The changing pattern of inhaled nitric oxide use in the neonatal intensive care unit.

OBJECTIVE: The purpose of this study was to evaluate the demographic characteristics and outcomes of neonates who were admitted to a neonatal intensive care unit and treated with inhaled nitric oxide (iNO) during the years 2000-08. The goal of studying this group of neonates was to evaluate how iNO use has evolved in infants and to estimate the frequency of off-label use of this drug in this population. STUDY DESIGN: Retrospective review of the Pediatrix Clinical Data Warehouse de-identified data set. Pediatrix Medical Group provides intensive care services in 244 hospitals in 32 states and Puerto Rico. Nine (3.7%) centers provide extracorporeal membrane oxygenation. RESULT: There were 494 255 neonates in the data set; 4316 (0.9%) were treated with iNO. The use of iNO increased from 154 of 32 967 patients in 2000 to 921 of 75 911 patients in 2008; a 2.6-fold increase (0.47 to 1.23%). There were 155 872 infants <34 weeks estimated gestational age discharged between 1 January 2000 and 31 December 2008; 1656 (1.1%) were treated with iNO. Since approval in 2000, the reported use of iNO in neonates <34 weeks increased from 0.3 to 1.8% in 2008; a sixfold increase in the reported use of iNO. The biggest increase occurred in infants between 23 and 26 weeks' gestational age (0.8 to 6.6%). In contrast, the increase in iNO use among neonates born ≥34 weeks has only increased from 0.5 to 1%. CONCLUSION: The use of iNO has increased and the greatest increase has been the off-label use among preterm neonates.

Real time patient safety audits: improving safety every day.

BACKGROUND: Timely error detection including feedback to clinical staff is a prerequisite for focused improvement in patient safety. Real time auditing, the efficacy of which has been repeatedly demonstrated in industry, has not been used previously to evaluate patient safety. Methods successful at improving quality and safety in industry may provide avenues for improvement in patient safety. OBJECTIVE: Pilot study to determine the feasibility and utility of real time safety auditing during routine clinical work in an intensive care unit (ICU). METHODS: A 36 item patient safety checklist was developed via a modified Delphi technique. The checklist focused on errors associated with delays in care, equipment failure, diagnostic studies, information transfer and non-compliance with hospital policy. Safety audits were performed using the checklist during and after morning work rounds thrice weekly during the 5 week study period from January to March 2003. RESULTS: A total of 338 errors were detected; 27 (75%) of the 36 items on the checklist detected >or=1 error. Diverse error types were found including unlabeled medication at the bedside (n = 31), ID band missing or in an inappropriate location (n = 70), inappropriate pulse oximeter alarm setting (n = 22), and delay in communication/information transfer that led to a delay in appropriate care (n = 4). CONCLUSIONS: Real time safety audits performed during routine work can detect a broad range of errors. Significant safety problems were detected promptly, leading to rapid changes in policy and practice. Staff acceptance was facilitated by fostering a blame free "culture of patient safety" involving clinical personnel in detection of remediable gaps in performance, and limiting the burden of data collection.

Influence of dietary phosphorus deficiency with or without addition of fumaric acid to a diet in pigs on bone parameters.

The purpose of this study was to examine if substantial bone loss occurs in weaned pigs by feeding a phosphorus-deficient diet with or without fumaric acid. Eighteen weaned pigs were used. The animals were assigned to three groups: group C (control; 0.65% P on DM basis), group LP (low phosphorus; 0.37% P on DM basis) and group LPF (low phosphorus plus fumaric acid; 0.35% P on DM basis plus 2% fumaric acid). These three diets were fed to the groups for a period of four weeks after a two-week adaptation period. Blood samples were collected once a week. Carboxyterminal telopeptide of type I collagen (ICTP) in serum was used as a bone resorption marker. Osteocalcin (OC) and bone-specific alkaline phosphatase (bAP) were used as bone formation markers. Bone mineral density (BMD) and content (BMC) were determined by peripheral quantitative computer tomography. BAP activities significantly increased (24%) in group LPF, and at the last sampling day group LPF had significantly increased activities in comparison to group C. In contrast, ICTP concentrations significantly increased with time in group LP and LPF, and at the last sampling day group LPF had significantly increased activities in comparison to group C. BMD and BMC in femur and tibia significantly decreased in group LP and LPF. The results show that P-deficient diets induce a bone loss. Fumaric acid did not influence the degree of bone loss. With a better understanding of its effect on bone, dietary phosphorus requirements in pigs could be more precisely defined.

Long-term excessive magnesium supplementation is deleterious whereas suboptimal supply is beneficial for bones in rats.

The long-term effects of a suboptimal magnesium supply inducing a marginal or moderate deficiency or of an excessive magnesium supplementation corresponding to a basal diet with a high pharmacological intake were investigated in 36 growing Sprague-Dawley female rats. The rats were randomly divided in three groups and received a purified diet with 7 g calcium, 5 g phosphorus and either 0.2, 0.5 or 2 g magnesium per kg diet for 7 months. At the end of the trial, plasma and erythrocyte total magnesium concentrations were significantly lower in the magnesium-deficient group than in the respective control group. Serum concentrations of 1,25-dihydroxyvitamin D, PTH and IGF-I and the length of the right humeri were not affected by the dietary treatment. The volumes corrected for body weight, the medio-lateral diameters and the ratios dry weight/length of the right humeri, and the dry weight corrected for body weight of the left tibiae and of the right humeri were significantly smaller in the magnesium-supplemented group than in the two other groups. The magnesium contents of the left tibiae and of the first lumbar vertebrae were significantly lower in the magnesium-deficient group than in the two other groups. In the right femora, dual energy X-ray absorptiometry revealed significantly smaller areas in the proximal part and significantly smaller mineral contents in the second proximal quarter in the magnesium-supplemented group compared with the two other groups. Peripheral quantitative computer tomography of the right humeri revealed in the cortex significantly larger values for the relative area, mineral content, mineral density and thickness in the magnesium-deficient group compared with the control group. The maximum point of the load-deformation curve was significantly reduced in the fifth lumbar vertebrae and in the proximal femoral metaphyses of the magnesium-supplemented group. These results indicate that the long-term suboptimal magnesium supply improved some of the parameters indicators of bone health whereas the long-term supplementation was deleterious.