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  • Blog Entries

    • By Stefan Johansson in Department of Brilliant Ideas
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      I like projects outside my clinical and academic work. 99nicu was the first big project that came out in public from my "Department of Brilliant Ideas".
      Since several years, I have devoted a lot of work for a project that eventually led to the startup Neobiomics, since 2019 under the wings of the Karolinska Innovations AB. Neobiomics provides ProPrems®, a high-quality multi-strain food supplement.
      Entering the startup universe has been like embarking a rollercoaster journey. In many ways a personally rewarding experience, but it has also been walking a challenging path with many obstacles to overcome along the way.
      Regardless of the ups and downs, bringing an idea into a startup context will make you work. A lot. (And for most of the first few hundred/thousand hours, without renumeration.)
      I recently saw a TED-talk by Darria Long (see it below), on how systematic strategies in emergency medicine can be used to cope with high work loads in general. And it struck me that we, as health care professionals, are well fitted as startup founders.
      Not anyone make the choice to work in health care. IMHO, we are a selection of people sharing a special compassion for what we do. And, through long education and training, the importance of know-how and experience is incorporated in our DNA.
      How does all this make health care professionals fit for startups?
      we build and work through trustful relations we like to meet the unknown we work hard for a clear objective, even if the outcome may be uncertain despite limited resources, we manage things first thanks to limited resources, we can prioritize our work is problem-based, not solution-based our work has structure, even in a seemingly chaotic  situation the detective work in medicine makes us good lateral thinkers Naturally, the startup universe requires its own specific skills (finance, legal, development, communication etc-etc). And the trajectory for becoming a startup founder is similar to becoming a health care professional - one needs to learn, practise and connect with others to make something out a brilliant idea.
      You have an idea? Make it happen!
      (this post is dedicated to KI Innovations AB)
       
       
    • By AllThingsNeonatal in All Things Neonatal
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      After several reports providing reassurance to breastfeeding mothers, two very recent reports are giving me reason to pause. The Canadian Pediatric Society has been recommending breastfeeding if a mother has COVID19 with precautions in place; Breastfeeding when mothers have suspected or proven COVID-19. It would be heresy to suggest that a mother not be permitted to breastfeed her infant but what follows are two reports that at the very least may need to enter the discussion when a COVID19 positive mother gives birth and is deciding about route of feeding.
      Toronto Case Report
      The first report was notable not so much for breastmilk but rather that a mother with a chronic immunodeficiency and pneumonia from COVID19 had placental surfaces that tested positive on PCR for COVID19. This was the main focus of the paper Probable congenital SARS-CoV-2 infection in a neonate born to a woman with active SARS-CoV-2 infection. In the same paper though, testing of breastmilk in this mother demonstrated a positive PCR with a semi-quantitative cycle time result (there are 40 cycles of amplification of RNA in PCR testing- the further away from 40 cycles the more likely it is a true positive).

      The results above were positive at 2 days and negative at 7 days. One could possibly excuse this case as an anomaly since the mother in this case not only was sick but also has chronic neutropenia but then along comes another report.
      Second Research Report
      This week a second report emerged that adds to the uncertainty around breastmilk. Detection of SARS-CoV-2 in human breastmilk looks at two mothers one of whom was negative on testing of breastmilk but the other unfortunately tested positive. The authors included the following timeline which is very informative.
      From the timeline above you will note that in the second case the mother becomes positive at 11 days of age and the infant tests positive around the same time the milk comes back positive. The infant in this case also develops RSV which likely explains the symptoms they developed later in the course. What is concerning to me though is that in this case while the mother was COVID19 positive, she was not acutely ill. When thinking of vertical transmission this has been something that has been postulated in suspecting that those with more severe illness have higher viral loads and therefore may be capable of vertical transmission. Not the case here if the results are to be believed. Adding to the strength of the result are Ct values for SARS­CoV­2 N peaked at 29∙8 and 30∙4 in whole milk and skimmed milk respectively so this seems real.
      How does this differ than past testing?
      What intrigues me about this study in particular is that past research on transmission into breastmilk has failed to detect the virus. It could be that previous testing close to delivery was negative and that with time might the virus enter breastmilk? At eleven days I think this may be the latest testing done. In virtually all cases reported about COVID19 positives in newborns the authors have always explained the painstaking steps they took to prevent postnatal infection. I do wonder now if some of these cases may be related to a small percentage of women carrying the virus in their breastmilk. This leaves us in a tough spot. What do we tell women who are thinking of breastfeeding and have COVID19? There will need to be discussion on this but one option is to proceed with feeding accepting there may be a small risk of transmission. A second option would be to test milk but if the transmission occurs late you may miss it in hospital on initial sampling Finally it may be worth pumping and discarding milk until mothers test negative and using donor breastmilk in the meantime (or formula for those who don’t have DBM).
      Regardless I think this information coming out will need to be digested and centres think about how they will approach this issue. My guess is these will not be the last reports on this.
    • By AllThingsNeonatal in All Things Neonatal
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      After developing a community of over 23000 people unfortunately I had to close my Facebook site due to concerns over a hack. Not to worry as I have created a new independent site to share information daily in Neonatology. I look forward to building an audience at this site and working to continue the dialogue I have come to enjoy with all the followers.
      I look forward to seeing you there!
      The New Site is at:
      https://www.facebook.com/allthingsneonatal2
       
    • By AllThingsNeonatal in All Things Neonatal
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      I doubt there is a unit in the world where at least once a day a discussion ensues about whether an infant is ready to wean or come off their CPAP. For many years we have made the decision based on a variety of markers. Some people would comment on the work of breathing, others on the FiO2 or what the oxygen saturations are at the moment as we round on the patient. Our unit has been pulling oxygen histograms off the patient monitor for years now to provide a more objective measurement to determine if an infant is ready or not. What is a histogram? It is a bar graph representation of the percentage of time in a 24 hour period that an infant has spent in several different oxygen saturation ranges.
      A group in Alabama recently published the following paper Oxygen saturation histograms predict nasal continuous positive airway pressure-weaning success in preterm infants. which attempts to answer the question as to whether this practice has merit.
      What did they do?
      They looked at 36 babies (24 control and 12 cases) in which controls were babies who successfully weaned off CPAP when on less than or equal to 30% oxygen in the first week of life and compared them to infants who failed and had to go back on. Success was defined as remaining off CPAP for 7 consecutive days while failure was having to go back on with in 7 days of discontinuation. All infants were <1250g at birth or less then or equal to 30 weeks gestational age at delivery. Infants were enrolled prospectively in an observational case-control study. During the study goal oxygen saturations were 90-95% and oxygen histograms were monitored q6h by respiratory therapists. Importantly, during the study there was no standard approach to weaning patients off of CPAP but as per many NICUs, discontinuation occurred when FiO2 was low and there were only 1-2 events per day requiring stimulation. The authors controlled for a number of potential factors which could influence success such as GA, BW, Sex, receipt of antenatal steroids, ventilation, caffeine dose, FiO2 prior to weaning and surfactant but found no differences between groups.
      What did they find though?
      As you might expect there was a difference found and it was in the histograms. The infants who ultimately succeeded in coming off CPAP were better oxygenated in the 24 hours prior to coming off CPAP. Of note, the cases had a median FiO2 of 22% and the controls 21% which was not statistically different.
      Looking at the above figure you can see that there were statistically significant differences in the two groups with the babies who successfully weaned off CPAP having significantly higher levels of oxygen saturation in the 95% and above ranges. The authors concluded “The optimal value of oxygen
      saturation achievement >95% to predict CPAP-weaning success by Youden index was 31.6% with a sensitivity of 75% and specificity of 75%.”
      In other words if you have about 30% of the time spent above 95% in the 24 hours prior to coming off CPAP you have a pretty good chance of success!
      Applying the information
      Who doesn’t like a study that validates your own practice?! The study is really a beginning though as the study tells us that for babies that are mildly ill (as evidenced by being on room air or 22%) that you can utilize the histogram data to make decisions about when it is best to stop CPAP. What this study though examined is a particular population of small infants who were all taken off CPAP in the first week of life. Would the same principals apply to an older infant or one who is larger at birth? I would like to think so but there are many infants who are on oxygen with BPD who are also weaning off CPAP after many weeks of age. We use histograms in this population as well to guide our weaning but an important measurement that must be taken into account is the FiO2. I can really manipulate a histogram to show anything I want for a baby on oxygen. If it is better from one day to the next is it because the lungs have improved or has the average FiO2 simply been higher in the preceding 24 hours? Conversely if it is worse does the infant have atelectasis or pneumonia or has nursing been more restrictive in FiO2?
      Further studies in this area need to create an objective tool that takes into account level of support and mean FiO2 when interpreting the histogram. Failure to do so would lead at times to incorrect decisions if you solely look at a bar graph. As with everything in NICU, the devil is in the details!
  • Upcoming Events

    • 25 June 2020 Until 26 June 2020
      0  
      Visit Conference website: http://www.lutonneocon.co.uk
    • 03 October 2020 Until 05 October 2020
      1  
      First announcement of 
      Recent advances in neonatal medicine
      IXth International symposium honoring prof. Richard B. Johnston, MD, Denver, US
      26-28 April 2020, in Würzburg, Germany
      Find more information in the attached folder.
      First_Announcement_01.2020.pdf
    • 17 November 2020
      1  
      The 17th of November each year is the World Prematurity Day. Originally started by parent organisations in Europe in 2008, the World Prematurity Day is an international event aiming at high-lighting the ~15 million infants born preterm each year.
      Read more about this day on the March of Dimes web site, and on Facebook.
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