Use of Premixed Parenteral Nutrition During a Phosphate Shortage in a Non-Critically Ill Population.

BACKGROUND: Drug shortages pose prescribing problems to clinicians. During fiscal year (FY) 2014, an acute shortage of intravenous potassium phosphate (K-Phos IV), a common supplement in parenteral nutrition (PN), prompted the use of premixed instead of individualized PN to conserve K-Phos IV. Here we quantify the K-Phos IV conserved by using premixed PN and the associated cost differences. MATERIALS AND METHODS: Costs of preparing premixed PN vs individualized PN of equivalent composition were calculated for FY 2014 at a single-center tertiary care facility. Quantity and cost of K-Phos IV saved were calculated based on the number of premixed PN prescriptions. Costs for FY 2015 were projected based on drug costs from July 2014. RESULTS: During FY 2014, prescribing premixed in lieu of individualized PN conserved 16,440 mmol K-Phos IV but increased the cost of PN by $4080.45. However, increases in K-Phos IV cost at the end of FY 2014 resulted in premixed PN as a relatively less expensive therapy than individualized PN for our institution. Cost savings of $7092.20 due to use of premixed PN is projected for FY 2015. CONCLUSIONS: Prescribing premixed PN conserves K-Phos IV during shortages, but it increased direct drug spending in non-critically ill patients at our institution during FY 2014. Persistent shortages can drive market costs of K-Phos IV, however, necessitating frequent reconsideration of resource utilization.

Guidelines for the safe and effective use of sodium phosphate solution for bowel cleansing prior to colonoscopy.

Oral sodium phosphate solution is used worldwide as a bowel preparation for colonoscopy, surgery, and medical-imaging procedures. Although recent reports of adverse renal effects associated with sodium phosphate raise concern, sodium phosphate preparations remain safe and effective choices for patients who receive proper instruction for their use. Improper use of any bowel preparation can lead to complications. The purpose of this article is to provide a guide for selecting those patients for whom oral sodium phosphate solution is an appropriate bowel-cleansing choice and to review the importance of patient education, dosing, and hydration to help ensure that clinicians and patients use these preparations safely.

Elevated atmospheric CO2 concentration alters the effect of phosphate supply on growth of Japanese red pine (Pinus densiflora) seedlings.

We demonstrated that the inorganic phosphate (P(i)) requirement for growth of Japanese red pine (Pinus densiflora Sieb. & Zucc.) seedlings is increased by elevated CO(2) concentration ([CO(2)]) and that responses of the ectomycorrhizal fungus Pisolithus tinctorius (Pers.) Coker & Couch to P(i) supply are also altered. To investigate the growth response of non-mycorrhizal seedlings to P(i) supply in elevated [CO(2)], non-mycorrhizal seedlings were grown for 73 days in ambient or elevated [CO(2)] (350 or 700 micromol mol(-1)) with nutrient solutions containing one of seven phosphate concentrations (0, 0.02, 0.04, 0.06, 0.08, 0.10 and 0.20 mM). In ambient [CO(2)], the growth response to P(i) was saturated at about 0.1 mM P(i), whereas in elevated [CO(2)], the growth response to P(i) supply did not saturate, even at the highest P(i) supply (0.2 mM), indicating that the P(i) requirement is higher in elevated [CO(2)] than in ambient [CO(2)]. The increased requirement was due mainly to an altered shoot growth response to P(i) supply. The enhanced P(i) requirement in elevated [CO(2)] was not associated with a change in photosynthetic response to P(i) or a change in leaf phosphorus (P) status. We investigated the effect of P(i) supply (0.04, 0.08 and 0.20 mM) on the ectomycorrhizal fungus P. tinctorius in mycorrhizal seedlings grown in ambient or elevated [CO(2)]. Root ergosterol concentration (an indicator of fungal biomass) decreased with increasing P(i) supply in ambient [CO(2)], but the decrease was far less in elevated [CO(2)]. In ambient [CO(2)] the ratio of extramatrical mycelium to root biomass decreased with increasing P(i) supply but did not change in elevated [CO(2)]. We conclude that, because elevated [CO(2)] increased the P(i) requirement for shoot growth, the significance of the ectomycorrhizal association was also increased in elevated [CO(2)].

Improving nutrient efficiency as a strategy to reduce nutrient surpluses on dairy farms.

Dutch nutrient policy aims at reducing leaching of agricultural nutrients by internalizing the negative externalities associated with inefficient nutrient use. This is done by taxation of nitrogen and phosphate surpluses that exceed a hectare-based threshold of maximum-allowed surpluses. One management strategy farmers may use to reduce the nutrient surpluses on their farms is to improve the nutrient efficiency of the agricultural production process. This study employs Data Envelopment Analysis (DEA) to calculate nitrogen and phosphate efficiencies and an overall nutrient efficiency measure for a 3-year panel of 114 Dutch dairy farms. Subsequent analyses show the impact of both farm intensity and nutrient efficiency on the nitrogen and phosphate surpluses. It appears that farm intensity has a positive effect on efficiency, but efficiency and intensity exert opposite influences on nutrient surpluses. This is especially the case for nitrogen. The magnitude of a possible reduction of nitrogen surpluses through a strategy of efficiency improvement is therefore limited by the intensity of the farming system, unless the technology with which nutrients are used by the farming system can be further improved or input/output ratios will be altered.