Heart rate characteristics predict risk of mortality in preterm infants in low and high target oxygen saturation ranges.

Background: The Neonatal Oxygenation Prospective Meta-analysis found that in infants <28 weeks gestational age, targeting an oxygen saturation (S pO2 ) range of 85-89% versus 91-95% resulted in lower rates of retinopathy of prematurity but increased mortality. We aimed to evaluate the accuracy of the heart rate characteristics index (HRCi) in assessing the dynamic risk of mortality among infants managed with low and high target S pO2 ranges. Methods: We linked the SUPPORT and HRCi datasets from one centre in which the randomised controlled trials overlapped. We examined the maximum daily HRCi (MaxHRCi24) to predict mortality among patients randomised to the lower and higher target S pO2 groups by generating predictiveness curves and calculating model performance metrics, including area under the receiver operating characteristics curve (AUROC) at prediction windows from 1-60 days. Cox proportional hazards models tested whether MaxHRCi24 was an independent predictor of mortality. We also conducted a moderation analysis. Results: There were 84 infants in the merged dataset. MaxHRCi24 predicted mortality in infants randomised to the lower target S pO2 (AUROC of 0.79-0.89 depending upon the prediction window) and higher target S pO2 (AUROC 0.82-0.91). MaxHRCi24 was an important additional predictor of mortality in multivariable modelling. In moderation analysis, in a model that also included demographic predictor variables, the individual terms and the interaction term between MaxHRCi24 and target S pO2 range all predicted mortality. Conclusions: Associations between HRCi and mortality, at low and high S pO2 target ranges, suggest that future research may find HRCi metrics helpful to individually optimise target oxygen saturation ranges for hospitalised preterm infants.

Pulmonary Resilience: Moderating the Association between Oxygen Exposure and Pulmonary Outcomes in Extremely Preterm Newborns.

Bronchopulmonary dysplasia (BPD) is a chronic lung disease of infancy associated with high morbidity and mortality. Although most prevalent following extremely preterm birth, BPD is diagnosed at 36 weeks post-menstrual age, when the disease trajectory is underway, and long-term physiological implications may be irreversible. There is an urgent and unmet need to identify how early exposures can be modified to decrease the risk of developing BPD before disease progression becomes irreversible. Extremely preterm newborns encounter a paradox at birth: oxygen is a life-sustaining component of ex utero life yet is undeniably toxic. Attempts at minimizing supplemental oxygen exposure by targeting lower oxygen saturations appear to decrease BPD but may increase mortality. Given the potential association between lower oxygen saturations and increased mortality, practice guidelines favor targeting higher saturations. This uniformly increases oxygen exposure, prompting a cascade of pathogenic mechanisms implicated in BPD development. In this review, we introduce the concept of pulmonary resilience: a homeostatic process driven by the autonomic nervous system (ANS) as a moderator of physiologic stress that when functional, could inform successful environmental adaptation following extremely preterm birth. We hypothesize that infants with early-life ANS dysfunction require a higher oxygen dose for survival; conversely, oxygen exposure could be safely limited in infants with more robust early-life ANS function, an indicator of pulmonary resilience. Characterizing the pulmonary resilience continuum to guide individualized supplemental oxygen dosing may reduce morbidity and mortality in this growing population of extremely preterm infants at risk for BPD.

Caregiver Experiences of Care Coordination for Recently Discharged Patients: A Qualitative Metasynthesis.

Caregivers of patients often provide key support for patients after hospitalization. This qualitative metasynthesis describes caregiver perspectives about care coordination for patients discharged from the hospital. A literature search of Ovid Medline and CINAHL completed on May 23, 2018, identified 1,546 studies. Twelve articles were included in the final metasynthesis. Caregiver perspectives about care coordination were compiled into overall themes. A subanalysis of studies in which patients were discharged with home health services was completed. Five main themes emerged related to caregiver perspectives on care coordination after hospitalization: (a) Suboptimal access to clinicians after discharge, (b) Feeling disregarded by clinicians, (c) Need for information and training at discharge, (d) Overwhelming responsibilities to manage appointments and medications, and (e) Need for emotional support.Findings from this metasynthesis suggest the need for clinicians to engage with caregivers to provide support, training, and communication after hospital discharge.

Effect of probiotics on the amount and pH of saliva in edentulous patients: A Prospective study.

CONTEXT: Probiotics have been prescribed to old aged patients' invariably with or without complete dentures for improving their digestive process. It is mentioned that probiotics do have an effect in increasing the amount of saliva in the oral cavity. Therefore, this study was planned to evaluate the amount and pH of saliva after using probiotics for 60 days in completely edentulous patients. AIM: This study aims to evaluate the amount and pH of saliva of edentulous patients before and after using probiotics. SETTINGS AND DESIGN: The interventional prospective study was conducted at the department of prosthodontics of the institute. METHODS: The study was conducted on edentulous patients. The whole unstimulated and stimulated saliva was collected at baseline and amount, and pH was measured. Then, each patient was given probiotic capsules reaching 3.3 × 107 CFU/g to consume daily once for 60 days. Saliva was recollected from patients, and its amount and pH was calculated and compared with baseline. STATISTICAL ANALYSIS USED: STATAIC-13. RESULTS: On comparison of saliva before and after consuming probiotics, there was an increase in the mean unstimulated and stimulated saliva from baseline to that after 60 days, the difference being 0.406 and 0.433, respectively. The difference was statistically significant with P < 0.001. The mean pH at baseline was 7.818 ± 0.231 which increased after 60 days to 7.825 ± 0.189, the difference being 0.007. CONCLUSION: This study concluded that probiotics increase the amount of saliva of completely edentulous patients and so it can be helpful in patients suffering from xerostomia/hyposalivation.

Perceptions of trained laypersons in end-of-life or advance care planning conversations: a qualitative meta-synthesis.

BACKGROUND: Laypersons including volunteers, community health navigators, or peer educators provide important support to individuals with serious illnesses in community or healthcare settings. The experiences of laypersons in communication with seriously ill peers is unknown. METHODS: We performed an ENTREQ-guided qualitative meta-synthesis. We conducted a systematic search of MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED to include qualitative studies with data regarding communication and laypersons in advance care planning, palliative care, or end-of-life settings. Study quality was appraised using a standardized tool. The analysis identified key domains and associated themes relating specifically to laypersons' perspectives on communication. RESULTS: Of 877 articles, nine studies provided layperson quotations related to layperson-to-peer communication associated with advance care planning (n = 4) or end-of-life conversations (n = 5). The studies were conducted in United Kingdom (n = 4) or United States settings (n = 5). The synthesis of layperson perspectives yielded five main domains: 1) layperson-to-peer communication, focusing on the experience of talking with peers, 2) layperson-to-peer interpersonal interactions, focusing on the entire interaction between the layperson and peers, excluding communication-related issues, 3) personal impact on the layperson, 4) layperson contributions, and 5) layperson training. Laypersons described using specific communication skills including the ability to build rapport, discuss sensitive issues, listen and allow silence, and respond to emotions. CONCLUSIONS: Published studies described experiences of trained laypersons in conversations with peers related to advance care planning or end-of-life situations. Based on these layperson perspectives related to communication, programs should next evaluate the potential impact of laypersons in meaningful conversations.

Factors Related to Physician Clinical Decision-Making for African-American and Hispanic Patients: a Qualitative Meta-Synthesis.

Clinical decision-making may have a role in racial and ethnic disparities in healthcare but has not been evaluated systematically. The purpose of this study was to synthesize qualitative studies that explore various aspects of how a patient's African-American race or Hispanic ethnicity may factor into physician clinical decision-making. Using Ovid MEDLINE, Embase, and Cochrane Library, we identified 13 manuscripts that met inclusion criteria of usage of qualitative methods; addressed US physician clinical decision-making factors when caring for African-American, Hispanic, or Caucasian patients; and published between 2000 and 2017. We derived six fundamental themes that detail the role of patient race and ethnicity on physician decision-making, including importance of race, patient-level issues, system-level issues, bias and racism, patient values, and communication. In conclusion, a non-hierarchical system of intertwining themes influenced clinical decision-making among racial and ethnic minority patients. Future study should systematically intervene upon each theme in order to promote equitable clinical decision-making among diverse racial/ethnic patients.