeries. We present a case of bilateral accessory renal artery with a striking pre-hilar branching pattern encountered upon digital subtraction angiography (DSA) for imaging of the renal arteries of a healthy 30-year-old man, renal transplant donor. The right kidney received two renal arteries from the aorta including a main hilar and one lower polar. However, the left accessory artery while originated from the aorta, simultaneously, supplied both upper and lower renal poles following its pre-hilar division that replaced upper/apical and lower segmental arteries of the single main renal artery, respectively. The left main renal artery divided into two anterior and posterior segmental arteries. Whether this should be categorized either as an accessory hilar artery or a unique variant of renal arterial supply, the so-called bipolar supernumerary renal artery, is a matter of debate. We discuss possible embryologic origin and clinical aspects of accessory renal artery.

The peri-hilar (extra-parenchymal) branching pattern of the renal artery is important for surgeons to know prior to kidney transplantation. The aim of this study was to identify the variations in peri-hilar branching pattern and morphology of the main renal artery. Arteriograms of 81 kidneys were examined. After marking the renal shadow, the main renal artery was traced laterally from its origin. Morphologically, the arterial branching patterns were classified into ladder (with sequential branching points) and fork (with a common branching point) types. The latter was either duplicated or triplicated. The peri-hilar morphology of the main renal artery was then categorized according to its primary and secondary divisions and their patterns. If a single category encompassed at least 5% of the observed figures, it was recorded as a "cardinal" peri-hilar arterial morphology. Otherwise, it was counted within the category of "infrequent" morphologies. At the level of the main artery, a fork pattern was observed in 92.6% (n = 75) (80.2% duplicated (n = 65) and 12.4% triplicated (n = 10)) and a ladder pattern in 7.4% (n = 6) of kidneys. Of 160 primary branches off the fork-type main artery, a secondary division was found in 68.8%. Only one further division (4.4%) was noted from the ladder-type primary arteries. Eight "cardinal" peri-hilar renal arterial morphologies were identified and represented 82.7% of all cases. At least ten "infrequent" morphologies were also found. These patterns showed some alteration with the presence of a supernumerary renal artery. We concluded that the peri-hilar branching of main renal artery is highly variable, though this may follow certain patterns. We believe that the results may be useful to surgeons operating at the renal hilum especially during kidney transplantation.

Romosozumab (ROMO) is a recently approved monoclonal antibody (approved by the U.S. Food and Drug Administration [FDA] in April 2019 and Health Canada in June 2019) for the treatment of osteoporosis in postmenopausal women. ROMO works by selectively inhibiting sclerostin-a glycoprotein that inhibits osteoblasts and further promotes bone resorption. The authors reviewed three phase III clinical trials (Fracture Study in Postmenopausal Women with Osteoporosis [FRAME], Active-Controlled Fracture Study in Postmenopausal Women with Osteoporosis at High Risk [ARCH], and STudy evaluating the effect of RomosozUmab Compared with Teriparatide in postmenopaUsal women with osteoporosis at high risk for fracture pReviously treated with bisphosphonatE therapy [STRUCTURE]) that demonstrated ROMO's ability to increase bone mineral density (BMD) at the lumbar spine and hip and the risk of vertebral and clinical fractures. Additionally, clinical trials demonstrated the risk for serious cardiovascular events among patients that received ROMO, and these severe adverse reactions deserve further investigation. Although ROMO presents as a potentially exciting therapeutic with serious clinical implications, the authors recommend further analysis using real-world evidence (RWE) studies to fully elucidate the cardiovascular event risk associated with ROMO administration.

Limited data are available to understand costs and trends over time in the Canadian pharmaceutical market across all sectors. To fill this gap, a retrospective time series analysis of annual prescription drug purchases in Canada between 2001 and 2020 was conducted using data from the IQVIA Canadian Drugstore and Hospital Purchases Audit. Spending has grown over the past 2 decades at a steady pace, with annual average growth of 5.3% and 7.1% in the retail and hospital sectors, respectively. Total prescription purchases in 2020 were approximately $32.7 billion, 4.3% higher than in 2019 (3.8% growth in retail, 6.9% in hospital). New approvals of specialty and oncology drugs and generic formulations of the top 25 drugs may influence drug purchases in 2021 to 2023. Overall drug purchases in Canada are projected to continue growing. The forecast for the outpatient sector is continued moderate levels of growth in drug spending (3% to 4%), with higher rates of growth (7% to 8%) in the hospital setting. Action should be taken to curb sustained growth in pharmaceutical spending in Canada. Otherwise, these costs may be shifted to other budgets, private industry, and/or patients.