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Alterations in autonomic cardiovascular function may result following mild traumatic brain injury (mTBI), but there is a lack of data evaluating autonomic function in adults with persisting post‐concussive symptoms (PPCS). We collected resting measures of heart rate (HR), heart rate variability (HRV), blood pressure (BP) and cardiac baroreceptor sensitivity in 50 adults with PPCS (42.8 (11.0) years; 24.5 (14.2) months post‐injury; 74% female) and 50 age/sex‐matched controls (43.0 (11.1) years; 74% female) with no lifetime mTBI history. HR and BP data were collected for ≥4 min when seated and standing. Between‐group differences (PPCS vs. control) were analyzed using linear regression. In the seated posture, participants with PPCS had significantly lower HRV than controls, specifically RMSSD (root mean squared of successive RR interval differences) (mean difference = −10.450, p = 0.001) and SDNN (standard deviation of RR intervals) (mean difference = −12.875, p = 0.001). In the standing position, PPCS had lower SDNN. Participants with PPCS had significantly lesser change in HRV, including RMSSD (mean difference = 5.981, p = 0.007) and LF/HF (low‐frequency to high‐frequency ratio) (mean difference = −2.229, p = 0.016), when going from seated to standing compared to controls. Findings suggest adults with PPCS have altered autonomic function relative to controls. Physical activity level and deconditioning are potential treatment targets to improve autonomic function.

BackgroundRecommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an interactive process guiding conversations about end-of-life care between a person, their family, and a health care professional. The ReSPECT process was developed to educate and train providers to ensure that decisions are made in advance and consistent with a person’s wishes. Launched in September 2021 across a multicultural conurbation in the West Midlands, instructors trained care professionals and facilitated the model in care homes, hospice and primary care settings. This paper analyses an audit of the ReSPECT model in care homes, offering suggestions for continued utilisation of the model.MethodAdapted to accommodate COVID-19 restrictions, ReSPECT training included face to face, virtual webinars, and regular ‘top tips’ communications. Third Quarter 2022, a single auditor assessed adherence to the ReSPECT model, quality of documents, and diversity of care homes/participants using a systematic chart review.ResultsThe auditor reviewed 1136 care plans, identifying 350 ReSPECT documents. For 30 audited care homes, 20–40% of residents had ReSPECT documentation, four homes achieved 64–87% completion rates. Medical conditions for 769 care participants in the audit, in order of frequency, were dementia, frailty, hypertension, and diabetes. The quality of documentation and errors varied, e.g., 67% of recipients had charted mental capacity deficits, yet most lacked formal capacity assessments. Variation also existed across professional disciplines conducting the care planning session. Analysis did not reveal any significant demographic differences between care recipients, although smaller homes themselves were more diverse, larger homes more likely to successfully complete and document the ReSPECT process. The recommendations highlight the need for additional training at institutional and provider levels, particularly regarding capacity assessment.ConclusionThe ReSPECT model has potential to improve end-of-life planning and capturing the persons wishes, but additional training and validation is needed to assure consistent adherence.

Background Therapeutic hypothermia (TH) is the gold-standard treatment for moderate and severe neonatal encephalopathy (NE). Care during TH has implications for long-term outcomes. Outcome variability exists among neonatal intensive care units (NICUs) in Canada, but care variations are not understood well. This study examines variations in care practices for neonates with NE treated with TH in NICUs across Canada. Methods A non-anonymous, web-based questionnaire was emailed to tertiary NICUs in Canada providing TH for NE to assess care practices during the first days of life and neurodevelopmental follow-up. Results Ninety-two percent (24/26) responded. Centres followed national guidelines regarding the use of the modified Sarnat score to assess the initial severity of NE, the need to initiate TH within the first 6 h of birth, and the importance of follow-up. However, other practices varied, including ventilation mode, definition/treatment of hypotension, routine echocardiography, use of sedation, use of electroencephalogram (EEG), MRI timing, placental analysis, and follow-up duration. Conclusions NICUs across Canada follow available national guidelines, but variations exist in practices for managing NE during TH. Development and implementation of a consensus-based care bundle for neonates during TH may reduce practice variability and improve outcomes. Impact This survey describes the current HIE care practices and variation among tertiary centres in Canada. Variations exist in the care of neonates with NE treated with TH in NICUs across Canada. This paper Identifies areas of variation that are not discussed in detail in the national guidelines and will help to set up quality improvement initiatives. Elucidating the variation in care practices calls for the creation and implementation of a national, consensus-based care bundle, with the objective to improve the outcomes of these critically ill neonates.

Using a derivation cohort ( N =349), we developed the first warfarin dosing algorithm that includes recently discovered polymorphisms in VKORC1 and CYP2C9 associated with warfarin dose requirement in African Americans (AAs). We tested our novel algorithm in an independent cohort of 129 AAs and compared the dose prediction to the International Warfarin Pharmacogenetics Consortium (IWPC) dosing algorithms. Our algorithm explains more of the phenotypic variation ( R 2 =0.27) than the IWPC pharmacogenomics ( R 2 =0.15) or clinical ( R 2 =0.16) algorithms. Among high-dose patients, our algorithm predicted a higher proportion of patients within 20% of stable warfarin dose (45% vs 29% and 2% in the IWPC pharmacogenomics and clinical algorithms, respectively). In contrast to our novel algorithm, a significant inverse correlation between predicted dose and percent West African ancestry was observed for the IWPC pharmacogenomics algorithm among patients requiring ⩾60 mg per week ( β =−2.04, P =0.02).