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Acute kidney injury (AKI) is a common complication among patients admitted to the neonatal intensive care unit. Nephrotoxic medications (NTMs) are known to increase the incidence of AKI, but the use of these -medications is often unavoidable. Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action) is a -quality improvement (QI) project that may be implemented at individual institutions and aims to systematically identify AKI in neonates and infants receiving NTMs. The purpose of this review is to describe nephrotoxic AKI in the neonatal population, introduce the Baby NINJA QI project and its potential to reduce neonatal AKI, and outline strategies for effective implementation of Baby NINJA., Competing Interests: Disclosure. The authors declare no conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria., (Copyright. Pediatric Pharmacy Association. All rights reserved. For permissions, email: membership@pediatricpharmacy.org.)

Objective: Vancomycin is commonly used in the neonatal population to treat Gram-positive bacterial infections. Despite frequent use, consensus on the ideal dosing regimen in low birth weight (LBW) neonates is lacking. The objective of this research is to determine how frequently vancomycin troughs within goal range (10-20 mg/L) are achieved with empiric dosing in critically ill neonates and infants weighing less than 2500 g., Methods: This retrospective review evaluated LBW infants who were admitted to a level IV NICU from January 2015 to December 2016. Patients were included if they had a vancomycin trough sample collected at steady state (after at least 3 doses). Three trough cohorts (subtherapeutic: <10 mg/L, therapeutic: 10-20 mg/L, and supratherapeutic: >20 mg/L) were compared with 1-way ANOVA for continuous data and a chi-square analysis for categorical data., Results: A total of 74 patients were included, with a mean birth weight (BW) of 819.7 ± 355.4 g and a mean gestational age (GA) of 26.4 ± 3.7 weeks. Only 27 patients (36.5%) had therapeutic vancomycin trough concentrations. Subtherapeutic troughs were recorded in 40 patients (54.1%), while supratherapeutic troughs were recorded in 7 patients (9.5%). Although there was no difference between the initial dose, initial frequency was significantly different between cohorts (p = 0.04)., Conclusion: Empiric dosing regimens do not produce vancomycin troughs within the goal range in most LBW patients., Competing Interests: Disclosure. The authors declare no conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria. The authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis., (Copyright Pediatric Pharmacy Association. All rights reserved. For permissions, email: mhelms@pediatricpharmacy.org 2021.)

Objective: To evaluate the pharmacokinetics and pharmacodynamics, dosing, efficacy, and safety of ketorolac in postoperative patients younger than 6 months of age., Methods: PubMed (1988-July 2020), Medline (1946-July 2020), and EBSCO Discovery Service (1988-July 2020) were searched to identify relevant published articles using the following search terms: ketorolac, neonate, infant. English-language articles evaluating the use of ketorolac in infants younger than 6 months of age were included., Results: Eight reports that included 239 infants receiving ketorolac were included. Of the included patients, 237 were younger than 6 months of age. Ketorolac exhibits rapid elimination of the analgesia-producing S (-) isomer, elimination half-life of 0.83 hours. Most patients received 0.5 mg/kg/dose every 6 hours for 48 to 72 hours. Analgesia was demonstrated by reduced use of open-label morphine and significant lowering of Neonatal/Infant Pain Scale scores. Adverse effects were minimal when ketorolac was used in term neonates and infants without baseline renal dysfunction., Conclusions: Randomized placebo-controlled trials of ketorolac use in this population are lacking; however, most published reports noted efficacy and safety with ketorolac in properly selected infants., Competing Interests: Disclosure. The author declares no conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria., (Copyright. Pediatric Pharmacy Association. All rights reserved. For permissions, email: mhelms@pediatricpharmacy.org 2021.)

Objectives: To provide a perspective on the current practice of randomized clinical trials (RCTs) of diagnostic strategies focusing on patient-important outcomes., Study Design and Setting: We conducted a comprehensive search of MEDLINE and included RCTs published in full-text reports that evaluated alternative diagnostic strategies., Results: Of 56,912 unique citations, we sampled 7,500 and included 103 eligible RCTs, therefore suggesting that MEDLINE includes approximately 781 diagnostic RCTs. The 103 eligible trials reported on: mortality (n = 41; 39.8%); morbidities (n = 63; 61.2%); symptoms/quality of life/functional status (n = 14; 13.6%); and on composite end points (n = 10; 9.7%). Of the studies that reported statistically significant results (n = 12; 11.6%), we judged 7 (58.3%) as at low risk of bias with respect to missing outcome data and 4 (33.3%) as at low risk of bias regarding blinding. Of the 41 RCTs that reported on mortality, only one (2.4%) reported statistically significant results. Of 63 RCTs addressing morbidity outcomes, 11 (17.5%) reported statistically significant results, all of which reported relative effects of greater than 20%., Conclusion: RCTs of diagnostic tests are not uncommon, and sometimes suggest benefits on patient-important outcomes but often suffer from limitations in sample size and conduct., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The purpose of this integrated literature review was to bring understanding to medical professionals of the psychosocial impact of parenting a child with life-threatening food allergies. Prevalence of life-threatening food allergy among children is increasing, and families continue to navigate the effects it can have on all members of a family. A comprehensive literature review was performed related to chronic childhood illnesses and life-threatening food allergies. Commonalities among the conditions exist related to stress, coping, and adaptive responses when parental perceptions and experiences are considered. This information may provide a conceptual context for the adaptation process involved with parenting a young child with life-threatening food allergies, revealing areas where nursing can serve to intervene and support this process.

Objective: To compare quality of care in for-profit and not-for-profit nursing homes., Design: Systematic review and meta-analysis of observational studies and randomised controlled trials investigating quality of care in for-profit versus not-for-profit nursing homes., Results: A comprehensive search yielded 8827 citations, of which 956 were judged appropriate for full text review. Study characteristics and results of 82 articles that met inclusion criteria were summarised, and results for the four most frequently reported quality measures were pooled. Included studies reported results dating from 1965 to 2003. In 40 studies, all statistically significant comparisons (P<0.05) favoured not-for-profit facilities; in three studies, all statistically significant comparisons favoured for-profit facilities, and the remaining studies had less consistent findings. Meta-analyses suggested that not-for-profit facilities delivered higher quality care than did for-profit facilities for two of the four most frequently reported quality measures: more or higher quality staffing (ratio of effect 1.11, 95% confidence interval 1.07 to 1.14, P<0.001) and lower pressure ulcer prevalence (odds ratio 0.91, 95% confidence interval 0.83 to 0.98, P=0.02). Non-significant results favouring not-for-profit homes were found for the two other most frequently used measures: physical restraint use (odds ratio 0.93, 0.82 to 1.05, P=0.25) and fewer deficiencies in governmental regulatory assessments (ratio of effect 0.90, 0.78 to 1.04, P=0.17)., Conclusions: This systematic review and meta-analysis of the evidence suggests that, on average, not-for-profit nursing homes deliver higher quality care than do for-profit nursing homes. Many factors may, however, influence this relation in the case of individual institutions.

Background: Differences in medical care in the United States compared with Canada, including greater reliance on private funding and for-profit delivery, as well as markedly higher expenditures, may result in different health outcomes., Objectives: To systematically review studies comparing health outcomes in the United States and Canada among patients treated for similar underlying medical conditions., Methods: We identified studies comparing health outcomes of patients in Canada and the United States by searching multiple bibliographic databases and resources. We masked study results before determining study eligibility. We abstracted study characteristics, including methodological quality and generalizability., Results: We identified 38 studies comparing populations of patients in Canada and the United States. Studies addressed diverse problems, including cancer, coronary artery disease, chronic medical illnesses and surgical procedures. Of 10 studies that included extensive statistical adjustment and enrolled broad populations, 5 favoured Canada, 2 favoured the United States, and 3 showed equivalent or mixed results. Of 28 studies that failed one of these criteria, 9 favoured Canada, 3 favoured the United States, and 16 showed equivalent or mixed results. Overall, results for mortality favoured Canada (relative risk 0.95, 95% confidence interval 0.92-0.98, p= 0.002) but were very heterogeneous, and we failed to find convincing explanations for this heterogeneity. The only condition in which results consistently favoured one country was end-stage renal disease, in which Canadian patients fared better., Interpretation: Available studies suggest that health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent.

Background: It has been shown that patients cared for at private for-profit hospitals have higher risk-adjusted mortality rates than those cared for at private not-for-profit hospitals. Uncertainty remains, however, about the economic implications of these forms of health care delivery. Since some policy-makers might still consider for-profit health care if expenditure savings were sufficiently large, we undertook a systematic review and meta-analysis to compare payments for care at private for-profit and private not-for-profit hospitals., Methods: We used 6 search strategies to identify published and unpublished observational studies that directly compared the payments for care at private for-profit and private not-for-profit hospitals. We masked the study results before teams of 2 reviewers independently evaluated the eligibility of all studies. We confirmed data or obtained additional data from all but 1 author. For each study, we calculated the payments for care at private for-profit hospitals relative to private not-for-profit hospitals and pooled the results using a random effects model., Results: Eight observational studies, involving more than 350 000 patients altogether and a median of 324 hospitals each, fulfilled our eligibility criteria. In 5 of 6 studies showing higher payments for care at private for-profit hospitals, the difference was statistically significant; in 1 of 2 studies showing higher payments for care at private not-for-profit hospitals, the difference was statistically significant. The pooled estimate demonstrated that private for-profit hospitals were associated with higher payments for care (relative payments for care 1.19, 95% confidence interval 1.07-1.33, p = 0.001)., Interpretation: Private for-profit hospitals result in higher payments for care than private not-for-profit hospitals. Evidence strongly supports a policy of not-for-profit health care delivery at the hospital level.