Rapid refeeding in anorexia nervosa: A dialectic balance.

OBJECTIVE: To examine the impact of our new rapid refeeding protocol on patients with anorexia nervosa (AN) in our Eating Disorders Program. We hypothesize that the new protocol would lead to a more rapid weight gain and a shorter length of stay, with no effect on medical complications or program completion. METHOD: This cohort design included consecutive inpatients and day hospital patients admitted to the program with a BMI <18 kg/m2 and a diagnosis of AN between 2007 and 2020; N = 326 patients. Main outcomes measured were rate of weight gain and length of stay. Safety indicators included electrolyte disturbances and supplementation required, complications including refeeding syndrome and completion of the program. A p value <.05 was considered statistically significant. RESULTS: Total length of stay was 21 days shorter for patients on the rapid refeeding protocol compared to the traditional refeeding protocol. Patients on the new protocol gained 0.21 more kg/week compared to patients on the old protocol. There was no difference in completion rates between programs. Electrolyte imbalances were mild to moderate and easily treated with oral electrolyte supplementation. There were no deaths or cases of refeeding syndrome with either protocol. DISCUSSION: This is the first Canadian study to assess the effectiveness and safety of rapid refeeding in an adult population. Rapid refeeding protocols can be safely administered and are cost effective. Shorter hospital admissions are desirable to minimize possible regression and dependency on inpatient services and positively impacts patients' quality of life. PUBLIC SIGNIFICANCE: This study advances the idea that rapid refeeding in patients with anorexia nervosa can be administered safely and effectively with close medical monitoring. In addition, rapid refeeding leads to shorter hospital stays, with a cost-savings to the health system. Shorter admissions are desirable to minimize possible regression and dependency on inpatient services and also positively impacts patients' quality of life.

Prescription Modification by Pharmacists in a Hospital Setting: Are Ontario Pharmacists Ready?

BACKGROUND: Under Ontario's Public Hospitals Act, the scope of professional practice of hospital pharmacists is approved by each hospital's medical advisory committee. Some Ontario hospitals have adopted policies or medical directives related to prescription modification, allowing pharmacists to broadly adapt, discontinue, hold, or renew prescriptions as part of their clinical scope of practice. OBJECTIVES: The primary objective of this study was to describe Ontario hospital pharmacists' perception of their readiness to independently modify prescriptions. The secondary objectives of this study were to gather opinions on the perceived benefits, drawbacks, facilitators, and barriers to prescription modification by pharmacists and to determine how various factors affect perceived readiness. METHODS: A confidential web-based survey with Likert-type quantitative questions and qualitative open-ended questions was distributed to 936 hospital pharmacists in Ontario between May and July 2019. Mean scores were calculated for the following constructs affecting prescription modification: self-efficacy, support from the practice environment, and support from interprofessional relationships. Independent t tests were conducted to compare responses between subgroups of interest. The answers to open-ended questions were analyzed thematically. RESULTS: The survey had a 29% response rate (n = 271). The mean self-efficacy score was 5.2 out of 7 (standard deviation [SD] 1.0, Cronbach α = 0.88), equivalent to "quite sure". The mean score for support from the practice environment was 3.3 out of 5 (SD 0.4, Cronbach α = 0.75), equivalent to "not a factor". The mean score for support from interprofessional relationships was 4.2 out of 5 (SD 0.1, Cronbach α = 0.80), equivalent to "weak support". Improved efficiency of care, timelier interventions to improve medication safety and efficacy, and improved interprofessional collaboration were cited as benefits of prescription modification by pharmacists. Potential for inappropriate decision-making and miscommunication were cited as concerns. Respondents in hospitals who were already performing prescription modification reported higher self-efficacy to modify prescriptions in clinical areas of both familiarity and unfamiliarity and greater support from prescribers. CONCLUSIONS: A large proportion of respondents to a survey of Ontario hospital pharmacists expressed an encouraging level of readiness to independently modify prescriptions. Responses to open-ended questions in this study provided valuable insights to inform widespread adoption of this practice change.

CONTEXTE: En vertu de la Loi sur les hôpitaux publics de l'Ontario, le comité consultatif de chaque hôpital approuve l'élargissement de la pratique professionnelle des pharmaciens d'hôpitaux. Certains hôpitaux de l'Ontario ont adopté des politiques ou des directives médicales concernant la modification de la prescription. Celles-ci autorisent les pharmaciens à adapter, cesser, suspendre ou renouveler largement les prescriptions dans le cadre de leur champ de pratique. OBJECTIFS: L'objectif principal de cette étude visait à décrire la perception des pharmaciens d'hôpitaux de l'Ontario de leur degré de préparation à modifier des prescriptions de manière indépendante. Les objectifs secondaires consistaient à recueillir les opinions sur les avantages, les inconvénients, les éléments de facilitation et les obstacles perçus par les pharmaciens au sujet de la modification de la prescription et de définir comment divers facteurs influençaient la perception de leur degré de préparation. MÉTHODES: Entre mai et juillet 2019, 936 pharmaciens d'hôpitaux en Ontario ont reçu une enquête confidentielle menée sur Internet comportant des questions quantitatives de type Likert et des questions ouvertes qualitatives. Les scores médians ont été calculés pour les concepts suivants liés à la modification de la prescription : l'autoefficacité, le soutien de l'environnement de pratique et le soutien des relations interprofessionnelles. Des tests t indépendants ont été menés pour comparer les réponses entre les sous-groupes sous-groupes qui intéressaient les auteurs. Les réponses aux questions ouvertes ont été analysées par thème. RÉSULTATS: Le taux de réponses à l'enquête se montait à 29 % (n = 271). Le score moyen pour le thème « Autoefficacité ¼ était de 5,2 sur 7 (écart type [ET] 1, Cronbach α = 0,88), ce qui équivaut à la réponse « Assez certain ¼. Le score moyen pour le thème « Soutien de l'environnement de pratique ¼ était de 3,3 sur 5 (ET 0,4, Cronbach α = 0,75), ce qui équivaut à la réponse « N'est pas un facteur ¼. Le score moyen pour le thème « Relations interprofessionnelles ¼ était de 4,2 sur 5 (ET 0,1, Cronbach α = 0,80), ce qui équivaut à la réponse « Soutien faible ¼. Les pharmaciens ont cité l'amélioration de l'efficacité des soins, les interventions en temps opportun visant à améliorer l'innocuité et l'efficacité des médicaments ainsi que l'amélioration de la collaboration interprofessionnelle comme étant des avantages de la modification indépendante des prescriptions. Ils ont aussi indiqué que le risque de prise de décision inappropriée ainsi que la mauvaise communication constituaient pour eux un sujet de préoccupation. Les répondants qui pratiquaient déjà la modification de la prescription en milieu hospitalier ont indiqué un gain d'autoefficacité de la modification des prescriptions dans des domaines cliniques qui leur sont familiers ou non, ainsi qu'un plus grand soutien de la part des prescripteurs. CONCLUSIONS: Une grande partie des répondants à une enquête menée auprès de pharmaciens d'hôpitaux de l'Ontario ont jugé que leur degré de préparation à la modification indépendante des ordonnances était prometteur. Les réponses aux questions ouvertes de cette étude fournissent des éclaircissements précieux sur l'adoption généralisée de ce changement de pratique.

An Exploratory Screening Study for Type 2 Diabetes in Hospitalized Adult Medicine Patients.

OBJECTIVES: Literature from stroke and cardiac hospital admissions demonstrate a higher prevalence of undiagnosed type 2 diabetes compared with the general population. Fewer diabetes screening studies exist in the general medicine population, none of which have been based in Canada. Our primary objective in this study was to determine the prevalence of probable undiagnosed diabetes (glycated hemoglobin [A1C]≥6.5%) in hospitalized medicine patients. Secondary objectives were to identify the prevalence of undiagnosed dysglycemia (A1C≥6.0%) and the subsequent management of emergent cases. METHODS: In this prospective cohort study, adult patients admitted to internal medicine at a tertiary hospital in Ontario were screened for diabetes using an A1C test over a 3-month period. Baseline demographics and outcomes were compared using t tests, chi-square tests and Fisher's exact tests for normoglycemia, undiagnosed dysglycemia and probable undiagnosed diabetes. A regression analysis was performed to identify any relationships between various cardiovascular-related risk factors and A1C. RESULTS: A total of 53 adult patients were enrolled. The prevalence of probable undiagnosed diabetes and undiagnosed dysglycemia was 7.5% (n=4) and 30.2% (n=16), respectively. Implementation of diabetes management strategies and/or documentation of the finding occurred in 4 of 16 patients. Regression analysis showed no relationship between either cardiovascular-related risk factors or admission glucose with A1C. CONCLUSIONS: A broader screening approach may capture previously undiagnosed cases of diabetes that do not belong to traditionally at-risk populations. Future studies should focus on identifying risk factors for undiagnosed dysglycemia in hospitalized patients, including ethnicity and barriers to community access, so that appropriate screening programs can be developed.

Association Between Use of Proton Pump Inhibitors and a Clostridium difficile-Associated Disease Outbreak: Case-Control Study.

BACKGROUND: The use of proton pump inhibitors (PPIs) has been implicated as a potential contributor to the development of Clostridium difficile-associated disease (CDAD) because of the ability of these drugs to substantially reduce the bactericidal effect of gastric acid. This study focused on the impact of PPIs, among other known risk factors, during an outbreak of CDAD in a hospital setting. OBJECTIVES: The primary objective was to determine whether there was an association between current use of a PPI and the CDAD outbreak. Secondary objectives were to evaluate any correlations between the CDAD outbreak and past use of PPIs, use of antibiotics, diabetes mellitus, enteral feeding, cancer, gastrointestinal surgery, inflammatory bowel disease, and previous care or residence in an institutional setting. METHODS: A retrospective case-control study was conducted. One hundred and fifty cases of hospital-acquired Clostridium difficile were identified. Patients were individually matched to controls for age, sex, date of admission to hospital, and hospital unit. The groups were compared with respect to each exposure. RESULTS: Eight case patients could not be matched with suitable controls. Therefore, data from 142 cases and 142 controls were analyzed. There was no association between current use of a PPI and the CDAD outbreak (odds ratio [OR] 1.0, 95% confidence interval [CI] 0.99-1.01). Similarly, there was no correlation between the CDAD outbreak and diabetes, enteral feeding, cancer, gastrointestinal surgery, inflammatory bowel disease, or previous care or residence in an institution. However, the development of CDAD was positively associated with use of antibiotics within the 30 days preceding the infection (OR 12.0, 95% CI 4.0-35.7) and with past use of a PPI (OR 2.4, 95% CI 1.4-4.3). CONCLUSIONS: The development of CDAD during a hospital outbreak was associated with use of antibiotics and with past, not current, use of PPIs.