Background This study analyzed the relationship between vancomycin area under the concentration-time curve (AUC) and acute kidney injury (AKI) reported across recent studies. Methods A systematic review of PubMed, Medline, Scopus, and compiled references was conducted. We included randomized cohort and case-control studies that reported vancomycin AUCs and risk of AKI (from 1990 to 2018). The primary outcome was AKI, defined as an increase in serum creatinine of ≥0.5 mg/L or a 50% increase from baseline on ≥2 consecutive measurements. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Primary analyses compared the impact of AUC cutpoint (greater than ~650 mg × hour/L) and AKI. Additional analysis compared AUC vs trough-guided monitoring on AKI incidence. Results Eight observational studies met inclusion/exclusion criteria with data for 2491 patients. Five studies reported first-24-hour AUCs (AUC0-24) and AKI, 2 studies reported 24- to 48-hour AUCs (AUC24-48) and AKI, and 2 studies reported AKI associated with AUC- vs trough-guided monitoring. AUC less than approximately 650 mg × hour/L was associated with decreased AKI for AUC0-24 (OR, 0.36 [95% CI, .23–.56]) as well as AUC24-48 (OR, 0.45 [95% CI, .27–.75]). AKI associated with the AUC monitoring strategy was significantly lower than trough-guided monitoring (OR, 0.68 [95% CI, .46–.99]). Conclusions AUCs measured in the first or second 24 hours and lower than approximately 650 mg × hour/L may result in a decreased risk of AKI. Vancomycin AUC monitoring strategy may result in less vancomycin-associated AKI. Additional investigations are warranted.

Objective: To compare the various paediatric weight estimation methods (Advanced Pediatric Life Support, Broselow Tape, Argall, and Best Guess) and parental estimate to measured weight. Patients and method: A convenience sample of children aged 1-11 years who presented to the emergency department over a 6 month period were eligible for inclusion. Data collected included height, age, ethnicity, parent estimate of weight and measured weight. Body mass index (BMI) was calculated. The outcome of interest was agreement between estimated weight and measured weight for each method. Data were analysed by descriptive statistics and performance of each weight estimation method was compared using mean difference (MD), root mean square error (RMSE) and agreement within 10%. Results: 410 cases were included in this study. The median age was 4 years, there were more boys (54.4%), and the majority of cases were of Caucasian ethnicity (74.9%). The mean BMI of the sample was 17 kg/m 2 and mean actual weight was 21.2 kg. Parent estimate was the most accurate method with 78% of parent estimates within 10% of measured weight and the lowest mean difference (20.6 kg) and RMSE (3.1 kg). The Broselow tape was the most accurate of the other methods, with 61% of estimations within 10% of measured weight. Conclusion: Parental estimation of weight is more accurate than the other weight estimation methods studied. When this is not available, the Broselow tape is the most accurate alternative method.

ABSTRACT:States are taking variable approaches to the Affordable Care Act (ACA) Medicaid expansion, Marketplace design, enrollment outreach, and navigator programs. We surveyed nearly 3000 low-income adults in late 2014 to compare experiences in three states with markedly different ACA policies: Kentucky, which expanded Medicaid, created a successful state Marketplace, and supported outreach efforts; Arkansas, which enacted the private option and a federal-state partnership Marketplace, but with legislative limitations on outreach; and Texas, which did not expand Medicaid and passed onerous restrictions on navigators. We found that application rates, successful enrollment, and positive experiences with the ACA were highest in Kentucky, followed by Arkansas, with Texas performing worst on most outcomes. Awareness of the ACA was low -less than half of adults had heard some or a lot about the law. Navigator assistance was the strongest predictor of successful enrollment, while Latinos were much less likely to complete the process. Twice as many respondents felt the ACA had helped them as hurt them, though advertising was strongly associated with perceptions of the law's impact. While the ACA is a national law, state policy choices have had major impacts on enrollment experiences among low-income adults and their overall perceptions of the ACA.

IMPORTANCE Empirical study findings to date are mixed on the association between team-based primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions. OBJECTIVE To evaluate the association of establishing team-based primary care with patient health care use and costs. DESIGN, SETTING, AND PARTICIPANTS We used difference-indifferences to compare preutilization and postutilization rates between intervention and comparison practices with inverse probability weighting to balance observable differences. We fit a linear model using generalized estimating equations to adjust for clustering at 18 academically affiliated primary care practices in the Boston, Massachusetts, area between 2011 and 2015. The study included 83 953 patients accounting for 138 113 patient-years across 18 intervention practices and 238 455 patients accounting for 401 573 patient-years across 76 comparison practices. Data were analyzed between April and August 2018. EXPOSURES Practices participated in a 4-year learning collaborative that created and supported team-based primary care. MAIN OUTCOMES AND MEASURES Outpatient visits, hospitalizations, emergency department visits, ambulatory care-sensitive hospitalizations, ambulatory care-sensitive emergency department visits, and total costs of care. RESULTS Of 322 408 participants, 176 259 (54.7%) were female; 64 030 (19.9%) were younger than 18 years and 258 378 (80.1%) were age 19 to 64 years. Intervention practices had fewer participants, with 2 or more chronic conditions (n = 51 155 [37.0%] vs n = 186 954 [46.6%]), more participants younger than 18 years (n = 337 931 [27.5%] vs n = 74 691 [18.6%]), higher Medicaid enrollment (n = 39 541 [28.6%] vs n = 81 417 [20.3%]), and similar sex distributions (75 023 women [54.4%] vs 220 097 women [54.8%]); however, after inverse probability weighting, observable patient characteristics were well balanced. Intervention practices had higher utilization in the preperiod. Patients in intervention practices experienced a 7.4% increase in annual outpatient visits relative to baseline (95% CI, 3.5%-11.3%; P < .001) after adjusting for patient age, sex, comorbidity, zip code level sociodemographic characteristics, clinician characteristics, and plan fixed effects. In a subsample of patients with 2 or more chronic conditions, there was a statistically significant 18.6% reduction in hospitalizations (95% CI, 1.5%-33.0%; P = .03), 25.2% reduction in emergency department visits (95% CI, 6.6%-44.0%; P = .007), and a 36.7% reduction in ambulatory care-sensitive emergency department visits (95% CI, 9.2%-64.0%; P = .009). Among patients with less than 2 comorbidities, there was an increase in outpatient visits (9.