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Stefan Johansson

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Article Comments posted by Stefan Johansson


  1. Here's the transcript of this journal club.

    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

    1. rate Population growth of the country
    2. The development level of the country
    3. Religious beliefs communities
    4. The ability of parents
    5. 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!


  2. So, our first JC ever is over. Three people from Sweden, India and Iran met up. Despite the small group, I think it was a great experience to sort-of meet IRL.

    I add a transcript from the Chat room below.

    ******************************

    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       
    I
    t 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!

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