Decreasing Inappropriate Use of Antireflux Medications by Standardizing Gastroesophageal Reflux Disease Management in NICU.

Gastroesophageal reflux (GER) is a functional self-limiting condition in neonates. When pathologic, it is called GER disease (GERD). There are wide variations in the management of signs, symptoms, and complications associated with GERD in the neonatal intensive care unit (NICU). Evidence does not support an empiric trial of GERD medications as a diagnostic tool or therapy in premature infants. METHODS: A multidisciplinary team developed evidence-based clinical practice guidelines (CPG) for GERD management. Process improvement included developing a GERD management algorithm, electronic order sets, and education for all providers. Multiple plan-do-study-act cycles done. RESULTS: Implementation of standardized GERD management guideline, decreased the overall use of antireflux medications from baseline, 15.1%-6.8% [χ2 (1, N = 1259) = 12.98, P < 0.001]. There was elimination of GERD medication use in preterm from baseline of 19.3% [χ2 (1, N = 220) = 12.18, P < 0.001]. The most frequently used GERD medication was lansoprazole, with an incorrect initial dosing rate of 55.0% that deceased to zero [χ2 (1, N = 33) = 10.73, P = 0.001]. Appropriate testing with PH probe with 24-hour multichannel impedance was observed (17.1%-28.0%) identifying patients with correct GERD diagnosis [χ2 (1, N = 101) = 1.41, P = 0.236]. Length of stay for GERD patient's improved from a median of 89-53 days. CONCLUSION: Standardizing clinical management leads to best practices for GERD management with appropriate diagnostic testing, eliminating incorrect medication dosing, and improved patient safety with value-based outcomes.

Beta-Thalassemia major and pregnancy.

OBJECTIVE: It was studied the clinical management and the medical outcomes of 6 pregnancies in 5 women affected by Beta Thalassemia major, based on last guidelines and pharmacological treatments. BACKGROUND: Paediatric Department and Department of Obstetrics and Gynaecology of the University of Catania. METHODS: These patients were taken among a group of 116 women affected by beta-thalassemia major divided into three subgroups, according to the characteristics of their menstrual cycle: 1) women with primitive amenorrhoea, 2) women with secondary amenorrhoea and 3) women with normal menstruation. Only one woman, affected by primitive amenorrhoea, needed the induction of ovulation. An accurate and detailed pre-pregnancy assessment was effected before each conception. This was constituted by a series of essays, including checks for diabetes and hypothyroidism, for B and C hepatitis and for blood group antibodies. Moreover were evaluated: cardiac function, rubella immunity and transaminases. Other pregnancy monitoring, and cares during labour and delivery were effected according to usual obstetrics practice. RESULTS: All the women were in labour when they were 38 week pregnant, and the outcome were six healthy babies born at term. There were no complications related to the pregnancy and to the immediate outcome after delivery. CONCLUSIONS: The improvements of current treatments, especially in the management of iron deposits, the prolongation of survival rate, will result in a continuous increase of pregnancies in thalassemic women. Pregnancy is now a real possibility for women affected by such disease. Although numerous complications can occur, vigilant monitoring by both experienced obstetricians and hematologists can lead to successful pregnancy outcomes (Tab. 1, Fig. 1, Ref. 16).