First Journal Club transcript

So, our first JC ever is over. Three people from Sweden, India and Iran met up to discuss two papers on PDA. Despite the small group, I think it was a great experience to sort-of meet IRL, although there is room for improvements, also on the technical side.

I add a transcript from the Chat room below.

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Stefan Johansson
** getting ready **
Welcome to the 1st 99nicu Journal Club
Tonight we are going to discuss a paper previously publ in ADC: http://fn.bmj.com/content/100/1/F55.full.pdf+html 
on the "Natural evolution of patent ductus arteriosus in the extremely preterm infant"

** patiently awaiting others to join... **

Stefan Johansson
Hi Selvan! How are you?
@Selvan - seems that we are not attracting a crowd
@amirmasoud2012! Welcome here!

amirmasoud2012
hello

selvanr4
yes stefan .it is day one . wait for sometime

Stefan Johansson
Shall we start? Did you read the ADC paper on spontaneous PDA closure? If so, what was your general impression?

selvanr4
yes. paper questions the need for treatment to close pda since around 70% pda close on their own

amirmasoud2012
It was interesting ... the more we were treated ....     

Stefan Johansson           
PDA's are a tricky business. Interesting that the unit (in the study) did not treat PDA's at all (with drugs)
But I think the rate of spontaneous closure is a mistake... they should have included all infants "at risk", i.e. also those who died, in the denominator.
But still, the spont closure rate would be around 55-60% if all infants were included               
What is your practises regarding PDA therapy?

selvanr4
yes stefan you are correct .they have excluded babies who died.and within 72 hrs . but still 55-60 good number               
we treat if they are symptamatic           

Stefan Johansson               
We do the same. But I think our general view has changed - to a more conservative approach                     

amirmasoud2012               
Better if we treat the unstable situation ...                 
modrate to large size pda 18:26

Stefan Johansson               
@amir - I agree. A major difficulty with PDA's is that some tiny babies are severly affected (say a 24w on mech ventilation), while other more mature preterm do just fine without tx (like a 31w on CPAP)    

selvanr4        
i heard from my friend who has worked in cardiff saying they have used it very rarely.            

amirmasoud2012               
can you accept the risk of no treatment?                     

Stefan Johansson               
I would be very hesitant NOT to give a significant shunt.          
I am a PDA-believer

Did you manage to get hold on the other paper in JAMA - about early echo and its benefits? 

In fact - that paper oppose the ADC paper - that there are benefits with early investigation (less lung bleeds for example)                   

selvanr4        
i just read the abstract. as you said it is for early echo!                    
i could not get full paper   18:33

amirmasoud2012               
I remember I do not have to search again                   

Stefan Johansson               
But it is a bit strange (the JAMA paper) - because they use timing of echo as a proxy for treatment.

selvanr4        
It will be difficult for me to keep my hands tied when you see a significant pda          

Stefan Johansson               
Actually, I have heard know of plans in the US (within the NICHD trial network) that they will make a placebo-controlled (blinded) RCT. Meaning they will give NSAID or placebo to treat a duct...
Very difficult trial, and complicated with cross-overs in case a baby really need to close the duct                 

selvanr4      
An early PDA is not always a benign entity- did you read the rapid response?      

An early PDA is not always a benign entity
Martin R Kluckow, Neonatologist Nick Evans, Sydney University

We read with interest the article by Rolland et al regarding a retrospective natural history study of the PDA in a cohort of preterm infants in a unit which conservatively managed the presence of a PDA after 24 hours(1). We have concerns about the data analysis and the conclusions drawn. In particular we question the decision to exclude...

Stefan Johansson               
Nick Evans is my principal mentor in PDA-thinking

This is a good conclusion! "Concluding from the data presented that the exposure to the risk of therapeutic intervention to close a PDA is not warranted based on spontaneous closure rates of a selected surviving sub-group is not justified."              

selvanr4       
Nice argument                   

Stefan Johansson               
In short, I think Kluckow and Evans want to say that the ADC study is crap

selvanr4        
yes stefan

amirmasoud2012

selvanr4        
what do feel is a best model to study the natural evolution of pda 

Stefan Johansson               
I think the best way would be to make serial echos on a prospective cohort. In fact I think Kluckow and Evans have done that
and showing that severe early shunts is associated with lung bleeds and IVH (really significant and bad things)              

amirmasoud2012               
Our third day we echo
And before the third day if not treated pda .               

Stefan Johansson               
@amir - generally do the same, but in very instable babies our guidelines is echo typically on 1-2 day of life

Stefan Johansson               
@amir and @selvan - my time is out now
it was great chatting with you despite some techn problems        

selvanr4        
thanks stefan                     

amirmasoud2012               
thanks
good idea    

selvanr4        
thanks amir 

Stefan Johansson               
I think we need to think about how we use                 
the chat room in the future                     
i.e. the technical side. I hope we meet again here    

selvanr4        
can we have offline postings?               

amirmasoud2012               
Keep going in the future    

Stefan Johansson               
@selvan - I will try to copy & paste the conversation into a word doc and then add it on the web site

selvanr4       
yes . hoping for the best   

Stefan Johansson               
We keep in touch! Ciao!