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Aim The starting fraction of inspired oxygen for preterm resuscitation is a matter of debate, and the use of room air in full-term asphyxiated infants reduces oxidative stress. This study compared oxidative stress in preterm infants randomised for resuscitation with either 100% oxygen or room air titrated to internationally recommended levels of preductal oxygen saturations. Methods Blood was collected at birth, two and 12 hours of age from 119 infants <32 weeks of gestation randomised to resuscitation with either 100% oxygen (n = 60) or room air (n = 59). Oxidative stress markers, including advanced oxidative protein products ( AOPP) and isoprostanes (IsoP), were measured with high-performance liquid chromatography and mass spectrometry. Results Significantly higher levels of AOPP were found at 12 hours in the 100% oxygen group (p < 0.05). Increases between two- and 12-hour AOPP (p = 0.004) and IsoP (p = 0.032) concentrations were significantly higher in the 100% oxygen group. Conclusion Initial resuscitation with room air versus 100% oxygen was associated with lower protein oxidation at 12 hour and a lower magnitude of increase in AOPP and IsoP levels between two and 12 hours of life. Correlations with clinical outcomes will be vital to optimise the use of oxygen in preterm resuscitation. [ABSTRACT FROM AUTHOR]

Objective: To determine whether hospital mortality (primary outcome) is associated with duration of bradycardia without chest compressions during delivery room (DR) resuscitation in a retrospective cohort study of randomized controlled trials (RCTs) in preterm infants assigned low versus high initial oxygen concentration., Methods: Medline and EMBASE were searched from 01/01/1990 to 12/01/2020. RCTs of low vs high initial oxygen concentration which recorded serial heart rate (HR) and oxygen saturation (SpO 2 ) during resuscitation of infants <32 weeks gestational age were eligible. Individual patient level data were requested from the authors. Newborns receiving chest compressions in the DR and those with no recorded HR in the first 2 min after birth were excluded. Prolonged bradycardia (PB) was defined as HR < 100 bpm for ≥2 min. Individual patient data analysis and pooled data analysis were conducted., Results: Data were collected from 720 infants in 8 RCTs. Neonates with PB had higher odds of hospital death before [OR 3.8 (95% CI 1.5, 9.3)] and after [OR 1.7 (1.2, 2.5)] adjusting for potential confounders. Bradycardia occurred in 58% infants, while 38% had PB. Infants with bradycardia were more premature and had lower birth weights. The incidence of bradycardia in infants resuscitated with low (≤30%) and high (≥60%) oxygen was similar. Neonates with both, PB and SpO 2  < 80% at 5 min after birth had higher odds of hospital mortality. [OR 18.6 (4.3, 79.7)]., Conclusion: In preterm infants who did not receive chest compressions in the DR, prolonged bradycardia is associated with hospital mortality., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: To determine rates of death or neurodevelopmental impairment (NDI) at 2 years corrected age (primary outcome) in children <32 weeks' gestation randomized to initial resuscitation with a fraction of inspired oxygen (FiO 2 ) value of 0.21 or 1.0., Study Design: Blinded assessments were conducted at 2-3 years corrected age with the Bayley Scales of Infant and Toddler Development, Third Edition or the Ages and Stages Questionnaire by intention to treat., Results: Of the 290 children enrolled, 40 could not be contacted and 10 failed to attend appointments. Among the 240 children for whom outcomes at age 2 years were available, 1 child had a lethal congenital anomaly, 1 child had consent for follow-up withdrawn, and 23 children died. The primary outcome, which was available in 238 (82%) of those randomized, occurred in 47 of the 117 (40%) children assigned to initial FiO 2 0.21 and in 38 of the 121 (31%) assigned to initial FiO 2 1.0 (OR, 1.47; 95% CI, 0.86-2.5; P = .16). No difference in NDI was found in 215 survivors randomized to FiO 2 0.21 vs 1.0 (OR, 1.26; 95% CI, 0.70-2.28; P = .11). In post hoc exploratory analyses in the whole cohort, children with a 5-minute blood oxygen saturation (SpO 2 ) <80% were more likely to die or to have NDI (OR, 1.85; 95% CI, 1.07-3.2; P = .03)., Conclusions: Initial resuscitation of infants <32 weeks' gestation with initial FiO 2 0.21 had no significant effect on death or NDI compared with initial FiO 2 1.0. Further evaluation of optimum initial FiO 2 , including SpO 2 targeting, in a large randomized controlled trial is needed., Trial Registration: Australian and New Zealand Clinical Trials Network Registry ACTRN 12610001059055 and the National Malaysian Research Registry NMRR-07-685-957., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To determine the association between SpO 2 at 5 min and preterm infant outcomes., Design: Data from 768 infants <32 weeks gestation from 8 randomised controlled trials (RCTs) of lower (≤0.3) versus higher (≥0.6) initial inspiratory fractions of oxygen (FiO 2 ) for resuscitation, were examined., Setting: Individual patient analysis of 8 RCTs INTERVENTIONS: Lower (≤0.3) versus higher (≥0.6) oxygen resuscitation strategies targeted to specific predefined SpO 2 before 10 min of age., Patients: Infants <32 weeks gestation., Main Outcome Measures: Relationship between SpO 2 at 5 min, death and intraventricular haemorrhage (IVH) >grade 3., Results: 5 min SpO 2 data were obtained from 706 (92%) infants. Only 159 (23%) infants met SpO 2 study targets and 323 (46%) did not reach SpO 2 80%. Pooled data showed decreased likelihood of reaching SpO 2 80% if resuscitation was initiated with FiO 2 <0.3 (OR 2.63, 95% CI 1.21 to 5.74, p<0.05). SpO 2 <80% was associated with lower heart rates (mean difference -8.37, 95% CI -15.73 to -1.01, *p<0.05) and after accounting for confounders, with IVH (OR 2.04, 95% CI 1.01 to 4.11, p<0.05). Bradycardia (heart rate <100 bpm) at 5 min increased risk of death (OR 4.57, 95% CI 1.62 to 13.98, p<0.05). Taking into account confounders including gestation, birth weight and 5 min bradycardia, risk of death was significantly increased with time taken to reach SpO 2 80%., Conclusion: Not reaching SpO 2 80% at 5 min is associated with adverse outcomes, including IVH. Whether this is because of infant illness or the amount of oxygen that is administered during stabilisation is uncertain and needs to be examined in randomised trials., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background and Objectives: Lower concentrations of oxygen (O 2 ) (≤30%) are recommended for preterm resuscitation to avoid oxidative injury and cerebral ischemia. Effects on long-term outcomes are uncertain. We aimed to determine the effects of using room air (RA) or 100% O 2 on the combined risk of death and disability at 2 years in infants <32 weeks' gestation., Methods: A randomized, unmasked study designed to determine major disability and death at 2 years in infants <32 weeks' gestation after delivery room resuscitation was initiated with either RA or 100% O 2 and which were adjusted to target pulse oximetry of 65% to 95% at 5 minutes and 85% to 95% until NICU admission., Results: Of 6291 eligible patients, 292 were recruited and 287 (mean gestation: 28.9 weeks) were included in the analysis (RA: n = 144; 100% O 2 : n = 143). Recruitment ceased in June 2014, per the recommendations of the Data and Safety Monitoring Committee owing to loss of equipoise for the use of 100% O 2 . In non-prespecified analyses, infants <28 weeks who received RA resuscitation had higher hospital mortality (RA: 10 of 46 [22%]; than those given 100% O 2 : 3 of 54 [6%]; risk ratio: 3.9 [95% confidence interval: 1.1-13.4]; P = .01). Respiratory failure was the most common cause of death (n = 13)., Conclusions: Using RA to initiate resuscitation was associated with an increased risk of death in infants <28 weeks' gestation. This study was not a prespecified analysis, and it was underpowered to address this post hoc hypothesis reliably. Additional data are needed., (Copyright © 2017 by the American Academy of Pediatrics.)

To succeed in today's complex and often adverse business environment, a healthcare organization's strategic direction must be calculated, focused, and financially sustainable. Strategic business planning is an essential tool to help organizations focus strategic choices within the financial realities of their environment. An effective strategic business planning cycle includes conducting an assessment, identifying business objectives, developing strategy, conducting an impact analysis, and developing an implementation plan.

Objective: To evaluate the difference in nutrient intakes and biochemical responses in newborn infants <33 weeks gestation who received standardized versus individualized total parenteral nutrition (TPN) regimes., Method: Comparison of nutrient intakes and daily biochemical responses in newborn infants <33 weeks gestation who received standardized regime versus those who received individualized TPN regimes from day 2 to day 7 of life., Results: Twenty-seven infants in the standardized TPN group and 31 infants in the individualized TPN group were compared. There were no statistically significant differences (P > 0.05) between the two groups in gestation, birthweight, Clinical Risk Index for Babies scores, daily TPN volume intake and biochemical responses. Infants in the standardized TPN group received less sodium (P < 0.01) and no potassium on day 2 as required, more protein (P < 0.02) every day, and more calcium and phosphate (P < 0.02 from day 4)., Conclusion: There were no significant clinical and statistical differences in biochemical responses in newborn infants <33 weeks gestation who received standardized versus individualized TPN regimes during the first week of life. The economic cost of TPN provision using standardized TPN formulation was approximately 30% lower.

Recent published data show that at hospital discharge, most infants born at <30 weeks of gestation would not achieve the median birth weight of the reference fetus at the same postconceptional age, and many would be less than the 10th centile. Estimating from the current recommendations of calorie and protein intakes, these infants accrue large deficits in intakes of protein and calorie during the first weeks of life. Postnatal growth retardation over a prolonged period of time is related to neurodevelopmental delays. While a total energy intake of 120 kcal/kg/day has generally been considered adequate, protein requirement in low gestation infants remains a matter for debate. Increasing the dietary protein:calorie ratio has previously been proposed as a strategy to enhance growth and to achieve a body composition similar to that of the reference fetus. Previous study data reveal that serum insulin-like growth factor I (IGF-I) concentration is positively correlated with protein intake, and nitrogen retention, in turn, is positively correlated with serum IGF-I concentration. Remarkably, elevated serum growth hormone but low serum IGF-I concentrations have been reported in low gestation infants and in infants with intrauterine growth retardation, suggesting IGF-I being a nutritionally regulated hormonal factor in the postnatal growth retardation. As neurodevelopment in extreme prematurity is likely affected by multiple factors, we hypothesize that a combined strategy of the previously proposed hormonal supplement with hydrocortisone and tri-iodothyronine together with increased dietary protein intake (progressively increasing from 1.5 g/kg/day intravenously administered amino acids immediately after birth, then 3.6 g/100 kcal at approximately 125 kcal/kg/day when enterally fed till the infant reaches a body weight of >or=1.8 kg and at >or=50th centile weight of the reference fetus at the same postconceptional age) would likely be synergistic and more effective in improving neurodevelopmental outcome., (Copyright 2003 S. Karger AG, Basel)

The risks inherent in today's healthcare environment make it difficult to predict financial returns from large capital investments or strategic initiatives. Discounted cash-flow financial models are an inadequate means of valuing capital investment opportunities. Real-option analysis includes in the value of a capital investment the ability of management to alter a strategic course or react to marketplace changes. The value of managerial flexibility is higher in an investment opportunity with considerable risk.

Cortisol and thyroid hormones are known to modulate the maturation of various fetal organ systems, enzymes, and biochemical pathways. The cortisol furnished by the structural and biochemical immature fetal adrenal gland renders the extremely premature infants relatively cortisol deficient in comparison with the term newborns. The premature infants also have elevated fetal androgens, the production of which persists until approximately 42 weeks of postconceptional age. The androgens produced by the fetal adrenal cortex and the müllerian inhibiting substance produced by the fetal testis have antiglucocorticoid and inhibitory effects on human fetal lung growth and maturation in vitro. Hypothalamic-pituitary-thyroid axis and thyroid function are also immature in extreme prematurity. In addition, there is reduced tissue thyroid hormone responsiveness. Superimposed on this is the reduced thyroid function seen in non-thyroidal illness in which elevated cytokine levels have been implicated. Repeated courses of antenatal steroids and high-dose postnatal dexamethasone appear to be deleterious to lung and brain development. This may be through inhibition of cell replication and catabolism as well as decreased thyroid-stimulating hormone secretion and reduced peripheral conversion of T(4) to T(3). Furthermore, dexamethasone has been found to enhance neurosteroid production in the immature brain, potentially altering brain development. Considered together, the relative cortisol deficiency/androgen excess and reduced thyroid function as well as prolonged high-dose postnatal dexamethasone therapy in these infants may be important factors in their high degree of morbidity. We propose to restrict antenatal steroids to a single course and hypothesize that the overall outcome of low-gestation infants would be improved with (1) hydrocortisone (i.v./p.o.) supplement at a fixed dose of 0.5 mg/kg birth weight every 12 h in infants <30 weeks of gestation from birth till 32 weeks of postconceptional age and (2) T(3) (i.v./p.o.) supplement at a fixed dose of 0.4 microg/kg birth weight every 12 h in those <27 weeks of gestation from birth till 32 weeks of postconceptional age., (Copyright 2002 S. Karger AG, Basel)

The purpose of this study was to find a safer, more rapid and easier disinfection process for the flexible fiberoptic bronchoscope (F.F.B.) by using ordinary disinfectants and a detergent. Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aures, E. coli, Serratia marcescens and Candida albicans were used as sources of contamination. The mixed bacterial growth preparations for contamination of the F.F.B. were the same as those previously mentioned in our study. Comparative bacteriological studies, between glutaraldehyde (GA) ethylalcohol (AL) and chlorhexidine (CHX) with and without usage of benzalkonium chloride (B.C.) solution and sterile water (W) as the detergent were performed and the following conclusions were obtained: 1. Contaminating microorganisms were reduced from 10(-3)/ml to 10(-4)/ml colony count after flushing with W and B.C. This procedure is very helpful for consecutive rapid disinfections or sterilizations of the F.F.B. 2. The effect of disinfectants with usage of a detergent was much better than without a detergent. Required immersion time in the disinfectants with detergent was reduced to periods as short as 60 seconds. 3. Of the three disinfectants, the most effective was CHX, GA next, and AL third. 4. Unsatisfactory disinfection occurred in some instances when there were functional disorders with the F.F.B. despite adequate amounts of disinfectant and detergent.