#066 - Journal Club - NIRS and IVH, Indomethacin prophylaxis, LISA, cardiac NICUs... and more

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As always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below.

Enjoy!

Transcript

Ben  0:40  
Welcome. Hello, everybody. Welcome back to the podcast. It's Sunday Journal Club. Daphna. How are you?

Daphna  0:49  
I'm good. I get to record from the beach. So how can I how can I complain? Right. Yeah.

Ben  0:55  
And while you're at the beach, fellows are starting,

Daphna  0:59  
right, what an exciting time, you know, I am gonna digress here, I know we have a busy schedule. But like, I am seeing these posts online about all this, you know, excitement. And I just remember how excited I was to start, fellowship and fellowship for me to credit to my program was one of, I don't know, my one of my favorite times of my whole medical training, I was very fortunate to have a really supportive medical training all along at the University of Florida, but it is such an incredible profession that comes with a lot of things right. Responsibility and stressors and, and mental load. But, but I am in the, in the summer times, I remember how fortunate I am to have this job. And that's how much I love medicine. But but a big congratulations to the incoming fellows. And if we can, whatever we can do to help we're gonna keep trying to do to, to support fellows, right as part of our content. So

Ben  2:09  
absolutely. So this this past week, we had Dr. Josh Renier, who's a, who's a program director, who gave us some very, very good advice, very good feedback on the role of being an educator. And next week, we'll have our perennial who's Dr. Alberto ano, who's an incoming fellow. And, yeah, I mean, we want to support trainees, and we hope that that new trainees can flock to the podcast and we can have a meaningful interactions. Actually, if you are a new trainee, I will reiterate that we have created the neonatal network, which you can learn more about on our website at the dash incubator.org. And we are having our first round of grant applications that we timed specifically so that new fellows could apply, there's $20,000 of grant funds to apply for it's not just one grant, it could be multiple small grants. And this is something that we're aiming specifically at young career neonatologist trainees so that you could have an answer on the grant application before the end of the year. And, and we will talk more about that, but but submit something, it could be a small study, and then you'll get some support. So this

Daphna  3:17  
is why I spent all my book money on frickin salivary swabs. So it's right, please,

Ben  3:23  
please, let us let us Yeah, yeah. And take advantage. That's I mean, when we say that we want to support fellows, we're really trying to, to actually do something about it. This is one of the ways and through the neonatal network, we'll be able to provide you access to cloud based solution for database so that you can have like access to a REDCap database, if you want to collaborate with other people. We have access to statistical software, we have access to liberal library management, like we have a lot of stuff. So yeah, in clinical side of things, my advice to new Fellows is Don't stress, it's like you're easier said than done. Right? What I'm saying is the reason I'm saying Don't stress is attendings, as we are showing on the podcasts are unanimously eager to teach. And so you don't have

Daphna  4:12  
to figure out like, I'm gonna like real people.

Ben  4:14  
And they're real people. They went through this as well. And they're there. It's like, it's like having the opportunity to cheat on a test you can ask, you can always ask and people will help you make the right decision. And then you don't have to figure everything out on the spot. So don't stress, learn as much as you can. And yeah, and good luck to everybody. We're happy to see our field grow. Okay, just a reminder as well, for our trainees, and for our attending colleagues. We do have CME credits for Journal Club episodes and neonatology review podcast episodes, all available on each episodes web page. Very straightforward. You fill out a quick survey and then you get a certificate emailed to you Good for these license renewal, whatever, whatever. So that's really it. Okay. All right, definitely. So what should who's going to start today? Yesterday? Uh, gosh. Okay. All right. Um, I'm going to start with this paper published in the Journal of parasitology. It's called association of early cerebral oxygen saturation and brain injury in extremely preterm infants. first author is Mohamed El Deeb. It's a paper out of Boston, Massachusetts, there's some I mean, not exactly sure. What is the level of this first author? If it is a fellow, then there's some names on the paper that will make you jealous. You have so trailing authors are Joseph Volpe, Terry Inder. So it's kind of neat.

Daphna  5:55  
Who's the who's who,

Ben  5:57  
yeah, I was like, if this guy, I don't know, actually, I could find out whether this person is a felon. But I'm like, Man, this is kind of nice. When you have a paper in your your name is next to these giants. It's kind of very cool. Anyway, kudos to, to Muhammad for, for getting that achieved. In any case, all right, on to the study. So obviously, this looks at near infrared spectroscopy. And the background of the study really highlights the fact that there are a limited number of studies that have explored the relationship between changes in the regional cerebral saturation and the development of germinal matrix slash intraventricular hemorrhages. And there's a lot of conflicting reports out there, whether a relative increase in the in the in the regional cerebral saturation, or a decrease reflects the true risk for the development of a head lead. And they actually quoted a few studies showing that some of them have said that some some are saying it increases or decreases. So it's confusing. So the goal of, of their project is to to compare cerebral regional, regional cerebral saturation values over the first five days of life in a population of extremely preterm infants with and without germinal matrix slash ivh. And then, in addition, given the known association between brain injury score at term equivalent MRI and long term outcomes, they wanted to see if they could establish maybe any relationship between these early nears data and patterns of brain injury on term equivalent MRI. So very interesting study. The design was that of a retrospective cohort study that included infants have born before 28 weeks of gestation, with near infrared spectroscopy data recorded within the first 108 hours of life. So they're mentioning that at their institution at bus, is it bus, bus and Gen bus and children Mass General? How do we call that place?

Daphna  8:02  
I think it goes by both Boston Children's has numerous hospitals. Fair enough?

Ben  8:06  
I mean, they in the in the Yeah, they're both Brigham and Women's Boston children. In any case, okay. So at their institution, starting on the on January 1 2018, all infants were born less than 28 weeks gestation, we're being monitored with near infrared spectroscopy for at least, the first three days of life as part of what they're calling the neonatal neurocritical care program at Brigham and Women's Hospital, neonatal intensive care unit. And so they took advantage of that. And we'll post it a little bit some of the pictures on how to they set it up, it's actually very neat they have the supplemental data for this paper is great because they have tons of pictures using mannequins. And so they could actually demonstrate how they're hooking the whole setup. And technically, if you wanted to reproduce some of these data points, you could just it's like a how to on how to set that up. It's kind of nice. So they included Obviously, every infants that were that was that were less than 28 weeks at birth, between 2018 and 2020. They excluded the collected a number of clinical and demographic data. Obviously, the nearest data is also well explained, I recommend you go in the paper if you want to find out which device they were using, and so on and so forth. What I want to spend a little bit of time on in terms of the methodology is the cranial ultrasound and how does that work specifically. So the clinical guideline at the institution dictates that ultrasounds are done on day of on day one, day three, day seven, and at one month of age, and then there's an additional ultrasound that could be done at 36 weeks postmenstrual Age unless they do an MRI. And then in the way they're presenting the data, they're going to call things early intraventricular hemorrhage versus later and early means that it happened within the first 36 hours of life. Okay, so I think I think that's Good. Okay, let's let's get to the results we have a busy show today. So 62 infants were included in the study cohort. And out of these 6228, which is 45.2%, developed germinal matrix, or ivh. And 54.8% did not. The demographic data is interesting, there were small babies. The gestational age was about 26 weeks in the in the in the cohort that didn't develop Heartbleed 25.1 in the babies that did develop ivh. And that was a statistically significant difference between the two groups. Interestingly enough other statistically significant differences in the baseline characteristics of these infants was the baseline hematocrit. And so the babies who developed an ivh had a lower baseline hematocrit, which was on average 40% Compared to 44%. Also, the babies who developed in ivh were more likely to be intubated. That was 19 infants that were intubated and developed an ivh versus 10% in the in the babies who did not. And then finally, the babies who developed ivh, not surprisingly, were more likely to have sepsis. That was 28% versus 6%. Yeah, interesting. I mean, it's a retrospective study, they couldn't really control for that stuff. But these and these are not surprising. So among the infants who did have germinal matrix slash ivh, it was very interesting, the breakdown between mild and severe was 5050 50% 50% of the cohort. The median hours of life until the first detection of hemorrhage did not differ significantly between the mouth group, which was about 37 hours and severe group which was 42 hours. Okay, let's talk about the nears measurements. So nears monitoring began at a median of about eight hours of life and ended at about 80 hours of life with a median duration of about 69 hours of monitoring. In terms of the regional cerebral saturation, based on the estimates from the unadjusted linear mixed models, the regional cerebral saturation trajectory for the babies who developed ivh exhibited a steady decrease after 36 hours while that for a while that for the babies who didn't have ivh was relatively stable over time. Infants with a germinal matrix or ivh, had significantly lower regional cerebral saturation values, then those with no ivh after 36 hours of life when the model and so that's the unadjusted, obviously, we talked about a lot of the differences between the two groups. But what was interesting is that when the model was adjusted for potential confounding, there was attenuation of the difference between groups as compared with the adjusted model. But the original Cerebro saturation trajectory still exhibited significantly lower levels among the ivh infants compared with the babies who did not develop ivh after 48 hours. And so it's actually very interesting, if you, I really appreciate when there's graphs in the paper. But in the paper, you can see the two difference between the adjusted and the unadjusted model. And you can see that the cerebral the regional cerebral saturation is significantly lower in the babies who develop the ivh. And then when they corrected for the co founders. It lost significance at various time points, but it's still pretty markedly is lower than in the babies who didn't develop ivh. So that was that was really interesting. So they tried to create this receiver operating characteristic curve. And so to assess the accuracy of ivh prediction between 37 and 48 hours of life using the regional cerebral saturations. The area under the curve the the D roc, if the sorry, the area under the ROC curve was point 714, indicating that the model that developed has a 71.4% chance to distinguish infants by ivh status, and that the estimate is significantly better than chance alone, right. They did some more statistical analysis, and they were able to get a model with a sensitivity of 75% specificity of 66%, the positive predictive value of 64% and a negative predictive value of 76%. So, better than chance, obviously, as they say, but not also. It's not the most impressive of models, right. In terms of term equivalent MRI, there was no significant differences in the new year's data. Looking at it by the Keto Cora severity category, using linear mixed model unadjusted or adjusted for potential confounding so there was it couldn't really connect to and so the study concludes that in France with germinal matrix or intraventricular hemorrhage exhibit divergent, regional cerebral saturation trajectories in the first few days of life when compared to infants without hemorrhage. And in those with ivh, the regional cerebral saturation levels decline decline after the second day of life, whereas in infants without hemorrhage, they have more stable nears data. And thus, and that's the main conclusion of the paper, non invasive monitoring of regional cerebral saturation using nears may provide a useful bedside tool to monitor interventions aimed at the prevention of germinal matrix and ivh. And I think that's the key. I think this is not making a case, this paper is not really making a case that you can just hook up the nears, strip on the baby's forehead, and then just follow that one data point. But combining this data point with other other aspects of the monitoring and the neuro protection bundle, you may be able to significantly reduce rates of ivh in your unit. So this is coming out of a very, very reputable group. And so very, very good data, we'll put some of these graphs on the Twitter page. But yeah, curious what you think. No, I

Daphna  16:11  
mean, we, you know, we all know that nears exist and it gives us some information. I think we've all been very hopeful that like this study would come out, right, or studies like it. And there are many, you know, others underway, saying, you know, how can we really use this clinically, or at least, and what they're alluding to is how can we use it as a marker to see if certain interventions are effective? So it's exciting. It's exciting. Anything we can do to help with our ivh problem, I think is is a good one.

Ben  16:44  
That's right. All right, definitely. Where are you taking us next?

Daphna  16:48  
So since we're in the, in the kind of neuro mindset, I'll do this paper, effective prophylactic indomethacin on intraventricular hemorrhage and adverse outcomes in neonatal intensive care unit. Lead author Colleen Miller, Senior author, Leif Nylund. Of the BPD. Collaborative.

Ben  17:07  
Yeah, our buddy leaf. Yeah. So

Daphna  17:09  
this is from the journal and

Ben  17:11  
second second author Peverel Prusa. Cough. We reviewed his papers before. Yes, all our buddies are on there. Good for them.

Daphna  17:19  
This is a in the Journal of Perinatology. And they're coming to us from Nationwide Children's. So what's the question? It's the ongoing the age old question about this relationship between prophylactic indomethacin and intraventricular hemorrhage and any adverse events associated with prophylactic? indomethacin? So is this a valid question? So the tip trial is probably the most recent trial that looked at this, as well and found a decrease in interventricular hemorrhage, but other trials have shown no difference in interest, stroke or hemorrhage? So there's been kind of a, a trend towards decreased mortality. So while in general, prophylactic medicine has kind of fallen out of favor. There's still this does it doesn't it kind of question. So this is

Ben  18:09  
still some attachment?

Daphna  18:10  
This? Yeah, sure. Yeah. I think people want to be sure, I guess. So. This is a retrospective cohort analysis. So interestingly, what they did they have three different teams across three different NICUs over in Asia and two of which are doing prophylactic indomethacin. At a dose of point one Meg's per gig queue 24 hours times three days for infants less than 27 weeks. And the first dose is within the first 24 hours of life. So basically, what they did is they took the cohorts they already had of babies who were receiving prophylactic indomethacin in these two units, compared to the babies in the the sole unit. It seems like who, that's not the standard of care. So the primary outcome was intraventricular hemorrhage on the first head ultrasound. And the secondary outcomes they wanted to look at are some of the potential adverse reactions related to indomethacin use, or that we have been concerned for all this time. So they looked at renal function, they lifted the changes in serum creatinine from DS, one to four, they looked at the urine output specifically looking for a 24 hour period where there was less than one mL per kilo per hour of time on positive pressure ventilation, neck sip, and the PVA and one thing I wanted to mention, you know, we like to try to point out some of the statistical methods occasionally, and they used a type of ERP, sorry, I got it. It's kind of a What about in there? They use the type of propensity score matching called inverse problem, inverse probability treatment waiting. And so I just wanted to mention that so basically, if you're not familiar with IP TW It's really a way to ensure that all subjects are matched. And they don't fall out of the analysis as opposed to routine propensity score matching where some babies may not find a match, so to speak. So, I did not know much about that. So I mentioned it. What else did they want to Okay, the baseline characteristics, they had 421 events. 61% received prophylactic indomethacin 79% of the 61% received the full three doses, and 39% of babies received none and represent the control group. They used a variety of variables to create their IP btw matching. And overall, they found no differences in the baseline characteristics of gestational age, birth weight, gender, app guards, maternal steroids, maternal drug use, and sorry, the drugs they were the medications they were looking at were maternal gentamicin, maternal indomethacin. Oh, and maternal magnesium. So no differences in those medications. And then, for the primary outcomes, they saw no difference in intraventricular hemorrhage at the first head ultrasound 31% versus 33%. So P value of point six, eight. For severe ivh, there was 11% in the prophylactic, indomethacin group and 16% and controls no difference P value point two one and odds ratio point seven, two, they babies. Then they looked at the babies who had the full course, versus babies who didn't get a full course of indomethacin. So interestingly, the full course had 24% ivh rate 22% in the less than two doses and 33% in the control group, but across not statistically different, and P equals 0.3 to two, I would have liked to see more data on those groups individually. And then they reported on the secondary outcomes, so there was no difference in presser support or hydrocortisone in the first seven days. Interestingly, there was increased use of caffeine and amp and gent in the prophylactic indomethacin group. So it's hard to say what what impact if any that had on the outcomes, there were differences of baseline creatinine point eight two and the prophylactic indomethacin again baseline creatinine versus point seven five and controls with a P value of point oh one, there was a rate of rise of Creatinine that was higher in the prophylactic indomethacin group P value of less than point 001. And there were differences seen and creating at day of life 4.99 Creating prophylactic medicine versus point seven nine and controls P value of point 001. And this was true even after adjusting for gentamicin exposure because there was more gentamicin exposure in the prophylactic indomethacin group. Finally, they did see a difference in the urine output. So they had more babies in the prophylactic indomethacin group with a urine output less than one mL per kilo per hour over some 24 hour period. With a p value of point 004. They didn't find any difference in operative closure use of ibuprofin. For PDA closure, they find no differences in neck and sip, they found no difference in oxygen requirements are 36 weeks, no difference in positive pressure ventilation at 24 hours of life. And then they did do a subgroup analysis where they looked at patients less than 24 weeks, and under or in 25 weeks and over and they didn't find any differences by subgroup analysis. So in general, they did not find a significant difference, I should say in the ivh outcomes,

Ben  24:06  
and if anything worse outcomes in the indomethacin group, especially when you look at this kidney function stuff that you mentioned, yeah,

Daphna  24:12  
we write we don't you know, it's it's always interesting, we talk about kidney function, right and the extremely preterm ability, ability

Ben  24:21  
to say kidney function, sorry, no, no. Why does it create mean?

Daphna  24:25  
What I mean is right, what does that mean for the baby? So it may be some other outcomes about long term kidney function, but yeah, it makes you it makes me worry a little bit

Ben  24:34  
that I have no idea why I want indomethacin to work, right.

Daphna  24:39  
Everybody does.

Ben  24:40  
I want it to work. You read the paper, the paper and I'm

Daphna  24:44  
really we're rooting for in Damascus, you're

Ben  24:45  
rooting for them? Like, ah, it doesn't work.

Daphna  24:49  
Because like I said, just earlier, we're looking for anything, right. Any glimmer of hope that can

Ben  24:55  
anything that we can use to help our babies. So great work. Yeah, your turn. Alright, my turn. I'm rambling. Okay, so the next paper I want to talk about is called the incidence predictors of success and outcome of Lisa, in very preterm infants. first author is gurgly ballage Baelish. I hope I'm pronouncing this correct. I'm probably mispronouncing it. From the city of Des person in Hungary. This is published in pediatric pulmonology. The background of this paper is quite interesting. And it really mentions the fact that as we're extending Lisa to more broader populations, some often smaller more immature infants, and to babies with more severe clinical illness, it's kind of interesting to find out exactly what are some of the parameters that will hint at whether Lisa will be successful or an utter failure. And so they're mentioning some prior studies that have identified that in babies less than 28 weeks in babies with high CRP or the presence or absence of antenatal steroids, they could have an impact on the success of Lisa. So what they're trying to do is to identify clinical factors predicting the success of the first Lisa procedure in very preterm infants. And alternatively, their second objective is to study the success rate of a repeat Lisa procedures and the avoidance of intubation and mechanical ventilation. So I think it's the right juncture for me to mention that Lisa means less invasive surfactant administration. And if you're still not familiar with Lisa, first of all, I recommend the video by our upcoming guests, Nathan sunburned who has a video on on Lisa on YouTube, which you should check out. And also if you are not familiar, it basically involves incubating a baby with an with a feeding catheter and instill and instilling the surfactant through that feeding catheter while the baby is on non invasive ventilation. It's the gist of it. I'm just doing this so that you can have some context. This was a single center retrospective study that was conducted between January 2014 and December 2019, in the Division of neonatology of the Department of Pediatrics at the University of depression. The study included preterm infants born before 33 weeks, completed weeks of gestation and who were stabilized on CPAP in the delivery room, then treated with Lisa and who were admitted to the NICU. They excluded infants requiring intubation in the delivery room, obviously, or immediately after admission to the neonatal intensive care unit. They also excluded infants with congenital anomalies. So a few important items about the study design, they are not going to go over their indication for surfactant administration, they were pretty standard. Lisa was the preferred method of administering surfactant in spontaneously breathing preterm infants. However, based on the clinical condition of the infant, the attending, neonatologist could choose the option of intubation for surfactant therapy. So this is I guess, why the study is, is retrospective. And yeah, that makes sense. Anyway, Lisa with contra indicated in a specific group of infants. And these were the babies who were hemodynamically unstable. The babies who had severe RDS defined as having an ephah YouTube of 60%, a pH less than 7.2 or and or permanent atelectasis on chest X ray. They also contraindicated in babies who had recurrent apnea despite despite caffeine loading, known air leaks and possible lung hypoplasia. Importantly, enough, no pre medication was given routinely before Lisa right and that's that's a big subject of discussion still, about how much sedation that you provide to a baby that you're expecting to spontaneously breathing. But I'm not going to get into that right now. nasal CPAP was continued during the whole procedure Lisa was performed by the attending neonatologist in all cases, and surfactant was instilled in small aliquot point to 2.4 ML over two to three minutes. Now, in terms of repeated surfactant dosing, a second or third dose of surfactant was given using Lisa during the first 72 hours of life if if the FIU to exceed exceeded 40% If other cause of respiratory failure had been excluded, or if no criteria for mechanical ventilation were met. What does that mean? So they in the paper to define the criteria for mechanical ventilation in the first 72 hours, as a preterm infant needing 50% Oxygen having a pH of less than 7.2 PCO to about 60. frequent episodes of apnea requiring stimulation or two episodes of apnea unresponsive to stimulation or requiring PPV within two hours. Okay, So now you have a bit of an idea. I mean, I think it's it's fairly reasonable the way things are conducted. The primary outcome was to examine the success rate of Lisa and to identify early predictive factors for the outcome of the set procedure. So during the study period 800 preterm infants were born at less than 33 weeks of gestation, of whom 158 underwent this procedure. The babies were relatively big, the birth weight was one kilo and 25 grams, the number of babies that were less than 750 grams was 3550, were between 750 and a kilo 26 were between a kilo and 1250 and 47 infants were above 12 150 grams 17% of the cohort was between 24 and 25 weeks 26% of the cohort between 26 and 27 25%, of the cohort between 28 and 29, and 30%, between 30 and 32. So a good breakdown. The first Lisa procedure was successful without further surfactant administration or mechanical ventilation in 54% of cases. And so that's that's already a very interesting number endotracheal intubation and mechanical ventilation was an assistant that was necessary in 34% of cases in the first 72 hours of life. I suggest you look at figure two, which we'll put on the Twitter page. And it demonstrates that the success rate of Lisa increases with increasing gestational age and the rate of CPAP failure cases gradually decrease. And it's quite an impressive graph because you can see really the relationship between the two. So I really, really liked that. Let's go into some of the more detailed findings. So factors that were associated with Lisa failure. So compared to the group, that success that was successfully treated with the first Lisa, those who had Alyssa Lisa failure had been usually born at a younger gestational age, as we just mentioned, lower birth weight, they had worse general condition as the people mentioned, which means that the one minute Apgar score was usually a bit lower and lower admission temperature, I thought that was very interesting. And that was statistically significant. So they did a multivariate logistic regression model, and they were able to identify six independent risk factors that predicted the probability of Lisa success. Sorry about that. The first one was the core temperature at the time of NICU admission, and it showed strong positive correlation with Lisa success with an odds ratio of 3.56. Another interesting one was an elevated CRP level, and obviously, so they found that an elevated CRP above 10 had an odds ratio of point two, eight, and it decreased the possibility of Lisa success. We don't tend to get CRP levels on admission, to be honest. So it was interesting to see that their birth weight was also the third factor that they identified with an odds ratio of 1.003 and maternal age were also significant predictors. Another factor, the highest respiratory severity score, which is defined as the CPAP level in centimeters of water times the FIU to in the first hour of life or at the time of Lisa was, was significant, and it was an independent risk factor and the odds of Lisa's success is decreased by 5.4%. For every point one increase in the risk of respiratory severity score. And then finally, an interesting one that I've sort of found to be true from experience is the dose of surfactant was found to be an independent risk factor. So if you use less than 2.5 mL per kilo, or less than 200 milligrams per kilo, the rate of lessor success decreased. The predictive power of this model was supported by an eight point by point eight five AUC value of the ROC curve created by using the de identified factors. Other interesting findings from this paper 62 patients which is 39% of the cohort receive the second dose of surfactant 31, so half of them via ET Tube 31. With Lisa, among the babies who received the second form of surfactant through Lisa, further surfactant treatment and or mechanical ventilation was avoided in 18 cases. So 58% of that cohort that needed the second dose of Lisa don't make sense as we get into the rabbit hole of the patients who does get tricky anyway, yeah. Interestingly enough, they found no association between the Lisa success and the dose of the administration of antenatal steroids. They also acknowledge that in the paper saying 92% of the population receive antenatal steroids so not the best cohort to find out whether antenatal steroids is a big factor.

But another interesting aspect was the time it took to get to Lisa. And so the time in minutes was 135, the median time in the people who had a successful lease procedure, versus 120, in the lease a failure. And I mean, this is, again, this is a difficult thing to, to look at it like is it the chicken or the egg is the fact that you could have waited a bit longer means that the baby was doing a bit better. So in conclusion, failure of Lisa is a relatively frequent event and preterm infants born before 33 weeks as they conclude, and is associated with adverse outcome. They're mentioning in the conclusion, the birth weight, the maternal age, the core temperature, the highest respiratory severity score, during the first hour of life, or at the time of Lisa, the dose of surfactant and the CRP level, are independent predictors of the outcome of the first Lisa, our predictive model can be used to identify infants where mechanical ventilation and or surfactant treatment can likely be avoided with a single visa procedure. A very interesting paper. I think it's highlighting a lot of stuff that we're trying to figure out as we're getting more used to this procedure,

Daphna  36:06  
then kind of the demographic features, you know, those clinical characteristics, even regardless of the, the, you know, primary outcome are useful.

Ben  36:15  
Right. Yeah. Yeah. And so, yeah, I think I think that was very interested in the fact that initial temperature mattered, I think, is that a is that a proxy for how stable the baby is on admission? And the dose? I think, the DOS, we've known already now that there's a it's a much more wasteful procedure, when surfactant is being given through the Lisa method, because obviously, there's a lot more leakage. And it's so so yeah, could we just need like we've said before, could we need more doses? And interestingly enough, how they were able through to Lisa procedures to write so they had 86 patients that were successful on the first trial, right. And then of the 72 that needed another dose, right. The half that got the Lisa, the second Lisa? Well, 60% of them did fine. So these are not insignificant numbers, and maybe with two courses of Lisa, could that be covering most of the population considering they were preterm infants? It's very interesting. So yeah, go check out this paper.

Daphna  37:21  
Thank you, buddy. I know we're rushing through things today. But I wanted to take a minute to review this article, I should say, a pediatrics perspectives article. in pediatrics. It's called breaking the fourth wall of medicine when the doctor becomes the parent, and is written by Teresa, Dr. Teresa Urbina, who was a second year, neonatal fellow when her baby was born, and was diagnosed with a double outlet right ventricle. And so I think it's a very short, concise read with just some really valuable pearls, about how we engage with families, from someone who's been on both sides. So I think it's super valuable. I encourage everybody to read it, I will kind of give the stated action items. And then again, everybody can, you know, take a look for more details. But none of these I think are earth shattering or revolutionary, but they bear reminding, and that the interactions we have with families every day, have significant impacts on on both the families and the babies. So the action item one, understand that is difficult, if not impossible to internalize the words that follow life changing news rapidly. And Dr. Bina describes, even though, you know, already had some knowledge about that a lot of knowledge about the diagnosis when you get a diagnosis, and it's followed by a lot of logistical information, that it's just impossible to navigate that flow of information and that how important it is for us to break up our information loads or boluses to families in a way that is more manageable action item to provide trusted resources to the family to counter potentially unhelpful information they may find on the internet regarding their child's diagnosis. And actually this action item really struck me because I think we tend to do this for some of those major diagnoses. But really every diagnosis in the NICU is important and meaningful and potentially seemingly catastrophic to the family and families. The minute they get some information are going to go on the internet and start reading about it so we might as well head that off. Bye, guys. giving valuable resource at the onset of even a routine admission for a moderate preterm or a late preterm infant and give parents kind of that autonomy to have control of the information, Action Item three, prepare families for what equipment they will see at the bedside and on their child. So I think so often we become desensitized to how medicalized these babies somebody's child is. And again, it gives parents and families back some control because they can mentally prepare for what they're about to see, even if they've never seen it before. Whereas in what Dr. Veena describes, you may come in, and even though, you know, she had spent time in the ICU, she knew what the equipment was. It's like she describes that that's all all you could see. And so I thought that was really helpful. Even when we're in, you know, bringing partners over to see you'll be W for the first time, we can describe some of that equipment action item for facilitate the family holding their child at the earliest moment possible. I think this goes without saying doesn't need any additional information. Except that that matters to families and waiting an additional two hours or six hours or 12 hours makes a difference. And if we can accommodate those interactions for bonding, it's awesome for families and potentially has some benefits for babies. Action Item five, when giving news over the phone about a procedure, we must provide information regarding urgency and allow families the option to be in the hospital before the procedure begins if clinically appropriate. And and this made me think of our interview with Dr. Holly Neville, where she said basically like, tell me how worried to be about this at the beginning. And so I can start to you know, make my mental accommodations and plans. And I know I have to do this on routine phone calls. I call a family and I'm a phone caller, I call all the time and I say nothing's nothing's wrong with little baby. today. I'm just calling for an update. I say it's the first line I say. And so parents know to expect that for me. So if that's not the case, I'll say listen, there's been a clinical change. And I think giving parents that feedback about how acute or serious the situation gives them more decision making power, what what a great action item. And the sixth one is referenced the child's sex and name when interacting with the family. And I think that's just the point of this was definitely we should be using baby's name. If you just can't remember the name? Well, at least, you know, don't get the stated birth sex wrong, because I think obviously, there's a lot of discussions about using gender and stated sex, but it but it bothers families, it makes it family feel it makes the family feel like you don't know their which baby is theirs, if you get the you know, gender wrong. And as we're learning more about what's important to families, I think it's you know, it's I think it's probably best just use baby's first names. And so making it a standard in your unit. And she described some of these opportunities just have the name readily available. So when you come to bedside, you don't have to remember the name, just have it there. So you can use the name. It's that's it, there's tons of data on that, even from the pediatric literature, how important it is to use a child's name

Ben  43:48  
1,000%, that was the biggest one for me. And it doesn't mean you have to memorize the name of every baby in your unit. But just like you're gonna go talk to a family just like, look,

Daphna  43:57  
take a look just so, you know, I think everybody should take a look, I think and she does mention how important this is just including, if you're in charge of training programs, this is an easy resource to immediately start some of that rapport building with families. So

Ben  44:17  
yeah, and I wanted to give a big thanks to Matt Harrell, who is the person who emailed us to recommend this paper. So yeah, definitely Thank you, Matt, for suggesting this paper. This was this was a very pleasant read. And it's I think something that is a great paper to hand to students coming into the unit.

Daphna  44:38  
Definitely everybody, right, our nursing colleagues, our tea colleagues, this is something every step every member on the team. Absolutely.

Ben  44:46  
Absolutely. And I do think hopefully that with experience, these things now should become things you're like, it's true, like right I mean,

Daphna  44:55  
I'm not sure we can say that about all everybody.

Ben  44:57  
I know. I know. But that mean I mean no None of these items were extremely surprising to me, right? I'm aware of these things. But I'm saying I remember as a as a new resident coming into the unit. These are the code of conduct that are very much specialized in to the specialized to the NICU. And so this is a great short read to understand a little bit about all the, it also gives a it conveys all the stress and the intricacies of parents and what they go through in the NICU. So no, definitely and obviously, everybody can benefit from reading this paper. But yeah. Alright, so another paper that we wanted to review today is actually published in the Journal of thoracic and cardiovascular surgery. The title of the article is outcomes after neonatal cardiac surgery, the impact of a dedicated neonatal cardiac program, first author is Nimrod, gold strim, who will be on with us in a few minutes. So we're taking a look at some of the cardiac babies, we recorded in a special interview with Amir Ashrafi, who, who organizes the new height conference, check that out if you're interested in attending that conference. But basically, this paper really looked at the outcomes of babies with neonatal congenital heart disease basically, right and, and this paper describes what is known as and, and encode in the paper as the quote unquote, Columbia model. So what the authors of the paper are describing is this new way of taking care of neonates with congenital heart disease. And the idea is that these children should not technically should not not that they should not these children at Columbia, Presbyterian are no longer being treated in the NICU. They're not treated in the PICU. They're not treated in the CICU, or the cvicu. But they have a dedicated cardiac NICU that specifically takes care of them. And that's something that is quite novel that is not readily available everywhere. And really the question and what the authors are trying to describe is to assess the performance of this particular model in preterm infants compared to full term infants with congenital heart disease. The primary goal of this study is to look at in hospital mortality, they're looking at other stuff like morbidity rates, length of stay, and they're gonna look at this through across different gestational ages. Now, they're comparing their outcomes to a few things to full terms, and to other databases, which to be perfectly honest with you, I'm not a cardiologist, so I was not really familiar with them the STS ch D surgical database, and the PC for clinical registry. So let's talk a little bit about what is that cardiac NICU. So the the neonatal cardiac program is something that was initiated at I have to give the I keep calling this Columbia. I actually worked at Columbia for some time. So I feel comfortable saying Columbia, but it's officially New York Presbyterians, Morgan Stanley Children's Hospital, right. I mean, this is the official name of the hospital. So they opened their neonatal cardiac program in January of 2006. All neonates with congenital heart disease were admitted to the cardiac NICU, which is basically a 17 bed sub unit, physically and functionally distinct in its structure in its team structure and practices. So and then, about nine years later, in 2017, the cardiac NICU moved to a newly constructed dedicated neonatal infant cardiac unit if you haven't, I mean, this is like I've been there. It's pretty phenomenal. Yeah. The to reflect the results solely from other cardiac NICU, the sensor data until June 2017. So how does that work? So the cardiac NICU is staffed by a dedicated group of duly trained cardiac neonatologist, pediatric cardiologist, cardiac surgeons, neonatal cardiac nurses, nurse practitioners, and allied providers with expertise in newborns, nutrition, pharmacy, speech therapy, lactation consultant, occupational and physical therapy, the whole gamut. So for those, yeah, for those of you who are short on nurses and other stuff, the idea that they could staff, this whole unit with all these providers is, it's pretty phenomenal. All phases of they're saying in the paper that all phases of care from admission to discharge, including post operative recovery occurs in the same location with the same team without transitions from one unit to another. And that's something that's important because for example, we definitely when we were working at Joe DiMaggio children, many times the babies would would transition from one place to the next. So they would be pre up in the NICU post up in the cvicu, where they would move depending on their needs. So they're making? Yeah, they're making a case that these babies are staying put in the same unit throughout their states. We're gonna say, Yeah, I

Daphna  50:15  
think that's potentially one of the most valuable points of the system. Because we know that transitions of care are a weak point, right. And we know that's where mistakes happen. That's where information is lost. So the team knows the baby, really, from the beginning to the end. So that's, I think, the first most interesting thing, and then, obviously, it's this multidisciplinary collaboration where when we work together, we can do really interesting things. It's disrupting these silos that we definitely have between the two worlds. So

Ben  50:51  
yeah, and they're actually drilling on this point by saying that there's further integration of the neonatal cardiac team, with prenatal maternal fetal medicine programs, fetal cardiologist to really provide, like you said, a seamless transition not just from within the hospital, but like from the prenatal consultation, or, yeah,

Daphna  51:11  
and I can imagine how meaningful that is for the families who, you know, prospective.

Ben  51:20  
Agreed. So the study design is a single center, obviously, retrospective cohort study of all the infants from the cardiac NICU who underwent cardiac surgery at New York Presbyterian at Morgan Stanley Children's Hospital between 2006 and 2017. The inclusion criteria were all subjects who underwent cardiac surgical intervention after admission to the cardiac NICU, and they excluded subjects who underwent transcatheter procedures as their sole intervention like a balloon valvuloplasty. Subjects were also excluded if a gestational age could not really be confirmed if they had incomplete medical records, or had an isolated ligation of the PDA. So they excluded that population as well. In terms of gestational age, the the did not look at babies on the continuous spectrum. They actually use categorical variables. And so they defined five strata strata for gestational age, and they had babies who were less than 34 weeks, these were called the very preterm group, then you had babies from 34 to 36, and six, these were the late preterm group, then you had the 37 to 38. And 60s were the early term 39 to 40. And six, these were the full term, and then they had all the babies beyond 41 weeks.

Daphna  52:41  
It's so funny when you think compared to our strata,

Ben  52:45  
oh, yeah, it's like, we've got like 2224 jealous, I mean, but even at 37 weeks, they're, they're tough to manage. Sure, sure. The primary goal of this study was to evaluate mortality, morbidity, length of stay. And then the secondary outcomes included the composite of morbidity, duration of postoperative mechanical ventilation, post operative, and hospital length of stay. And all these were measured in survivors. So 2045 patients were admitted to the cardiac NICU during the study period 640 with congenital heart disease who required no intervention during their hospitalization, 90 who require transcatheter procedures. And then of the 1315 patients remaining Comfort Care was an option for 46 of them. So that's a good reminder as well, that yeah, sometimes comfort care should be a plan of care as well. There were 20 preoperative deaths, and four of which occurred in the less than 34 weeks group. So now that we have some baseline characteristics out of the way, there's a ton of data obviously, in this paper. And for the in the for the, in the interest of time, I'm going to I'm going to try to go through some of the meat of the paper. So in terms of mortality, the total of 75 out of 1238 study subjects died during the hospitalization, which has a mortality rate of 6.1%. In house mortality rate in very preterm infants and late preterm infants was 17.6 and 8.7%, respectively. Now, where it gets interesting is compared to the full term group, very preterm infants were more likely to die during the initial hospitalization, with an adjusted odds ratio of 3.5 to so quite impressive, and no other gestational age group had a significant increase in the odds of mortality compared to this reference full term group. And then the in hospital mortality rate in this very preterm infants with isolated congenital heart disease, meaning that they had no other issue, aside from the cardiac defect, meaning no other, no other, sometimes, you know, could be part of a syndrome could be. So these represented only 57 infants and the mortality rate was 10.5%. So, in case for those of you following, this means that when we're comparing very preterm infants as an entire group, the mortality rate was about 18%. And this went down to about 11%. When you're just looking at babies with isolated CHD. And in the full term group, the mortality rate was 4.4%. So still higher than the full term group. And the odds ratio is 1.96. A bit high, but still lower than before. I want to commend the authors on these central illustrations, it's very notable put them on Twitter, very easy to actually understand some of these results and make sense of what they're talking about. In terms of morbidity, there was an increased risk of morbid events in the very preterm group with an odds ratio of 4.8. And in the late preterm group with an odds ratio of 1.83, compared to full term group, in terms of the length of stay multivariable regression showed that very preterm infants and late preterm groups had increased post operative and hospital length of stay, and post operative ventilator days as compared to the reference for term group. And I invite you to look at table five and some of the other tables in this paper. So the conclusion is that their experience with this new dedicated neonatal cardiac program is able to produce lower mortality and morbidity rates, particularly in the very preterm and late preterm group, which is kind of a big deal considering that these are really, really the tough ones, to manage Absolutely. The greatest survival advantage in very preterm infants with isolated CHD. So these babies, actually they were able to get to see the highest degree of, of survival, the greatest survival advantage, as they call it. And so they're suggesting that the Columbia model could represent an alternate structure to the to the demands and the needs of this very much vulnerable population. I want to go back to one more thing, because they don't, they mentioned this in the introduction that they wanted to compare their rates to some of these registries and databases. And they only started doing that in the paper in the discussion. So you have to get to that. Rate and so. So the so we're going to, I'm going to just quote their paper, because they're summarizing the numbers. And I think it could be easy, because of the different categories to get stuck as to how do you compare. So the crude mortality rate for the late preterm group was about 8.7%. And then the unadjusted crude mortality range, the unadjusted crude mortality rates ranged from 13% in the late printing group from the PC four registry and 16% from the STS CHD. database. So quite a market decrease, right. So they got about 9%. And the other two databases have 13 and 16%. And then they give you more information on these different databases and who these include. So they fit so they were able to fare better than then infants actually reported in those two databases. So we're very happy to actually have the first author on with us Nimrod Gulch from and we're going to ask him some questions about the feasibility of establishing this model, because it seems at least from a resource standpoint, it's it's quite demanding. But again, the outcomes do speak for themselves. So without further ado, let's welcome Dr. Gold Trump to the show. Nicole Chan, thank you so much for being on the show with us this morning. Pleasure to be here.

Unknown Speaker  58:50  
Thank you for having me on.

Ben  58:51  
No, that's the pleasure is ours. I mean, we just we just reviewed your paper on the air. Congratulations, what a beautiful study and congratulations on these great outcomes.

Speaker 3  59:01  
Thank you. It's, it takes a village and a lot of time and effort. And we're just very proud of the work and hoping this can be a version of how neonatology can continue to be incorporated in congenital heart disease.

Ben  59:15  
Right. And so talking about this taking a village, I mean, in the paper, you do mention all the staff and in the in the level of specialization that your staff has to actually work in this cardiac NICU. I wanted to ask you the first question, which is if if you are entertaining the possibility of dedicating a unit to your NICU cardiac patients. In terms of setting this up in terms of the logistics, even in the paper, you do mention how you guys moved while while your current cardiac NICU was being built? It seems like it takes a lot of resources in terms of of real estate staffing and so on. Can you Tell us about what that commitment looks like. And what in your opinion, would determine that hospital should make this commitment to a cardiac NICU?

Speaker 3  1:00:10  
Yeah, it's a great question. And, you know, one major message that, you know, that I hope the community takes from this is partly about the modeling itself. And, and there's a version of something that others can incorporate into their systems. But more importantly, even the idea that just involving the right specialties for the patient, right and bringing the specialists to the patient and the combination of neonatology benefiting the neonate and preterm baby as more important, and that, while this is one great model, every hospital system may have its own nuances, right. And it may be challenging to do exactly what we're doing. But it might not be hard to bring in those people as more involved stakeholders. To give a little bit of context, it took years for our mentor and founder Dr. Ganga, Krishna Murthy of this cardiac neonatal program, to both collaborate and work with our surgeons who really bought in and invested in this and it's a credit to them to value neonatal driven, cardiac intensive care program. And then she took it upon her with our staffing to develop neonatal nurses into cardiac neonatal nurses, and build up an Advanced Care Provider Program, integrating our fellows into the training program for neonatal cardiac training. And this took years to evolve. And that's what our data is representing a program built within a NICU with buy in and staking from CT surgery, cardiology. And, and again, many programs could work on this template. And if you had leadership that wanted to do that, it is absolutely a possibility. But not every hospital is built this way. But we hope we can take from this is that if you bring in neonatologist, right, if your physical unit is somewhere else, if you're neonates and preterm infants are cared for in a multi ICU or Multi Floor system, finding a way to bring that core group who gets this extra training into the fold could be of an added benefit to these babies.

Ben  1:02:18  
My next question is, is really related to trainees and regionalization of care. I think there's a lot of hospitals these days who have made the commitment, not the commitment, I think it's a default, where they're saying, you know, we don't have cardiac intensive care, we don't have cardiac surgery, so our fellows don't get that exposure. And that's already becoming a significant proportion of training programs. I feel like if we are moving towards a place where the larger Children's Hospital develop these cardiac NICUs, and we sort of regionalised the care of these infants. Do you think that this might have a negative effect in which now more and more fellows in outlying hospitals will not get training in the management of cardiac babies? And how can we mitigate that, in your opinion?

Speaker 3  1:03:07  
It's the question for the next generation, right? How really like there, what's going to be the answer for this? And how do you expose enough people in training, who, as you're saying, are getting exposed to level twos, level threes and level fours? Right, they're not always getting the same kind of exposure? I don't know honestly, if I have a good answer. What we have found here, for example, is we have fellows from a variety of rotating institutions from around the New York City area, who come to us for monthly rotations from at least two and I think, obviously, possibly three fellowship training programs to get their congenital heart and cardiac ICU exposure. Whether it's enough at least to give them interest in training, I think so from the perspective of like, hey, here are the basics, here's what you need to do, if you're not going to work in a major regional center. And for those who are really interested in then, you know, pursue and consider further training to kind of move their skill set up to take this on. I don't know what the right answer is because you have to

Ben  1:04:09  
give them right off the bat fellowship. Yeah, because it feels like this is gonna be it feels like point of care. echocardiography, cardiac intensive care. I mean, this, this, in my opinion, lends itself to a one year and one year additional fellowship. Hopefully, maybe that can be integrated in your NICU training or added after NICU training, but it sounds to me like you guys are doing a lot of stuff that may not be absorbable through one or two rotations. I feel like it's it's complex. It's it's a high degree of excellence. There's not much room to also there's not much wiggle room with these cardiac babies. You have to be really on the

Speaker 3  1:04:48  
correct and precise and this template is not novel. If you think about what pediatric cardiologists do, right? What do they do after three years of training if they want to do some thing that's not an offshoot of general cardiology, whether it's inpatient or outpatient. They do a year of electrophysiology. They do a fourth year fellowship in cardiac catheterization, or in heart failure. We're not doing anything that that's novel critical care. intensivist. Right. may do you know about double boarding fellowships in CIC in pediatric ICU in cardiology. So the our other colleagues and disciplines have all found the value in additional training that we just focus on an even narrower subset, within your own discipline. And I think what our paper also shows us that neonatologists can have a role. And we think, a valued role in improving the outcomes, the general, not just mortality, as we showed from our paper. But I think, overall, what I hope is that this pans out into further studies where this overall level of care can promote both developmental maturation try to show you know, the more patient centered values that we want to get right. And this is hopefully what we're going to be pursuing in the next three to five years with his studies is do the better outcomes, right? The neurodevelopmental stuff also get improved upon, or is the scale to catch these kids up potentially better. And that would be a profound thing if we can show but the idea is that neonatologist should be pursuing the same thing as our critical care and cardiology colleagues. Because I think there's there's clearly a role for that additional training.

Ben  1:06:28  
Yeah, I mean, after reviewing so many papers, and and being in the field of neonatology for for this long now, there's a few tenants that I think always are correct, right. risk stratification is usually always the right answer, and like you're describing multidisciplinary approach to the care of complex patients is always correct. It's and I think this is an important piece of your paper is that it really highlights how it's not about one group of people just taking care of a set of a specific set of patients, but rather, a collaboration between people with expert training and various aspects of the care that eventually get to these better outcomes. So yeah, I think this is this is this is critical.

Speaker 3  1:07:06  
Yeah. And similar to neuro NIC use, right, that are springing up around the country and BPD clinics, right. This is all within our disciplines, that are some specialty in the in the kind of outcome driven programs that our babies need. And in our opinion, congenital heart disease for neonates and preterm infants should be a collaboration with all the specialties, including the technologist.

Daphna  1:07:31  
Yeah, I am so glad you guys brought up both both patient centered care and this multidisciplinary approach because I think that's really what is sets you apart right from it from anything else. So my I have two questions. My first question is, what has your experience with families been? Because I do know, it's those transitions of care that really can be frustrating for families, and you guys are really ameliorating that stressor, I think all together. So that's the first and my second is more of a logistical question. You know, when you have a lot of big personalities and maybe different perspectives on the same problem? How do you guys, how do you guys manage that? Since you have to share the patient's?

Speaker 3  1:08:20  
Yeah, I'm gonna start with the second one first. For the first, you know, with in any high stakes, medical profession, the more cooks in the kitchen, the more opinions, there's going to be a way more collaborative approach did you have to do, we are truly blessed, I have to say, and really fortunate to have not just technically excellent surgeons, but surgeons who are also wonderful human beings, and individuals to work with primarily Emile Bhatia, who has been the head of running our program for over a decade now. And recent trainees who have come into the fold, Dr. Kapha. And now, our newest surgeon, Dr. Andrew Goldstone. It is, in my opinion, probably the most important part to be able to work collectively collaboratively, share ideas, share opinions that differ right and be able to advocate for your patients, even when you don't always agree and to come to kind of consensus, that cannot be overlooked honestly, and being able to work with not just surgeons, but a cardiology division that also expresses interest is very expert in what they do echocardiographers technicians, cardiac cath people. And the idea is to just, you know, be professional, be open advocate for the patient and understand that we're going to disagree and be able to work through for the sake of the patient. And really, I I'm just so fortunate to be able to work here and to have an environment that we can have open and free discussions and being able to share sometimes, you know, non congruent opinions about what we think the best thing is to the patient and have other people try to listen and make the best decisions that particularly come to a head when the patients are caught blanks right? And when the answers aren't known, and when you have problems with, you know, how bad is that TR? And like, do we go in and do another surgery just because the patient is connected to non evasive support, and it's your anatomy and your, you know, pas or something really small then like when you bite the bullet and move try to move this patient forward surgically rather than it's complex. But from a team perspective, it's probably the most important thing to the success of our program long term. Because the more friction you have, the harder it is to, to work collectively and effectively.

Ben  1:10:32  
Yeah, because it because when you think about an intensivist, cardiothoracic surgeons and cardiologists in the same room spa, you can you can see the sparks already. Yeah.

Speaker 3  1:10:42  
And, and it can, and it sometimes does get, you know, heated in terms of, you know, opinions and perspectives. But I think those are important, right? People have to freely be able to express why, and they're in there, and where's the evidence, where's your experience of things. And I'm really just fortunate that we have to kind of farm and that's it, anything else that can be taken from our program, it's to be able to do that right? talk openly and freely and express yourself and have your colleagues be able to hear your perspective. And from the parents perspective, you know, I'm biased because I work here, and we hear all the good things about it. But, you know, we certainly have, you know, the patients who are, quote, unquote, stuck, right, who have a lot of hard medical conditions, chronic medical conditions. And, you know, that takes a different nuance that takes a different perspective to be sitting with families and not, you know, take away hope, but to give them realities. And, again, I think we do it as well as we can. And again, we're biased because even in the bad times, we just hear the good things from parents who are thankful for what we do. I'm sure there are times when things don't go well. But, you know, our team is just so dedicated, our nurses are just so passionate, and the family see that, you know, commitment that the nurses have in the team to be there and be present that, that in and of itself as anything else. This is just a high complexity, high risk group, you need to be present, you need to be there, the more you can be just physically with family, especially not just in good times, but in the hard times when their child isn't doing so well. engenders you, and they see this team approach and whether the outcome is good or not as good as you'd like to what the family can take away from that at least is I was there with a team that care for my child.

Daphna  1:12:28  
I think that's such valuable advice for for all the teams, right? Leave it if you have totally separate teams, but they're these transitions of care. And you have to make decisions together. I mean, I think, I think we can all and whatever our units look like and our hospital systems look like and, you know, use this information to create a better multidisciplinary team and better transitions of care.

Speaker 3  1:12:53  
Yeah, absolutely. We, we really like our model that, you know, we can keep the baby from start to finish. You know, it's the same group of nurses, the same doctors, we certainly hear feedback from families have how much they appreciate that. And we hear more about it, you know, when they go through later stages of second surgery, it's reoperations. And they're moving from an inpatient floor to an ICU back to the finish floor to a different floor that the stability of just having a one unit process for a long period of time was grounding for them right to be able to just be in one place and not have to move within different teams to know their child was a unique and valued aspect of our of our system from over here, folks.

Ben  1:13:33  
Well, this was this was tremendously valuable. Name. Thank you. Thank you so much for making the time will Will we be seeing you at new heart this year?

Speaker 3  1:13:41  
You absolutely will, myself, Dr. Krishna Murthy are gonna be there as a whole team. So hopefully

Ben  1:13:47  
we can try to we can try to bring you on the show again in August to try to talk about some of the stuff you guys are presenting. Congratulations again, on this amazing paper, we'll obviously link it on the webpage and we encourage everybody to go check it out. Because it is really a nice demonstration of how this comprehensive multidisciplinary specialized approach could be beneficial to a patient population that has let's be honest, has given our field so much trouble over the past over the past year. So again, congrats.

Unknown Speaker  1:14:14  
Thank you so much. And thank you for having me on your program.

Ben  1:14:17  
Thank you any other paper before we go into our we've officially moved away from rapid fire we we realized this was a terrible name. So we're going with the friends reference of the lightning round, where we're gonna review papers relatively quickly, just to give you a sense as to what's out there in the in the literature. But before we go to the lightning round, definitely any other papers that you wanted to review.

Daphna  1:14:40  
You should get there. Yeah. Okay,

Ben  1:14:42  
so let's let's do it then.

Daphna  1:14:44  
We're already gonna go over.

Ben  1:14:46  
We're plenty over time already. Plenty of time. Okay, so the first paper I wanted to mention is in pediatrics and it's not really a paper it's a it's a statement or recommendation. It's called COVID-19 vaccines in Children and adolescents. It's not even an article, but I just wanted to mention that this came out in pediatrics. There's a recommendation there that says that the AAP recommends COVID-19 vaccination for all infants, children and adolescents six months of age and older who do not have contraindications to receiving a COVID 19 vaccine authorized or approved for use for their age. This includes primary series and or booster doses as recommended by the CDC. I think this is something that's important for us to know, as we often discharge babies in the NICU close to the age of six months and what do parents should know about that? There's a lot of other recommendations regarding how pediatricians and neonatologist should be advocate for vaccinations and so definitely check this out in pediatrics. I'm gonna go through my list if that's okay, that's not right. Yeah. Okay. Okay. So the next paper is in pediatric pulmonology. And it's called diagnostic accuracy of point of care ultrasound compared to standard of care methods for endotracheal tube placement. first author is Sabina RF from Pakistan. And this was an interesting paper, not testing something that's completely unfamiliar to us, but they wanted to evaluate the diagnostic accuracy of point of care, ultrasound, and time to interpretation for correct identification of tracheal versus esophageal intubation, compared to a composite of standard of care methods in neonate. This was a cross sectional study that was conducted in the NICU at Agha Khan University in Karachi, Pakistan, they had about 350 neonates who were enrolled in this study. point of care ultrasound user interpretation showed 100% sensitivity and 94% specificity using an expert as the reference standard. The diagnostic accuracy of point of care ultrasound compared with at least two standard of care methods demonstrated 99.7% sensitivity 91% specificity and 98.9% agreement. And the median time required for POCUS interpretation was 3.0 seconds. Let that sink in for a second.

Daphna  1:17:06  
Yes. And their routine. I don't know how they got their routine X ray is as fast as they did good for them.

Ben  1:17:14  
Yeah, yeah. Don't look at how fast they get their x ray. It's a lie. There's no way to get an x ray that fast.

Daphna  1:17:20  
Maybe they have it in Unit

Ben  1:17:24  
tech. I'm moving to if they can get X rays, this fat I'm moving to Karachi. And so it's an it's an article that's showing how Pocus is a rapid and reliable method for identifying 82 placements. I think these papers are extremely extremely valuable. They provide the evidence that if you want to spearhead a change of practice in your unit, this is the data that you're going to use and when you have this valuable data, definitely take a look at it. Another paper I wanted to look at was published in the archive of disease and childhood fetal and neonatal edition. It's called five minute Apgar score and outcomes in neonates of 24 to 28 weeks gestation. first author is Prakash Shah from Toronto, Canada. This was an interesting study something that we've talked about on previous podcasts about the association between a five minute Apgar score and mortality and severe neurological injury. And it was a retrospective study of babies that were born 24 to 29 weeks, and they looked at in hospital mortality and severe neurological injury which was defined as grade three or four periventricular slash intraventricular hemorrhage, or periventricular leukomalacia. Briefly, they looked at 92,412 neonates and as the five minute Apgar score increased from zero to 10. Mortality decreased from 60 to 8%. However, the five minute Apgar score could not really be associated in any statistically significant manner with decreasing patterns of severe neurological injury. The Apgar score alone had an area under the curve of point six four for predicting mortality, which increased 2.73 With the addition of gestational age, so a good predictor of in hospital mortality but nothing when it comes to severe new neurological injury, a very interesting paper, some very impressive graphs, especially when it comes to the mortality Association. A very important paper that I'm putting in the rapid fire in the in the lightning round because there's not much to discuss on this but it's called Online clinical tool to estimate the risk of bronchopulmonary dysplasia in extremely preterm infants. first author Rachel Greenberg, this is coming from the NICU HD neonatal Research Network published in the Archives of disease and childhood fetal and neonatal edition. This is basically an updated version of the BPD Risk Calculator. And so they go over how they, how they looked at what the day did the data that they collected from 2011 to 2010. Muntean. They included 9000 and almost 200 infants. And what they found, which was interesting and how the new calculator so how does the new calculator basically the one thing I want to go over, I'm going to start over. So the one thing I do want to go over is how does the new calculator differ from the previous one. And what they found was that the birth weight was the most predictive of death or BPD severity on postnatal day one, while the mode of respiratory support was the most predictive factor on day three 714 and 28. The predictive accuracy of the model increased at each time period from postnatal day one with a statistics of point six, seven, to postnatal 28.7, for one. And so they use this, this database this data to create a web based model that provides a predicted estimate of BPD. By postnatal day I've started using this already, it's available in the same place you used to get the old calculator. If you've if you've used the BPD, the BPD risk calculator in the past in the same place, you'll find the updated one. And we'll then get in our in our show notes. And then finally, since this is since we've been talking about cardiology stuff, I had this paper in the Journal of Pediatrics, it's called the impact of management strategy on feeding and somatic growth in neonates with symptomatic tetralogy of flow result from congenital cardiac research collaborative. First authors, George Nicholson is from the congenital cardiac research collaborative investigator out of Vanderbilt. And basically what they wanted to do was looking at the evaluation of if you treat it to trial as your follow through via primary or staged repair, how would that impact growth and it was a retrospective multicenter cohort study. And the primary outcome was the change in weight for age through Z scores. From the initial intervention to about six months of age, the secondary outcome included methods and motor feeding feeding related medication feeding related readmissions. So the study cohort included 140 infants that went through a primary repair, and 240 infant that went through a stage of repair. Interestingly enough, that's one of the main reasons why I want to break down this paper prematurity was more common in the staged repair group. And I've wondered this in the past having to deal with patients with the challenge to follow is would they be better serves were the primary repair are we because feeding them and growing these babies after is such a such a pain. But what this study shows is that after adjustment, the W, the delta w AC, which looks at the change in z scores basically did not differ between the treatment groups over the first six months of life. For the entire cohort, the Delta WASD was negative. And the secondary analysis revealed that subjects with adequate growth were more likely to be orally fed and at initial hospital discharge. So obviously, they were doing a bit better. But the conclusion of the paper is that in neonates with travelers your follow growth trajectory over the six months, the first six months of life was substandard, irrespective of treatment strategy. So if like me, you felt like what a primary repair would have been better for a baby that doesn't have to go through these stages repair? Well, it doesn't seem like it impacts growth, those patients with adequate growth were more likely to be discharged from the index procedure on oral feeds. And that is all I have for lightning round. This week.

Daphna  1:23:32  
You did a great job.

Ben  1:23:33  
Thank you, ma'am. Okay, well, that don't have anything else. We have overtime. All right, definitely. I'll see you as Oh, no, there was one thing I wanted to mention. I'm out of the country. There is no Neil review podcast this week. We will be back on July 18. I think we're going to be looking at GBS so stay tuned for that

Daphna  1:23:58  
with a vengeance.

Ben  1:24:00  
Aggressive. All right. I will say thank you for listening to this week's episode of the incubator. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other