A Canadian Academic Hospital's Initial MAID Experience: A Health-Care Systems Review.

BACKGROUND:: Following the Supreme Court of Canada's Carter Decision, medical assistance in dying (MAID) became possible with individual court orders in February 2016. Subsequently, on June 17, 2016, legislation was passed that eliminated the need for court orders, essentially making physicians the arbiters of these requests. Canadian health-care facilities now face the challenge of addressing this unprecedented patient health-care need. AIM:: To describe the manner in which London Health Sciences Center has approached local and regional requests for MAID, including the administration, ethics, privacy, and clinical process. DESIGN:: A health-care systems descriptive study. SETTING/PARTICIPANTS:: Between June 6, 2016, and May 30, 2018, London Health Sciences Center's MAID Internal Resource Committee triaged and referred 260 cases. Ninety-six received the requisite assessments were deemed eligible for and received MAID. RESULTS:: The procedure was completed in hospital 59 (61%) times, and 37 (39%) times in the community (either private residence or long-Term Care facility). Nineteen patients did not meet MAID criteria and 63 patients died while awaiting the procedure. The median wait time between first request and referral was 1 day. The median time between referral and the procedure was 12.0 days. The ratio of referrals to completed cases is 96 of 260 (or 37% conversion rate). CONCLUSION:: Our MAID processes, including our committee structure, referral triage process, and physical site have all undergone extensive review and improvement cycles throughout these first 2 years with the aim of ensuring that this procedure is managed in a respectful, confidential, safe, efficient, and patient-centered manner.

Prevention of necrotizing enterocolitis with probiotics: a systematic review and meta-analysis.

CONTEXT: Necrotizing enterocolitis (NEC) is the most frequent gastrointestinal emergency in neonates. The microbiome of the preterm gut may regulate the integrity of the intestinal mucosa. Probiotics may positively contribute to mucosal integrity, potentially reducing the risk of NEC in neonates. OBJECTIVE: To perform an updated systematic review and meta-analysis on the efficacy and safety of probiotics for the prevention of NEC in premature infants. DATA SOURCES: Structured searches were performed in: Medline, Embase, and the Cochrane Central Register of Controlled Trials (all via Ovid, from 2013 to January 2015). Clinical trial registries and electronically available conference materials were also searched. An updated search was conducted June 3, 2016. STUDY SELECTION: Randomized trials including infants less than 37 weeks gestational age or less than 2,500 g on probiotic vs. standard therapy. DATA EXTRACTION: Data extraction of the newly-identified trials with a double check of the previously-identified trials was performed using a standardized data collection tool. RESULTS: Thirteen additional trials (n = 5,033) were found. The incidence of severe NEC (RR 0.53 95% CI [0.42-0.66]) and all-cause mortality (RR 0.79 95% CI [0.68-0.93]) were reduced. No difference was shown in culture-proven sepsis RR 0.88 95% CI [0.77-1.00]. LIMITATIONS: Heterogeneity of organisms and dosing regimens studied prevent a species-specific treatment recommendation from being made. CONCLUSIONS: Preterm infants benefit from probiotics to prevent severe NEC and death.

Thiamine prescribing practices within university-affiliated hospitals: a multicenter retrospective review.

BACKGROUND: Patients with suspected thiamine deficiency should receive treatment with parenteral thiamine to achieve the high serum thiamine levels necessary to reverse the effects of deficiency and to circumvent problems with absorption common in the medically ill. OBJECTIVE: To quantify rates of parenteral administration of thiamine across university-affiliated hospitals and to identify factors associated with higher rates of parenteral prescribing. DESIGN: Multicenter, retrospective observational study of thiamine prescriptions. METHODS: Prescriptions for thiamine were captured from computerized pharmacy information systems across participating centers, providing information concerning dose, route, frequency, and duration of thiamine prescribed from January 2010 to December 2011. SETTING: Fourteen university-affiliated tertiary care hospitals geographically distributed across Canada, including 48,806 prescriptions for thiamine provided to 32,213 hospitalized patients. RESULTS: Parenteral thiamine accounted for a statistically significant majority of thiamine prescriptions (57.6%, P < 0.001); however, oral thiamine constituted a significant majority of the total doses prescribed (68.4%, z = 168.9; P < 0.001). Protocols prioritizing parenteral administration were associated with higher rates of parenteral prescribing (61.3% with protocol, 45.8% without protocol; P < 0.001). Patients admitted under psychiatry services were significantly more likely to be prescribed oral thiamine (P < 0.001). CONCLUSIONS: Although parenteral thiamine accounted for a statistically significant majority of prescriptions, oral thiamine was commonly prescribed within academic hospitals. Additional strategies are needed to promote parenteral thiamine prescribing to patients with suspected thiamine deficiency.