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    99nicu.org
    We would like to invite all members to participate in a short survey on probiotics. As you know, probiotics are commonly given to preterm infants to reduce the risk of necrotizing enterocolitis. However, in many countries there is a lack of a product designed specifically for preterm infants.
    99nicu was approached by an independent and non-profit project that aims to provide such a dedicated probiotics formulation for preterm infants.
    The survey takes about 5 minutes to complete. All information provided will be treated confidentially.
    Please use this URL to respond to the survey: https://www.surveymonkey.com/r/STFZTZD
    Stefan Johansson
    Ethical questions are common in neonatal care. Dominic Wilkinson is not only a consultant neonatologist, he is also an ethicist who has written a fantastic book. The title "Death or Disability" catches questions we and parents commonly ask. I can recommend this book to everyone. It should be available in the staff book shelf in every NICU.
    Leaning against examples of situations and practises over the last 2000 years, Wilkinson dissects ethical questions related to clinical care and decision-making. First, he focuses on the question of the “best interest”. I was especially caught by the chapter on competing interests, when decisions in the NICU may be complicated by imbalances between what may be considered to be in the best for the infant, in the best for the parents, and even in the best for other infants and families when resources are constrained. Then Wilkinson continues with addressing our difficulties to make predictions of later outcomes and how that uncertainty may impact our treatment decision, and the interests of the infant and parents.
    You can read the full review on our review section, here!
     
    Stefan Johansson
    We are launching a new Series - interviews with interesting people within the big world-wide neonatal community. Our goal is to publish one interview per month.
    First out is Mats Blennow, Stockholm, Sweden, senior consultant neonatologist at the Karolinska University Hospital and professor in neonatal neurosciences at the Karolinska Institutet. Furthermore, he was also a president for the European Society for Neonatology (2008-2014).
    Mats Blennow took a break from the level-3 NICU life in Stockholm to do something extraordinary...
    * * * * * * * * * * * * * * * * * * * * * * * * 
    Where are you working now?
    I am working in Irbid, a city in the north of Jordan approximately 25 km from the Syrian border. I work here in a project run by Medecins sans Frontieres (MSF- Doctors without Borders).
    This is, for MSF, a unique setting as Jordan, a middle-income country, is considered safe and developed. This in contrast to the usual MSF projects dealing with situations in war, natural and man-made disasters.
    The MSF rationale for this project is that the Syrian refugees here do not have free access to the Jordanian health care. In my project we provide maternal and neonatal health care for the approximately 130,000 syrian refugees living in the Irbid Governate. We run a highly efficient maternity unit, annually providing antenatal, maternity and neonatal care for 3,500 pregnant women and their offspring. The project is housed in a private hospital, where MSF rents 2 floors.
    I work as a pediatric/neonatal expat in the small neonatal unit. Recently, in matter of fact this week, we have expanded the unit from 10 to 16 cots/incubators. I would describe this as a level 2 unit, for example we do not provide ventilator care or long-term TPN. Our admission criteria include babies from 32 weeks gestation. Very preterm infants are referred to other local private or Ministry of Health facilities, and then MSF covers the costs of care also there.
     
    Why did you choose to go on this mission to Jordania?
    Since many years I have wanted to broaden my views on paediatrics and neonatology to other settings than working in a tertiary NICU in a high-income country, preferably by working for some NGO. The reputation of MSF is highly respected by everyone. For example, in a survey in Sweden, more than 50% of the responders expressed high confidence in the work MSF provide in more than 70 countries. The MSF charter stating the organisation is to provide medical help irrespective of race, religion, creed, or political convictions and doing this observing neutrality, impartiality and independence is to me fundamental.
    The fact that my current mission is in Jordan is primarily not from my own choosing. Signing up to work for MSF, I had full confidence that the organisation would send me on an important mission.  
     
    What is it like to work there? What are the largest similarities and differences compared to the NICU you normally work at in Sweden?
    The work has many similarities, but also differences, to the work I usually do in Stockholm. The national staff is well educated with very good theoretical and practical knowledge. Nurses and doctors work together, although the emphasis on teamwork is not as strong as in Europe.
    The organisation of health care is not as developed as back home, and a lot of attention needs to be given to organise for referrals to tertiary units, to follow-up clinics and for more advanced tests and examinations. For example, when I first arrived here we did not have access to blood cultures. Due to this, many infants with only risk factors for early onset infections were given full courses of antibiotics despite no clinical signs of infection. Consequently, this resulted in prolonged stays in the neonatal unit and mother-child separations as many families live far from Irbid and have several children at home needing attention.
    Another difference is the access to respiratory support. My primary task was to start CPAP care in the project, which was successfully started after 2 weeks. Before that, infants with any respiratory distress were given nasal cannula oxygen with FiO2 of 1.0 and rather high flow rates.
    Perhaps the biggest difference however was the nursing care of the infants. I was lucky to be able to recruit a neonatal nurse expat, and together we worked hard to implement as many elements of developmental care as possible, including reducing ambient noise, covering incubators, nesting and supporting the infants position, and clustering of blood sampling. We also managed to expand the area of the neonatal unit with 2 additional rooms allowing mothers to remain with their babies 24/7 in the unit.
     
    What expertise have you brought to Jordania and what experience can you bring back to Stockholm?
    Medically, my most important contribution has been to update the protocols on non-invasive ventilator care. This includes implementing nCPAP treatment, but also t-piece ventilation for resuscitation, guidelines for treatment of apneas, use of fractionised oxygen and emergency surfactant treatment before referral of very preterm infants with RDS unintentionally delivered at the MSF hospital.
    I have also trained the staff after updating many other protocols, such as those for infants at risk of septicaemia and the use of a Neonatal Early Warning Signs (NEWS) protocol in the maternity.
    To bring back home is the knowledge of good care being given also in this resource limited setting, problem solving in an environment that doesn´t have all the expertise available just around the corner. The basic principle to always have a humanitarian approach to everything we do in medicine.
    Working with the dedicated MSF-expats from all over the globe is extremely rewarding. In my project we had expats from France, Scandinavia, Canada, Liberia, Sudan, Lebanon and Australia. Personally, I think I will after my mission come out as a better and more humble person J.
     
    What is your advice to those wanting to go on a similar mission?
    Take a good course preparing for NGO work. It was invaluable for me to take an 8-week course in Humanitarian Health Assistance and 1 week of Preparation Primary Departure (PPD) before leaving. There is also an abundance of information to be found on the webpages of UNHCR, WHO, MSF and other NGOs. There it is possible to, once the destination is decided, to get detailed information about the country, project and security issues.
    Most important is to keep an open mind to new cultures and experiences, to have a great respect for the knowledge and integrity of everyone you meet; patients, locals and colleagues.
     

    ISH - the hospital where the delivery unit and NICU is located.

    The NICU environment at ISH

    The first infant recieving nCPAP in the MSF NICU.

    Umm Qais - a popular area to visit in norther Jordan - an old town with a history going back >2000 years. From this site it is possible to view (from the left): Israel, Lake Genesaret/Tiberia, Palestine (in the valley), the southern parts of the Golan mountains, and distantly Lebanon and Syria.
     
    Stefan Johansson
    The topic for this journal club on 12 January was outcomes of infants with Apgar score of zero at 10 min.
    Commonly guidelines are that resuscitation may be stopped if an infant is till asystolic by 10 min of age and despite adequate resuscitative efforts. However, an interesting case series published in ADC concluded that a relatively large proportion of infants surviving despite Apgar score of zero at 10 minutes had a normal neurological assessment on follow-up.
    The paper was accompanied by an interesting editorial.
    Both articles are available as Editor's Choices at the ADC web site:
    http://fn.bmj.com/content/100/6/F492.full
    http://fn.bmj.com/content/100/6/F476.full
    ADC also produced a podcast that you can listen to here:
    https://soundcloud.com/bmjpodcasts/how-long-should-resuscitation-continue-at-birth-in-the-absence-of-a-detectable-heartbeat
     
    Here comes the transcript of the JC!
    -----------------------------------------------------------------------------
    Stefan Johansson
    Hi everyone and welcome to the 2nd 99nicu JC! The topic this time is outcomes of infants with Apgar score of zero at 10 min.
    Commonly guidelines are that resuscitation may be stopped if an infant is till asystolic by 10 min of age and despite adequate resuscitative efforts. However, an interesting case series published in ADC concluded that a relatively large proportion of infants surviving despite Apgar score of zero at 10 minutes had a normal neurological assessment on follow-up.
    You find the original article and the and the editorial: http://fn.bmj.com/content/100/6/F476.full
    What was your general impressions reading the article and editorial?
    Fcardona
    It was definitely an eye-opener for me. I mostly considered APGAR of 10 as sure predictor of death or terrible outcome
    Jonathan Davis
    My overall impression that is that this is an important topic area and one that is currently under justifiable scrutiny.
    I too was surprised at the survival potential
    Stefan Johansson
    What is your current (or previous) guidelines about resusc when the Apgar is /was zero at 10 minutes?
    amirmasoud2012
    The decision is difficult
    Jonathan Davis
    In Bristol where I currently work we don't have a specific guideline
    Fcardona
    neither do we here in vienna have a guideline
    Stefan Johansson
    The Swe guidelines has been to continue resusc until 15 min if there is asystole
    Jonathan Davis
    it is generally accepted that one would stop resuscitation once a consultant has at least been present
    dracunculus
    In Ulm where I currently work we dont have a guideline, but I think nobody would stop resuscitation here after 10 minutes
    Stefan Johansson
    I have felt discomforted about this (as the international guidelines are evaluation at 10 min). Have had cases with apgar0 at 10' who started going at >14 minutes... and outcomes were quite bad (severe CP)
    Jonathan Davis
    if out of hours that should be at max 20 minutes
    Stefan Johansson
    Do you generally use chest electrodes to monitor heart beats?
    Jonathan Davis
    I agree Stefan the push for longer resus is definitely one that shouldn't be made with haste
    amirmasoud2012
    Several issues must be considered
    rate Population growth of the country The development level of the country Religious beliefs communities The ability of parents The health system support If the above condition is better we continue to resuscitation.
    In our country under the above conditions there and I 'd rather stop after ten minutes of resuscitation
    Stefan Johansson
    @Amir - valid points, the context matters                  
    Jonathan Davis                  
    I certain agree that all the above must be taken consideration... the evidence base of survival and with or without disability is also important
    Dracunculus
    We are starting to use ECG electrodes.
    Stefan Johansson
    One thing about the case series in ADC - how certain where the authors that apgar was really zero? It does not say how heart beats were monitored.
    Could the babies be Apgar=1 at 10 min?                    
    Jonathan Davis
    That is the flaw in these papers, the apgar is a subjective measure
    who listened... and for how long and how practised where they    
    fcardona
    I agree stefan, it is unclear how objective heart rate was assessed
    Jonathan Davis
    ECG is the new european rests council guidance fcardona?            
    Stefan Johansson
    Thanks for support  I just think there is some problem with the internal validity of this report
    After the JC I can recommend this blog post by MichaelN (All Things Neonatal) ; http://99nicu.org/blogs/entry/169-apgar-score-of-0-at-10-minutes-why-the-new-nrp-recommendations-missed-the-mark/
    How do you handle the contact with parents in a situation like this? Do you give a "trial of life" on mechanical ventilation etc and discuss options thereafter? (In Sweden, we generally (I think) do not listen enough to the voices of the parents)             
    Jonathan Davis                 
    If heart rate was achieved, a trial of life is appropraite                  
    early measures of brain injury are difficult and poorly predictive    
    fcardona
    yes, jonathan - ecg is suggested for use during neonatal resuscitation in the 2015 guidelines 
    Jonathan Davis
    parents wishes extremely important and the context as above essential
    fcardona
    i agree about parents wishes
    Jonathan Davis                  
    I had a recent case of no heart rate at 10, baby extremely unwell. Trial of life with EEG and discussion with parents at the bedside
    additional colleague opinion sought also for second brain
    Stefan Johansson
    This is just an impression but in the "pre-cooling days" (when I was fulltime at a level3 unit) I think babies were more often given palliative care if the asphyxia was very severe. Now we are more active, start cooling shortly after birth (usually within 2-3 hours), and then there is a rolling stone of activity.
    @Jonathan - good point about intercollegial support and discussion                   
    Jonathan Davis
    Very true re activity. Early marker of severity of asphyxia can often mislead and none are perfect... some work done by the Brain group in cork... will look for link
    on early predictors from umbilical cord samples
    Stefan Johansson              
    One problem is the lack of models that can predict bad outcomes with good precision. How could we do better?
    Jonathan Davis                  
    https://clinicaltrials.gov/ct2/show/NCT02019147
    fcardona
    I agree, do we know anything about the EEG and MRI in the survivors of this study?
    Stefan Johansson
    @Francesco - I cannot find this info in the paper only that "All eight deaths were because of withdrawal of life support in view of severe encephalopathy on clinical exam- ination, electrocortical inactivity on electroencephalogram (EEG) and extensive damage to the brain on MRI”
    Jonathan Davis                  
    the group in cork appear to be collaborating with the Karolinska Institutet
    Stefan Johansson              
    @Jonathan - I see that. The current head of the Karolinska Neo Dep (Boubou Hallberg) is a co-investigator
    fcardona      
    in the study: i am still concerned about selection bias in the study. what is the denominator of the study population?
    Stefan Johansson              
    @Francesco - you mean, where is the epidemiologist  
    fcardona
    I guess
    Jonathan Davis                  
    I think the study represents a pragmatic interrogation of the data that is routinely collected and submitted to the ANZNN
    fcardona      
    and how many cases with apgar 10 of zero were not included because they didnt make it into the database
    Jonathan Davis                  
    I think we are back to the antithesis of the 'were they sure it was zero' argument
    where there miscounted apgars?
    Stefan Johansson              
    Valid point, if we are to study outcomes, we need to know about the population base. If you look into the blog post I linked to above, I non-secretely display one of my fancy research ideas...
    Jonathan Davis                  
    The population as far as I can tell is all babies who were admitted to KEMH and PMH in WA..
    Interesting that APGAR is now being used or certainly reported as a predictor.
    In my training the APGAR score was always derided as an unreliable subjective measures
    I need to confess that I will soon be a consultant in the unit that authored the paper in Australia. I haven't had anything to do with the paper however... nor any other particular bias
    Stefan Johansson              
    @Jonathan -  But in 2001 even NEJM had an article about that Apgar was not entierly wrong
    @Jon - are you moving to Australia?!   
    Jonathan Davis
    The first question.... Yes I have come to the conclusion that my mentors had an anti APGAR bias... a subjective measure but potentially a useful one.. experienced hand quiet useful..
    the second question.. yes starting hopefully next month... fellowship in oz previously and now appointed in Perth..
    Stefan Johansson
    This is off-topic... but Perth sounds great!                  
    Jonathan Davis                  
    yes... sorry.. needed to disclose that fact                    
    Stefan Johansson              
    @Jonathan - no worries!  
    @all: what can we learn from the paper and editorial?
    I think one important thing raised in the editorial is that "Clinicians must be guided primarily by the best interests of the infant."
    Jonathan Davis                  
    I think personally we can learn that perhaps 10 minutes may not be long enough... the resuscitation needs to be effective and all reversible causes need to be excluded                   
    Also the suppose to me was that the outcomes are still not great but they are better then I expected and that needs to influence what we discuss with parents.        
    Stefan Johansson
    another important message it seems, is that noone with Apgar=0 at 20 min did survive
    +1 on that last comment
    Jonathan Davis
    I will have to duck out of the conversation at this stage... but although involved in the podcast... the discussion with Ben Stenson and Dominic Wilkinson makes interesting listening... expands on the editorial a little..
    Stefan Johansson              
    And here is the link to the podcast:
    https://soundcloud.com/bmjpodcasts/how-long-should-resuscitation-continue-at-birth-in-the-absence-of-a-detectable-heartbeat
    Jonathan Davis
    thanks for the great discussion.. I tweeted along the way!!            
    Stefan Johansson
    I will also need to leave now. Any final thoughts ?
    amirmasoud2012
    thanks
    Stefan Johansson              
    Thanks all for a another great experience!
    Meet you next time!
    fcardona
    We are very happy to announce we have reached over 1000 likes on facebook!
    We feel social media is an important channel to communicate with all of you and keep you up-to-date with what's happening on our 99nicu site!
    If you have not done yet, go ahead and follow us on facebook, twitter & linkedin!
    Stefan Johansson
    First and foremost - I would like to wish you the best for the upcoming New Year 2016!
    During 2015, I think 99nicu thrived really well. Especially memorable moments were:
    our first virtual journal club the comeback of the 99nicu Polls plenty of great blog posts from Keith Barrington and Michael Narvey our upgrades that resulted in a great new interface (finally fully responsive on mobiles), made possible by educational grants from Acta Paediatrica and the ROP trial. our sharing of the Orphan-Europe webcast on PDA echo assessment For 2016, I hope 99nicu reaches its full potential as the busy community needed by professional in neonatal medicine. This is what I personally think about for 2016:
    future journal clubs, (next is scheduled 12 January) more active discussions in the forums more blogs  (email me on info@99nicu.org if you need help to start a blog) a crowd-sourced Pharmacopedia (Neonatal Formulary) the 99nicu 10year anniversary, in May 2016! New Years Greetings from the early frosty winter in Stockholm!
    Stefan Johansson, MD PhD
    Stefan Johansson
    We have set the date for the next Journal Club to Tuesday 12 January 2016, at 7 PM (GMT).
    The topic this time is outcomes of infants with Apgar score of zero at 10 min.
    Commonly guidelines are that resuscitation may be stopped if an infant is till asystolic by 10 min of age and despite adequate resuscitative efforts. However, an interesting case series published in ADC concluded that a relatively large proportion of infants surviving despite Apgar score of zero at 10 minutes had a normal neurological assessment on follow-up.
    The report is accompanied by an interesting editorial.
    Both articles are available as Editor's Choices at the ADC web site:
    http://fn.bmj.com/content/100/6/F492.full
    http://fn.bmj.com/content/100/6/F476.full
    ADC also produced a podcast that you can listen to here:
    https://soundcloud.com/bmjpodcasts/how-long-should-resuscitation-continue-at-birth-in-the-absence-of-a-detectable-heartbeat
     
    Please read those articles and join the Journal Club in the Chat room. Note that you need to log in to enter the chat room.