Objective: To examine the impact of looking at the needle versus looking away from the needle on pain and fear during vaccination in adults.Methods: This was a pilot randomized, 2-group parallel trial with adults receiving influenza vaccinations. Participants were stratified and randomly assigned to either look at versus away from the needle. Participants self-reported their pain and fear during vaccination. Results:Of the 184 subjects who agreed to participate, 160 were enrolled; 66% were female. A 3-way ANOVA (looking allocation assignment x looking preference x sex) revealed significant main effects suggesting that being asked to look increases fear (p=0.025) and those who prefer to look away are more fearful (p<0.001). Females reported higher pain and fear scores (p=0.017 and p=0.001, respectively). There were no significant interactions.Discussion: Advising individuals to look away from the needle reduces fear. A larger trial including a larger and diverse sample is recommended.ii

There is variation across Canadian jurisdictions in time to the initiation of biologic disease-modifying antirheumatic drug (bDMARD) therapy among adults with rheumatoid arthritis. From a pan-Canadian perspective, harmonizing time to bDMARD initiation across jurisdictions may result in savings to publicly funded drug plans in some jurisdictions but increased drug expenditures in others. The extent of savings or increased costs is dependent on jurisdiction, the number of new bDMARD users, and whether patients receive a biosimilar or originator bDMARD.

Membranous nephropathy is an autoimmune disease and one of the most common causes of nephrotic syndrome in adults. The incidence of membranous nephropathy is 1.2 in 100,000 persons per year worldwide. Approximately 80% of patients with membranous nephropathy have a classification of primary (or idiopathic) membranous nephropathy. The treatment goal of patients with primary membranous nephropathy is to induce remission. Current treatment options include calcineurin inhibitors (cyclosporine and tacrolimus), cyclophosphamide, and rituximab. Rituximab is not approved for the indication of primary membranous nephropathy in Canada. This review aimed to evaluate the evidence on the use of rituximab compared to cyclophosphamide, tacrolimus, and cyclosporine in adult patients with primary membranous nephropathy. A systematic review of the efficacy and safety of rituximab versus cyclosporine, tacrolimus, or cyclophosphamide was conducted with 18 included randomized controlled trials. A network meta-analysis of 11 of the 18 included randomized controlled trials was uninformative due to the small number of studies, the heterogeneity in the studies, and unreliable point estimates and wide credible intervals obtained with the network meta-analysis. Due to the uninformative nature of the network meta-analysis, a narrative analysis was conducted of the head-to-head trials of rituximab. Two randomized controlled trials showed no evidence of a difference between rituximab and cyclophosphamide, whereas rituximab resulted in a better response rate (complete remission and the composite outcome of partial or complete remission) at 24 months compared with cyclosporine. There were no head-to-head trials comparing rituximab with tacrolimus. Given the small network of studies, the heterogeneity in the included studies, and the limited information provided by the network meta-analysis and the pairwise comparisons of the MENTOR and RI-CYCLO trials, CADTH was unable to conduct an informative economic evaluation. Further, in addition to the clinical evidence gaps, there were also issues identifying information to inform key parameters to address the policy question of interest to decision-makers. Given the limitations associated with the clinical evidence and absence of evidence to inform key model parameters, an economic evaluation would not be able to quantify all relevant incremental costs and effects of using rituximab over the currently used alternatives.