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#092 - Journal Club 37

Hello Everyone 👋

We have an exciting series of articles lined up for you in this week's journal club. I want to apologize for my sore voice as I am trying to recover from laryngitis. As usual, you can find the articles we discussed down below and the link to a website we brought up on the show as well. We are so thankful to the people who have emailed, tweeted, and texted us stories of how the podcast has helped the lives of patients and families in the NICU. We would love to feature these stories on our end-of-year show in December, so feel free to send us your stories. You can send us an audio message, a written email, or whatever is easier for you, and we will be so happy to read/play this on the podcast during that end-of-year episode. No need for names if you don't want to, maybe just your location (our community has crossed many oceans lol) we will let the story/message speak for itself. Thanks in advance.

Have a great sunday!

This is the link to the website we mentioned on the show that helps provide green rides to families needing assistance.


The articles covered on today’s episode of the podcast can be found here 👇

Disparities and Early Engagement Associated with the 18- to 36-Month High-Risk Infant Follow-Up Visit among Very Low Birthweight Infants in California. Lakshmanan A, Rogers EE, Lu T, Gray E, Vernon L, Briscoe H, Profit J, Jocson MAL, Hintz SR.J Pediatr. 2022 Sep;248:30-38.e3. doi: 10.1016/j.jpeds.2022.05.026. Epub 2022 May 18.

The Prevalence and Clinical Significance of Congenital Anomalies of the Kidney and Urinary Tract in Preterm Infants. Hays T, Thompson MV, Bateman DA, Sahni R, Tolia VN, Clark RH, Gharavi AG.JAMA Netw Open. 2022 Sep 1;5(9):e2231626. doi: 10.1001/jamanetworkopen.2022.31626.

Neurological examination at 32-weeks postmenstrual age predicts 12-month cognitive outcomes in very preterm-born infants. Huf IU, Baque E, Colditz PB, Chatfield MD, Ware RS, Boyd RN, George JM.Pediatr Res. 2023 May;93(6):1721-1727. doi: 10.1038/s41390-022-02310-6. Epub 2022 Sep 23.

The Clinical and Cost Utility of Cardiac Catheterizations in Infants with Bronchopulmonary Dysplasia. Yang EL, Levy PT, Critser PJ, Dukhovny D, Evers PD.J Pediatr. 2022 Jul;246:56-63.e3. doi: 10.1016/j.jpeds.2022.04.009. Epub 2022 Apr 14.

Ventricular Volume in Infants Born Very Preterm: Relationship with Brain Maturation and Neurodevelopment at Age 4.5 Years. Sheng M, Guo T, Mabbott C, Chau V, Synnes A, de Vries LS, Grunau RE, Miller SP.J Pediatr. 2022 Sep;248:51-58.e2. doi: 10.1016/j.jpeds.2022.05.003. Epub 2022 May 11.

Developmental Dysplasia of the Hip Is Not Associated with Breech Presentation in Preterm Infants. Leonard SP, Kresch MJ.Am J Perinatol. 2022 Sep 12. doi: 10.1055/s-0042-1756139. Online ahead of print.

Lower pass threshold (≥93%) for critical congenital heart disease screening at high altitude prevents repeat screening and reduces false positives. Sneeringer MR, Vadlaputi P, Lakshminrusimha S, Siefkes H.J Perinatol. 2022 Sep;42(9):1176-1182. doi: 10.1038/s41372-022-01491-6. Epub 2022 Aug 17.


The transcript of today's episode can be found below 👇

Speaker 1 1:01

Hi, everybody. Happy Sunday. We've got Journal Club today. Ben, how you doing with your laryngitis?

Ben 1:11

I'm here. Yeah, my laryngitis is getting better. Thankfully. On the advice of my family, I started steroids yesterday.

Unknown Speaker 1:20

Oh, man, and they're helping you

Ben 1:23

very much. So it's a good thing we're recording today and not yesterday. So everybody, welcome to the incubator. I'm sorry, I didn't do the intro today. But every word counts. Apparently I want to have Bishop make it to the hour.

Daphna 1:34

That's right. That's right. Well, we don't have much housekeeping to do today. No, no, we've had a, we've had a busy week, down here in Florida. Thankfully, down where we are in South Florida, we've been pretty much spared. But we know that our colleagues on the other coast are dealing with a lot of loss and destruction. And so concerning. Yeah, we're thinking about everybody who is within the path of the hurricane and is continuing to deal with the fallout, obvious.

Ben 2:13

So one of the things that we came across is the need for babies to be transferred. And even though it might be too late for this hurricane, because obviously things are in motion already. There's not a great system, right to redistribute patients across a certain area. And even though this should fall on a government agency, I think the people should know that the podcast is here to help in that case. So if you have a need, then we're happy to promote and get the word out there that babies need to be transferred and get help. So yeah.

Daphna 2:51

Yeah, and you know, Florida actually has a kind of a neonatal transport group, I guess you could say. And so they were able to mobilize pretty pretty quickly, but certainly, certainly not. All areas have that.

Ben 3:10

That's right. Okay, you want to get started today, I just wanted to mention that an episode of the Spanish version of the interviewer is going to come out tomorrow or early this week. Obviously, it's journal clubs, and they're asynchronous. So it's not a translation of this week's Journal Club. Right. But yet, we're being we're able to keep up with more regular schedule. And so kudos to the team taking care of that. And our first interview in Spanish is coming up soon, so stay tuned. That's right.

Daphna 3:42

And the first Portuguese episode was was recorded today in in Brazil. So that's exciting. How do you know? They sent us a little message on Twitter.

Ben 3:57

Oh, exciting. Very exciting.

Super cool. Okay.

Daphna 4:01

Okay, well, I'll go first. This article is called disparities in early engagement associated with the 18 to 36 month high risk infants follow up visit among very low birth weight infants in California. That was another mouthful, but it tells you exactly what they're looking at. This is in the Journal of Pediatrics, the lead author ashwiny Lux, mon Nan, and the senior author is Dr. Susan heights. Heights did he say Right?

Ben 4:37

No, it's hence. She thought this out and I still got it. I used to mispronounce her name for many years and she's the one who corrected me on the day.

Daphna 4:48

We're very excited because we just recorded an episode with Dr. Hints. Did I get it right?

Ben 4:59

Yeah, okay.

Daphna 5:00

And so we'll be releasing that one shortly as well.

Ben 5:04

I don't think so.

Unknown Speaker 5:05

Not sure.

Ben 5:07

Not totally. I think it's, I can actually, yeah, I can actually tell you that hold on, I can tell you when she's, I think she's on our 2023 lineup. She's going to be an early 2023 episode, it was that good that we wanted to sort of these very, very good episodes we want to leave for like early in the year as a breakout shows and stuff. And hers was phenomenal.

Daphna 5:27

For sure. We talked about so many important topics, including infant follow up, but we covered a broad array of topics, so we wanted to kick off the year,

Ben 5:37

but at the pace at which does the year is going 2023 years, shortly as

Daphna 5:42

it's okay, so this is coming to us from California through the California Perinatal Quality Care Collaborative. So what's the question, they wanted to really look at the follow up rates in the infant high risk clinic and the factors that might impact completion of the program. So this was a retrospective cohort analysis using the CPQ CC, neonatal intensive care unit database. Then the CPQ CC, the California Children's Services, high risk infant follow up database, and their vital statistics birth cohort database. So they use these kinds of three databases in parallel, that had their own kind of reporting system and data collection, to try to get as much information as possible. And, in general, their high risk infant Follow Up Program provides for three standard visits. Usually, they're done that four to eight months, 12 to 16 months. And then the third and final visit is the 18 to 36 month visit. Again, those are corrected age. So the inclusion criteria for this study were infants with very low birth weight or poor in less than 32 weeks gestational age between 2010 and 2015. And the primary outcome was word did they attend the one follow up appointment between 18 to 36 months. And then secondary outcomes, they looked at the associations of maternal neonatal and hospital characteristics, with the successful follow up visit between 18 to 36 months. So the baseline characteristics are during the study period greater than 21,000 infants were referred. And through their analysis, about 1900 infants were excluded. So that left 19,284 expected infants in the high risk infant follow up and of that group 10,249 53% then attended at least one visit between 18 to 36 months. So they found that multiple socio demographic characteristics were associated with this follow up visit. So maternal age of 19 years or less, and black race were associated with lower 18 to 36 month visit rates, whereas things like maternal foreign birth having both parents as caregivers, higher maternal education, and Spanish as a primary language were associated with higher visit rates. And I'll talk a little bit more about some of those things. So and in terms of maternal age, again, young mothers were more associated with non participation in the 18 to 36 months visit. And then, just likewise, almost in a linear fashion, older mothers were more likely to bring in the infant for follow up. And in terms of Nativity, so foreign born mothers were more likely than us born mothers to bring their infant to follow up and then race. Specifically, here, they were talking about black versus white, so the mothers of black race were less likely to bring their infants to follow up, but the mothers who were primarily Spanish speaking, were more likely to bring their infants to follow up than English speakers. Mothers with a college degree or graduate degree were more likely to complete the visit. They also looked at a bunch of neonatal clinical morbidities and having more clinical morbidities were associated with higher 18 to 36 month visit rates, and infants with lower gestational age were also more likely to complete that visit. On the other hand, those born small for gestational age were actually less likely to complete the clinic visit independent of gestational age Not surprisingly shorter patient distance to the high risk clinic. And high risk infant clinic volumes for this specific clinic were associated with higher 18 to 36 month visit rates in the unadjusted analysis. There also was a correlation between an early high risk infant visit. So if the babies were seen, at one of those four to eight month visits, or the sorry 12 to 16, one visit, they were much more likely to complete the 18 to 36 month visit. They also looked at caregivers who had reported concerns about their babies. So for those families that reported concerns at a previous high risk in the follow up visit. They were more likely to be seen at the 18 to 36 month visit. But even those who did not complete did not report concerns. There still was a reasonable portion of those families who came for the higher risk follow up at the 18 to 36 months. What else did I want to tell you? When caregivers had more concerns. So one to two caregiver concerns were reported by 36% of those who returned for the 18 to 36 month visit compared with 32% among those who did not return. So having more caregiver concerns was associated with having higher visit rates. So the other interesting thing that they noticed, really in their discussion, I thought the discussion was very, very valuable. And so I really hope we can direct everybody to take a look there. And they talked a little bit about some of their descriptive analysis. That's where they talked to moms, mothers about why they weren't going to infant follow up. And this is, you know, quote, mothers often felt isolated and have limited support and resources to attend clinic or did not want to hear bad news that may be presented at a follow up appointment. So those are certainly things I think we can talk about and discuss prior to discharge to enhance completion of high risk follow up. The other things they talked about at their discussions are, how can we improve, follow up after discharge. So certainly, having a good experience in the NICU, especially strong patient provider communication, yields higher participation in the follow up clinics, but the opposite is also true. So parents who experienced not necessarily a bad outcome, but specifically bad communication, or communication that they felt was disrespectful or caused them to trust the team last, or if they experienced racism in the NICU, those parents were much less likely to bring their babies to follow up, which makes perfect sense. The other things that they talked about doing to enhance participation of follow up is meeting the follow up staff beforehand. So if you have a neonatologist, or maybe a therapist or social worker who's going to do the follow up care, and having the families meet those people in the NICU before discharge is helpful, scheduling the appointment before discharge. So we know this across all follow up. Families are much more likely to go to appointments if they've already been scheduled for them. And then obviously accessibility to clinic. So transportation is such a big issue for so many of our families. And this has been true in a bunch of studies that the closer they are to clinic, the more likely they are to go to follow up. But they also pointed out could tell a visit be an alternative. We actually talk about this with Dr. Hints when when when we do her interview early next year. Um, so I thought it was a really I thought it was a really good descriptive study, just so that we can be on higher alert about which families may need more counseling. The truth is all the families need more counseling, right? Because our rates of follow up are still not good. But

Ben 14:38

but but I think you you underscored so many things that we can target almost, you know, like it's immediately right. We don't need to like have a shotgun approach in this case because it gives you so many direct intervention for selected populations that are very interesting. Like you mentioned, telehealth, maybe telehealth, as if for Visitors, okay, not the best. But what about telehealth as a as a check in like, before they leave, you do a telehealth visit and they meet the team over there. And that may increase participation in the first visit, I thought it was very interesting to see their babies with their different morbidities and see that babies who have BPD, neck ivh, their rates of follow up are much higher. And so then maybe the babies were doing so very well that we tend to say, Oh, you got your kid, it's so great, and so on. Right? Maybe that's the family where when they do go home with 345 appointments, because they have like one more cardiology appointment one more, I don't know, neurology appointment or something like that. You can say, hey, this is actually a very important for you not to miss. And because it looks like patient parents who have experienced a lot of issues, unfortunately, in the NICU, tend to realize that the situation is more severe and they need so I thought it was very interesting, because yeah, it's I, I didn't expect to see these numbers to be that drastic. And, and I think there's also, in this paper, a lot of societal issues that are very, very much highlighted. Some of them, we're not going to be able to do very much on a day to day basis in the NICU. But we can try to change the tide by, like you said, working on certain things. If if distance is an issue, then how can we make that shorter, even artificially without moving people but getting access to transportation and things like that? I refer basically to our interview with Elizabeth Symington, on the podcast as well, where there are ways to make things easier for parents. Yeah,

Daphna 16:39

for example, I mean, I'm so excited about this program that we are growing in South Florida. It's a it's using green cars, to provide free transportation for prenatal care, and child health appointments. And they're going to include us in the NICU also. So it's a really exciting initiative to study what the needs are in our specific neighborhoods, and to improve access to care. So

Ben 17:16

yeah, so the thing that will if you guys are interested, yeah. Oh, sorry. No, I thought I muted myself. I'm sorry. If you guys are interested in at least not even if you don't want to support Bradley's find out what's being done. It's an initiative called green cars for kids. And you can find out more about it on at the green cars four with the number four We will link this to the show notes so you can check it out.

Unknown Speaker 17:42

Okay, I guess it's your turn. My time was called to do it.

Ben 17:46

Yeah, for sure. I mean, I apologize in advance for the audience. This is not optimal sound. The first paper I wanted to talk about today is from a friend of the show, Dr. Tom Hayes out of Columbia. And he published a very interesting article in JAMA open. So Tom Hayes will be on the show next year. But the paper is called the prevalence and clinical significance of congenital anomalies of the kidney and urinary tract in preterm infants. It's a great study. I know Tom has been working on that for some time. So we were all very excited to see the paper come out. So coquard, which is the congenital anomalies of the kidneys and urinary tract, I think it's a horrible acronym, but

Daphna 18:32

I think I was just gonna, it was coming. I was just gonna say it. I like saying that. I like saying the acronym, is what I was gonna say. And then you had to say the opposite.

Ben 18:45

Well, it's personal preference. But anyway, I'm going to refer to I'm going to use the acronym obviously, for brevity. But the etiology of Calcutta is incompletely understood. There's exposure to teratogens folate with new guys acid, I'm sorry, account for some fraction of the cases, but we're not really completely sure as to what's the entity's developmental anomalies of the kidney. There's a strong genetic etiology of kocot with 10 to 25% of cases attributable to genetic disorders. genetic disorders associated with kocot are frequently associated with other congenital anomalies most of the time extra renal, such as developmental delay, congenital heart disease, immune deficiencies and endocrine disruption. There is not much data on incidence and prevalence of Calcutta in the NICU. And so the question that the team is asking is what is the prevalence of Calcutta and what are their associated morbidity and mortality? So this was a retrospective multicenter cohort study of infants born before 34 weeks of gestation, using the famous pediatrics clinical data warehouse, where they reviewed close to, I mean, that cost 409,704 infants so over 400,000 infants These spend births that took place over the last 20 years between 2020 20. And what they defined as kocot were any structural anomaly of the kidney or urinary tract system, present at birth and recorded as a diagnosis in an individual's electronic medical record. The the list of items that, that encompass coklat were specifically any abdominal wall defects including prune belly syndrome, and bladder exstrophy, renal ectopy, or fusion, unilateral or bilateral renal agenesis, renal hypoplasia or dysplasia. Urinary Tract dilation and anomalies of the urethra are ureters forms of caca that were not otherwise specified, and multiple different forms of caca together. So they determined the prevalence of cockroach in that in that population. They collected many other variables sex, gestational age, birth, weight, race, et cetera, et cetera. They evaluated the association of cockroach with death or severe illness prior to NICU discharge by multiple logistic regression. And another important outcome that was looked at was death or severe illness. And severe illness was defined as acute kidney injury and stage renal disease requiring dialysis severe ivh or PVL. Medical or surgically treated neck severe BPD 36 weeks severe ROP cultural proven sepsis, or shock requiring pressors. So far, so good. So of the 400, and almost 410,000 infants in this cohort 46.6% are girls. So it was pretty evenly matched. The mean gestational age was 30 weeks, and the mean birth weight was 1.49 1.5 kilos. So the main finding, obviously is that the diagnosis of Calcutt was found in that population and 8093 infants which is 2% of cases. And that's a number that, to be honest, is something we should all sort of recall because at this point, this is the best estimate of a prevalence, right? So if you admit 100 Babies 2% of them are are likely to have a congenital anomaly of the kidney or of the urinary tract. Now what was the breakdown of these 8000 individuals with Kirkwood, the following number of cases were found by category. So very few had an abdominal wall defect that was point 7%. Renal ectopia fusion was found in 155 infant that's 1.9%. And by the way, I'm talking about 1.9% of these 2%. So obviously, we know the Genesis was seen as in 3.3%. We know hyperplasia, or dysplasia was seen as 6.3%. The bulk of the of the anomalies were urinary tract dilation and anomalies of the urethra or ureters, 70%, posterior urethral valve, you know, up dilation, things like that pelvic dilation, things, things like that. 15% were not specified, and only 3% had multiple congenital anomalies. A diagnosis of Kakadu was significantly associated with either ambiguous or male sex with earlier gestational age, lower birth weight, the presence of known genetic disorders, and with congenital anomalies of other organ systems. There's a very nice graph that we will post on our Twitter page that shows an inverse linear correlation between the prevalence of Calcutta and earlier gestational age. And that's something that's also very interesting, the R square on that curve is point eight, seven. And that was obviously statistically significant. So the earlier the baby is born, the more likely they are to have kocot. In that case, you can see on the y axis, that there's a prevalence in of packet per 1000 births. And it's about close to 30 when you're 23 weeks, and it goes down to about 15 When you're at 33 weeks, so it's quite impressive. So it's quite a steep slope. genetic disorders that were associated with Calcutta included aneuploidy copy number variants and single gene disorders. That's that's what they found. Finally, let's look at some of their clinical outcomes. So after exclusion of infants transferred from or other facilities, they had data on 324,000 infants. Multiple logistic regression demonstrated that the presence of kocot was associated with a significantly higher odds ratio of combined outcome of death or severe illness when adjusted for known risk factor. And the bar was 3.96 with a confidence interval of 3.7 to 4.24, so it wasn't wide. Now it's, this was this is not so One thing to take lightly. Rather, infants with cocoa isolated, or with extra Renaud anomalies had significantly risk of every illness studied. So, remember the list that I gave of all the different outcomes. We mentioned those in the methods, but with each one they were at high risk. The crude or of severe illnesses or death in preterm infants with cochlear was comparable without found in infants with congenital anomalies of the heart and central nervous system. So this is, I mean, okay, I'm gonna read the conclusion, I'm gonna tell you my thoughts. And so their conclusions are quite strong. They're saying that there's a lot of important implications, obviously, as we mentioned in this paper for practice and research, they're saying a few things. First, they say the presence of cockroach should prompt clinicians to consider consider a genetic workup. I think that's something that's not always done. And that's very true. We demonstrated an association between genetic disorders, including aneuploidy, copy number variants, and single gene disorders. This is consistent with the recent guidelines of the American College of Medical Genetics and Genomics, which recommend genome wide sequencing for individuals with congenital anomalies and developmental disorders. Say second, they say the presence of cockpit may be considered as a risk factor for serious morbidity and mortality. The care of preterm infants necessitates risk benefit consideration and planning care. Our findings may prompt higher pretest probability for sepsis, shock. Aki, NEC, and other serious illnesses encountered frequently in the new annual practice. And this association may influence counseling and discussion with families particularly in high risk cases. Finally, these findings indicate the need for multiple lines of research, prospective screening and longitudinal surveillance of preterm infants that would clarify the risk of death or severe illness imparted by kidney anomalism. Prospective genome wide sequencing of preterm infants with CallKit would delineate the genetic architecture of disease, I think Tom is working on that actually identify specific gene disease Association, and inform improved clinical management. So, yeah, I think we tend to pull Rino anomalies, you know, it's like, the kidneys work, why do I care. And when you see all these associations, you wonder about getting these ultrasounds, maybe sooner you wonder about having these ultrasounds and other information sooner to help you prepare better for some of these potential comorbidities, and counseling families, and also potential extra renal anomalies. So crepe paper, congrats to Tom and his team and the team at an X. He doesn't work from an X, but obviously, I'm talking about the pediatrics database. Very, very interesting paper.

Daphna 27:46

Yeah, you know, I think in particular, right, so when you're the newborn nursery, you may see some findings on on prenatal ultrasounds, you know, that you're like, okay, it was that the fall comes up, but you know, make me take another look, but I feel like especially in the NICU with some of these preterm babies or babies who ended up in the NICU or otherwise healthy, you know, I think even more so those, those renal those, you know, these cathodes should get, it should really give you pause. And I mean, in general, I think this is like, the golden era for people interested in the neonatal of kidney, I think this is such a blossoming field, you know, so people who, you know, they've been talking about it for decades, but they really didn't get the limelight, like, say, the lung in the heart and the brain. But I think we're going to be learning so much about the neonatal.

Ben 28:42

And this is why it's going to be super interesting to speak to Tom next year, because it's most likely going to be one of the main port of entries for precision medicine. And I know he's working hard on on that. And the idea that the first place we can find out more about our patients on an individual basis is their kidneys, because we do get echoes and we do get brain ultrasounds and stuff. But like I said, the kidneys get get a bit left by the wayside in the NICU. And that's, that's going to change.

Daphna 29:12

You know, we have a kidney vital sign, like, continuously, right, like we monitor urine output all the time, and it's always changing. There's so many babies that don't have normal urine outputs, and you just kind of like, you kind of just like deal with it along the admission, right. So I think this is this is really interesting.

Ben 29:33

This episode is proudly sponsored by rocket meat Johnson recommened Johnson is dedicated to the research and development of nutrition products that help support baby development at every stage, including an extensive and female portfolio for premature and low birth weight infants learn more at HCP dot meet Yeah, I made it through

Daphna 29:54

who did the okay one down. All right, I have another neurodevelopmental study. Where did he go? So this article was entitled neurologic examination at 32 weeks postmenstrual Age predicts the 12 month cognitive outcomes in very preterm born infants. And the lead author Sabal hoof, senior author, Joanne George, this is in pediatric research. So what's the question? They wanted to use the Hammersmith neonatal neurologic exam? And see, Does it predict outcomes in infants born at less than 31 weeks? Compare the comparison was the Bailey at 12 months. So the Hammersmith if you're not familiar with it, and I mean, it's kind of a it's kind of subjective. So I think that's why there's you know, debate about it. But the kind of the main features of it, it's a 34 item assessment with six sub sub scales, which are total to provide this global scale. And so you know, they do this assessment of cranial nerve function. By looking at the face, the eyes, the visual and auditory response and sucking and swallowing. They do an assessment of posture, and assessment of the baby's movements and assessment of tone. And then the motor components are really reflexes and reactions, these motor milestones, and then they look at overall behavior of the infant. So their study design, they were looking at all events are in less than 31 weeks of birth. And they were evaluating evaluated using the Hammersmith at the 30 to 32 weeks postmenstrual age, and again at the 40 to 42 weeks postmenstrual age. And then the infants were evaluated, like I said, at 12 months using the Bailey three. In addition, they used kind of, quote unquote, healthy term controls, to look at the hammer, hammer, Hammer Smith scores. I'm not the one that lost my voice. I mean, word finding difficulty.

Ben 32:22

If you also lose your right, that's it.

Daphna 32:26

So the baseline so they had 119 preterm infants that did the early assessment, so that was the one at 30 to 32 weeks postmenstrual age, and then they had 107 preterm infants do the late assessment at 40 to 42 weeks, and they had 104 of those infants returned for the 12 month follow up. So I thought was a pretty good group. The mean gestational age of birth was 28, and four weeks, and the mean birth weight was 1093 grams 71% were born by C section 70% received antenatal steroids 25% and had any ivh 7% with a grade three for ivh 17%, with postnatal steroids 4% with sepsis, 4% with neck and 29% with BPD defined as oxygen requirement at 36 weeks. But of note in this cohort, it was interesting to me that given their BPD rate that the mean ventilator days was two and the mean CPAP days was 25. So you can I guess take that with a grain of salt. But for you know trainees who are wanting to do neuro developmental studies, I think it was important to see what things they looked at. So definitely steroids is something you should be looking at for developmental follow up, obviously ivh. And then we know that inflammation is a predictor of poor neurodevelopmental outcomes, or were hypothesizing that. And so that's why looking at sepsis and neck and BPD was important. So the primary outcome was to really look at the scores and compare the early and late assessments and then look at those in comparison to the term baby. So I thought this pictorial here, this graph they had of the scores was really cool, really clear. So I implore people to take a look at it. So definitely post it, but

Ben 34:35

it's a box craft. Yeah. And there's like, in blue, you have the preterm. Yeah. And then you have the in red next to them the term equivalent.

Daphna 34:44

Yeah, sorry. So the blue is the preterm early assessment,

Ben 34:49

right. The pre term term equivalent is the one in red, and then you have your term controls.

Daphna 34:55

Yeah. And so, you can see that for almost all the measures During the pre term, early assessment has the lowest scores, followed by the median scores or the pre term late assessment. And then the term controls obviously are at the top of the boxplot. And so, except for the tone pattern subscale, preterm born infants achieved lower median scores at both the early and the term equivalent and age assessments again, across all the other sub scales and for total score. And of note, like I said, the Early Assessment had lower scores than the term equivalent age. For tone preterm babies scored similarly on the early and late assessments. And within the preterm born group than the median early assessment scores, like I said, were all lower than the term equivalent assessment scores. The preterm born group also displayed a wider range of scores across all the subscales and total scored compared to the term board reference sample and you can definitely see that in the box plot. The sensitivity specificity and accuracy of early in term equivalent age Hammersmith assessment to predict the Bayley three cognitive scores less than or equal to 85. So they use that that cutoff at the 12 months corrected age. And then they want they use the fifth percentile values of the term control data as kind of the cutoff points. And so you can see that in one of the tables listed, but they at early Hammersmith assessment, the reflexes subscale had the strongest predictive value, a sensitivity of 100%, specificity of 21%, positive predictive value of nine negative predictive value of 100%. And the term equivalent age tone pattern subscale demonstrated the best combination of sensitivity and specificity, sensitivity of 71%, specificity of 63%, positive perfect positive predictive value of 13%, and a negative predictive value of 93%. And then they were trying to use some area under the curve analyses to determine the best cut off points to have the best predictive value for cognitive outcomes. And they felt that their early assessment so again, the one that is done between 30 and 32 weeks, had slightly better predictive ability for cognitive outcomes than the term equivalent age assessment. Abnormal signs subscale at the early time point produced the strongest combination of sensitivity and specificity for predicting cognitive impairment at 12 months on the Bayley three, sensitivity, 71% specificity 71%. And then the total optimality scores and early assessment also led to a sensitivity of 71%, specificity only about 51%. And then they went on to show some of the other potential cut offs and assessment values. But I was impressed to see how much or that the early assessment was kind of associated with cognitive outcomes. So obviously, there's some limitations to the study, it's still a pretty small study. And some might argue that the 12 month follow up is too soon to really evaluate outcomes. And, you know, in general, I think when neonatology first began, we were doing a lot more kind of developmental screening in the unit with these motor and neurologic assessments right at the bedside, and we've kind of moved away from them. But it's interesting to me to see them kind of start to come back and find some validity and potentially a clinical practice. So

Ben 39:16

that's, I thought it was very interesting. I'm sure I'm gonna ask you, I'm going to use you as an expert in a second and ask you what my my question is. But in the box, what was interesting is that there's the different subsections of the test, but in the total, so in the sub sections, the error bars are flying all over. Yes. And that's a problem, obviously. But in the total score, it's quite progressive. So as you said, In the beginning, we know that the tool is not perfect. So you're like, Okay, it's not perfect, but maybe, can I get a trend? Could I establish where we're going? Get an indication, it's not going to be a diagnostic gold standard type of assessment. But maybe it can help me say, Hey, we're done. Definitely not on track or pay like this is going to be what's interesting now that my question to you is, do you think that with more practice more data points, this is going to be standard of care in the NICU that we're going to start doing neuros mental assessment at 32 weeks? And let's be honest, the kids that we really want to do this on, are the kids who are going to stay there for another 10 weeks anyway. So is this going to be what we're going to do every three, four weeks, we're going to have like two, three assessment points already done in the NICU?

Daphna 40:31

Yeah, I especially think what you said about trends is important, right? So at the very least, you'd expect it to get better from the early to the late assessment. And so if that's not happening, that's like, it would be a huge red flag. And so I think that's potentially very valuable. I think when we think about these descriptive things in the NICU, I think we have to say like, what are we going to do with the information? You know, are we going to offer more resources than we already offer? Maybe Maybe we'll implore to these parents like we, like they described in the other study that when parents knew, you know, when the babies had more comorbidities than the parents were more likely to come to follow up. So maybe if we're doing the developmental test at bedside, and we're including parents at bedside, we can say to them, yeah, we think this is important. And this is why.

Ben 41:26

And maybe this will close the loop for your first article. That's right.

Daphna 41:30

Yeah. I do think though, you know, a lot of the NICU we've all been men, and we say, well, there's a spectrum of outcomes. And we know that these things help babies, like we speak in generalities. parents really want to know, like, what are you seeing in my babies specifically? And so I definitely think there's value. Obviously, the, the parameters, this, the statistical parameters aren't perfect. But I think it certainly gives you a trend, like you said, a trending clinical picture. And so I think there's this and these assessments can be done pretty quickly at the bedside right? And engaging parents. Thank you. Big Can I probably one

Ben 42:22

day, we will post off not doing one. Because you're definitely not up to par. Not you. I'm saying the audience.

Unknown Speaker 42:31

I'm spending that much time at the bedside anyways. You might as well.

Ben 42:35

I'm saying like when you go at the bedside, like every every ounce of your body is in motion doing something, which is something that I don't know how to do yet.

Daphna 42:43

Any anyways, thank you for the question. I think I think, I think will if, listen, this is what I think I'm gonna get on my soapbox. I think if clinicians had enough time to spend at the bedside, and there were not so many clerical duties and administrative duties, and logistical kerfuffles we wouldn't have we would have, we would have the time to sit with families and walk them through a developmental assessment, regardless of what it says right? Regardless, but just to say, these are the things we're looking for in your baby as they mature. And I think that would be very valuable.

Ben 43:28

I read that article in the Harvard Business Review, where they said that for doctors to bond with their patients and build that trust. Again, we have to implement the gross system, which stands for get rid of stupid stuff. And that means all the documentation and stuff that helps no one, except maybe not even sometimes we people don't even know that 99% of time we document and it's not even helpful for billing. People think, oh, it's for billing. It's like not even not even true. I have two more, I may have to actually. So this article is published in the Journal of Pediatrics, it's called the clinical and cost utility of cardiac catheterization and infants with BPD. first author is Emily Yang. And it's coming out of a group in the US Boston so on. Second, Arthur is our friend Phil Levy, who was on the show for the new heart. So we're big fans of Phil. I mean, I was not familiar with his work and his personality. He's such a great guy. And the paper is on par with with him because I read the paper and it was a roller coaster of surprises and it's very fun. So just to give you some background, the presence of pulmonary hypertension associated with BPD can significantly impact both cardiac pulmonary nutritional and other mental outcomes and people born preterm. We know that pulmonary hypertension increases significantly healthcare utilization and leads to a mortality ranging between 14 to 47%. At present most places use echocardiography For the initial evaluation of people of infants born preterm at risk of pulmonary hypertension, however, we all know that the gold standard is right heart catheterization. Now, the consensus guidelines from the American Heart Association, which I was not aware of, by the way, the American Thoracic Association and the European pediatric pulmonary vascular disease network, recommend, and listen to this, that a cardiac cath be obtained before starting pulmonary vasodilator therapy. I was like holy shit. And these are like, there's not even sometimes you hope that there's a pretty strong guideline in Jewish law, you hope that always there's an opinion that allows you to do whatever you want to do. And here, I was hoping that one of these association was going to disagree, but they're all there. They're all saying we have to do it. However, there's a growing precedent in high middle and low income economies that this invasive assessment and genders environmental risk, with rare additional benefit beyond knowledge gained through the non invasive imaging. Then he mentioned that the barriers to treatment with pol Benefiel, a common firstline, pulmonary vasodilator have decreased. Generic formulations are available since 2016. And the safety is well described. And so some centers, us included have initially decided to initiate some benefit for pulmonary hypertension based on echocardiography alone and not having to do with a cardiac cath. And so the the question that the paper is asking is, what is the clinical and cost utility of doing a right heart catheterization before the initiation of visual dilators. And that's something that we have a standard in our unit of high acts of excellence, and we want to do things at the at the tip of the spear when it comes to evidence based practices. And that's something that technically and logistically, we don't have the opportunity to do. And it always nags me citation wouldn't be better if we could get a heart rate higher cap, which if we need to, we sent babies to another institution to get that done. But it always feels like we're doing a bit of a lesser medicine. And so I was very curious to see that. And then you look at the methodology, and I thought I was in for a big disappointment, because they basically did a Markov state transition model to simulate the clinical scenario of a preterm infant who is being evaluated by echocardiogram for the presence of pulmonary hypertension associated with BPD. So what does that mean? The Markov model is basically like a flow diagram. And you put a patient through it, and every node is a potential outcome. So you say, Okay, you get an echo, what is the risk that this baby has hypertension on echo, x, and then the baby gets shuffled to one arm? And then in there, you say, okay, so then you start to identify, well, what is the chance of complication, one arm and it keeps doing this? Obviously, it's computer generated. So it goes through multiple, multiple iterations. And, and it evaluates I mean, if you go in the paper, they actually have a diagram of the Markov state transition model. Have you? Have you seen it?

Daphna 47:59

Yeah, I mean, in this paper, but not not previously ahead, was?

Ben 48:02

Yeah, it's like, it's extensive. Like it barely fits, by the way in the in the publication and the PDF. And at the end of every arm is an outcome, either the baby does better, the baby gets admitted some something right? That's, and that's what,

Unknown Speaker 48:15

like a March Madness.

Ben 48:17

Yeah, it's a racket. So, I'm going to, so obviously, every every node, every outcome possible is probability weighted, so and they have data to support that. And until you reach what they call an absorbing state or outcome, which is what I just mentioned. In this particular model, patients with pulmonary hypertension associated with you were evaluated and treated by one or two model the treatment either empiric sildenafil, or Cath, treat or Cath, obligated treatment. So the baby were then you know, they could either go through one or the other. Patients in both treatment arms entered the model as premature infants in the neonatal ICU at a corrected age of 36 weeks, which is when you define PPD. The model cohort lacked hemodynamically significant post tricuspid valve shown such as VSD PDAs, and illustrated no echocardiography concern for alternative diagnosis. That's important obviously, because that's possible, and sometimes common. A positive screening echocardiogram was defined as a pathologically elevated peak pulmonary pressure based on a septal position or tricuspid. regurgitation, velocity, specificity and sensitivity were defined in accordance with published test performance characteristic identifying pulmonary hypertension associated with BPD with invasively, measured pulmonary vascular resistance PVR or of I'm sorry, three or more indexed would units ID aw use. Depending on the scenario echo had false positives, obviously but right heart cath was considered the gold standard. So there was no not a possibility in the Markov states to go through a false positive for cardiac cath. Regardless of the strategy chosen a probability of adverse response to sell the NFL upon initiation was assumed the model rent for a course of 12 month cost was analyzed, they also looked at quality adjusted life in years. And so, when you read the methods, you're like, alright, in a theoretical model, what do you think they're gonna say, right? They're gonna say fine, like, it's you. If you do a right heart cath, it's, it's better outcomes. And then you read the results, and you're like, oh, wow, the characterization obligates strategy resulted in a probability weighted average increase in cost of $10,778. As well as point 02, fewer quality of life years, then empiric strategy. With regard to each paradigms effectiveness, the quality of life years were 40.1 and 40.03, for the catheterization obligate an empiric treatment arms respectively, so no change. One way sensitivity analysis demonstrated that empiric treatment was identified remain cost effective across all scenarios, a three way sensitivity analysis varying the prevalence and clinical significance of alternative diagnosis. When starting empirical data, Phil did not alter our findings, the empiric treatment strategy remained the leading cost and effectiveness strategy. Whew. Now, similarly, the catherization obligate strategy remained dominated as indicated by negative ice R, which, which stands for incremental cost effectiveness ratio across a wide range of assumptions of echocardiography test characteristics. Now, the one question that they ask is saying, well, we tested them at 36 weeks. And what if you do an echo and there's nothing there with what if you needed something they did also, they did a sensitivity analysis, in which only those who have not yet been catheterized could revisit the diagnostic decision and incur the associated cost of this diagnostic uncertainty. Because you may say, I kept them at 36 weeks, I know, I don't really need to repeat it. But then you say, the kid that hasn't gone through that has a chance to incur that option in the future. Still, this change, increase the effectiveness of the catheterization obligates strategy to be sufficiently higher than the empirical treatment strategy. But the catherization obligate strategy remained significantly above the willingness to double UTP the willingness to pay threshold with an incremental cost effectiveness ratio of 1.2 something million dollars per quality of life years, thereby not meeting criteria for being considered cost effective. Additionally, they run a 1000 patient Monte Carlo probabilistic sensitivity microstimulation demonstrated that empiric treatment with Saldana field remain cost effective the cost effective paradigm in 98% of cases. The conclusions of the paper are that the encouragement was identified in preterm infants with pulmonary hypertension associated with BPD when compared with catheterization obligate treatment is cost is a cost effective strategy. It was shown to be associated with decreased cost and with improvement in quality of life years, these find things suggest that forgoing catheterization before the initiation of sildenafil in uncomplicated pulmonary hypertension. Obviously, we talked about that in the methods all these shots and stuff may be warranted and likely confirms the growing realization that echocardiography offers a reliable non invasive tool for screening, diagnosing and monitoring pulmonary hypertension in preterm infants. Bam, what a paper.

Unknown Speaker 53:35

It made you feel better.

Ben 53:37

Yeah. Because you think that sometimes if you let the numbers do the, to the job, right, because there was no patience, but it was just a simulation, right? You think you're losing that human sort of real life? You know, uncertainty, and it's like, and it didn't, it confirmed what we all perceived was probably the right course of action. Obviously, we're talking uncomplicated, we're talking we're talking on complete like you don't want you're not talking about the babies who have very complicated pictures. But the the typical case all right.

Unknown Speaker 54:15

All right. You'll be able to sleep tonight them thinking that we're doing the right thing.

Ben 54:22

Yes, absolutely. Absolutely.

Daphna 54:25

Okay, I have another developmental I love them. I love them. Okay. This was called. I'm actually I was actually very interested to read this paper, but this is called ventricular volume and infants born very preterm relationship with brain maturation and neurodevelopment at age four and a half years. Lead author minsheng, a senior author Stephen Miller, this is in the Journal of Pediatrics coming to us from Canada. So the question was really to evaluate the relationship of ventricular volume, in particular event tricular dilation with brain maturation and neurodevelopmental outcomes at age four and a half years and children born very preterm, and this is something I don't know, I feel like we're seeing a lot of recently. And so, you know, babies who maybe don't have any ivh, but still have this kind of persistent ventricular dilation. So what does that mean for them long term. So, this their study design was using a number of MRI scan. So they did when performed shortly after birth, and infants born between 24 and 32 weeks gestational age, and then another MRI at term equivalent age. And they looked for ivh, they looked for white matter injury, and they looked for a number of other measures of particularly kind of white matter and myelination maturation, so they were looking at the fractional anisotropy. And this these measures of diffuse diffusivity. So the radial and I mean, diffusivity, which we'll talk about when we get here. So I guess maybe we just get into the data. So I told you, they were looking at infants born between 24 and 32 weeks gestational age, they infants were excluded, if they had some sort of congenital infection, congenital malformation or syndrome, or a large parenchymal, hemorrhagic infarct greater than two centimeters on ultrasound are excluded. Very specific. So I wanted just to mention their follow up so at four and a half years, they use the Wechsler IQ scales, and then the the movement assessment battery for children to to do the neurodevelopmental follow up. Okay, so their primary outcome, they had 212 infants that had this early MRI done that 208 of those had acceptable image and all the correct segmentation measurements. Subsequent to that, and of the 208, they had 194 that had the term equivalent age MRI, and further analysis, patients were then categorized into normal and abnormal of this ratio, the ratio they use is the ventricular volume to total cerebral volume. So again, the measurement was really this ratio of how big is your ventricles compared to how big is your total cerebral volume, and they based on based on the 75th percentile of the ventricular volume to total cerebral volume ratio, using the results of the early MRI. So it fits in the quote unquote, abnormal ventricular volume to total cerebral volume group are more often male, or have younger gestational age, and they had higher incidences of intraventricular hemorrhage. They had more instances of hypotension. But interestingly, they had no difference in SNAP scores, which is like a clinical illness score. If you're not familiar with it, they had no difference in PDA they had no difference in culture positive infection. And then within the abnormal ventricular volume to total cerebral volume group 80% of those with MRI data at both time points, had reduction in the ventricular volume to total trubel volume ratio from the early MRI to the term adjusted age MRI. So in general, it meant that the ventricular volumes in comparison were became smaller over time, or that the denominator became bigger over the time. The secondary outcomes so larger ventricular volumes in early life, and add term adjusted age were associated with lower IQ scores. And in addition, larger ventricular volume at the term adjusted age MRI was also associated with lower motor scores. And I know you love it when they put it in this. This type of data Yeah, across the range of observed values on the early MRI every one centimeter cubed increase in ventricular volume was associated with a point six point lower, full scale IQ. And on the term MRI every one centimeter cube increased in ventricular volume was associated with a point or point lower, full scale IQ and a point eight point lower motor score. White Man Are injury volume significantly modify the relationship between ventricular volume in the early life and the full scale IQ. So the negative there's a negative association between ventricular volume and full scale IQ. And this was accentuated by a greater white matter injury volume. And even after controlling for white matter, injury volume, the total cerebral volume and all the other variables he could think of ventricular volume was independently associated with a decrease IQ and motor scores or preschool age. And overall, this was really seen, again, another one where the graphs speak volumes. This was seen in like a linear fashion where the larger ventricles, the larger the ventricles were, they predicted Portner development. They also looked at a lot of these MRI measurements, so we can talk about them briefly, but I know we're like nearing an hour already. So FA are the FRAC the fractional anisotropy is a really a measure of conductivity in the brain. And then these measures of diffusivity really help us understand myelination. So in general, the white matter, fractional anisotropy increases and mean diffusivity decreases with advancing postmenstrual age and it really helps demonstrate kind of a maturation of the Aldo dendrite glia. And so in this study, there were significant associations between ventricular volume and the mean, fractional anisotropy mean diffusivity and radial diffusive did this diffusivity. In the white matter tracks and gray matter groups after adjustment for sex, postmenstrual age, the white matter injury, ivh and total cerebral volumes. And in general, so they, they looked at a bunch of areas, they looked at the Plik, they looked at the corpus callosum, so all the data is there. But overall, it's suggested that there were lower fractional anisotropy in a variety of places and higher diffusivity in a number of places, and taken together overall suggested that the ventricular dilation was associated with abnormalities in white matter, myelination. And kind of the maturation of that process. Interestingly, the deep gray matter maturation did not show pronounced, pronounced alterations, either even in the face of ventricular dilation. So in short, we can't just ignore those babies with ventricular dilation, I thought was interesting. I know. What is that was interesting about this study was that they were doing MRIs on really little babies really early on, but I thought the data was useful. And I you know, in their discussion, they describe that there are probably things that we just can't see on MRI about injury to the brain, and, you know, potential kind of volume loss that's leading to this ventricular dilation. So we just we just can't ignore it. There's something going on there. More reasons for good post natal follow up post discharge, follow up?

Ben 1:03:37

And yeah, and yeah, potentially you need for MRI term and stuff. Yeah. Well,

Unknown Speaker 1:03:42

don't get me started on that one. No,

Ben 1:03:44

I think we have we have papers lined up for next journal club on that. So we will, we will get you started next time. I wanted to mention this last article that that came out in this in the American Journal of parasitology. And it's paper that got some discussion on Twitter, so I just wanted to bring it up. It's called developmental dysplasia of the hip is not associated with breech presentation in preterm infants. first author is Samantha Leonard. And that's a paper out of the Netherland. So basically, I'm going to, I'm going to We're way over time already, but I'm going to spare you the background and the question they're asking is that is there a relationship between breech presentation and the amount of displeasure of the hip DDH in scene in full term infants, in preterm infants as well, meaning we tend to consider if a baby if a baby girl is born a term breech, we say that's a risk factor for gdh. They'll need close monitoring, follow up ultrasound, whatever. But when a 24 weaker is born, does that make is that the same? So they did a retrospective chart review of about 2000 infants born between 2008 and 2017 at less than 35 weeks of gestation, and admitted to their to the NICU at Penn State Children's Hospital in Pennsylvania. I don't know why I said the Netherlands I'm sorry. Um, it's just too late for me this not from the Netherlands, it's from the US.

Unknown Speaker 1:05:06

They may have had some authors from the Netherlands.

Ben 1:05:09

No, no, it's probably the register my notes probably I just left some some data there. Anyway, they looked at a bunch of clinical characteristic gestational age, birth weight mode of delivery, the presence of hip clicks and recordings, ultrasound results, diagnosis of DDH, based on both physical examination and hip ultrasound performed at 46 weeks corrected age, defined as 46 weeks, right, I mean, meaning four to six weeks after you wish to do date. And the definition of developmental dysplasia that they're using is an abnormal hip exam with a positive Barlow or Endor Ortolani. And in a graph classification stage to B or higher. The graph classification is basically this radiographic classification, looking at alpha angles, and it goes from like, I think, one to four, and to be as is abnormal, to be plus is abnormal. And they also looked at less than 50% contact between the femoral head and the acetabulum. Okay, so let's look at some of the results because we're over time, but they had 1800 infants born less than 35 weeks, and they excluded a few because they were missing some, some clinical variables. So in the end, they have 1533 infants for final analysis. The median, and interquartile range of gestational age of infants born in the breech versus vertex presentations were not different. They were on average 32 or 30 versus 33 weeks. The birth weight of infants born in the breech versus vertex position were also not different 1547 versus 1776. And because female gender was a risk factor for the middle displeasure of the hip, they analyzed the female to male ratio of the two groups and there was no difference. In total, and this 1500s or so babies, they found six infants diagnosed with ddH. In the entire cohort, two were male, four were females. The incidence of DDH in preterm infants born in the breech position was point four 7%, so less than half a percenter versus vertex point three 6% and that those two things were not statistically significant. The sensitivity of breech presentation in detecting DDH is 33%. It's very low. The specificity is a bit higher 72%. The positive predictive value of a breech presentation for detecting DDH is 0.47%. The negative predictive value is 99.6%. None of the infants had unstable hip exams. That's something that I always check. And it's disappointing to see that babies with DDH never presented. The incidence of hip clicks with negative Barlows and Ortolani test in infants with breech versus vertex presentation was not different either. So you can look at the data. And the conclusion is actually strongly worded. They say that they found no association between prematurity and the mental displeasure of the hip, regardless of presentation at birth. Breech presentation is not a risk factor for deviation preterm infants, based on our results, the practice of obtaining hip ultrasounds can no longer be recommended for preterm infants born at fewer than 35 weeks, born in the breech presentation with a normal hip exam. It's a retrospective study. But obviously, you can tell that if you had designed this prospectively, how many? Like how many births do you need to throw to actually get enough patients? This is like 2018 2017. So that's, like nine years, it's a long time to get just like six cases. And, and yeah, I still think personally from from an experience standpoint, that it's being breached for a long period of time. So I think if you're born at 23 weeks, and you are breached, I don't know if it makes that much of a difference. But if you're 3435, I think it probably plays a bigger role, because you

Daphna 1:09:07

would have liked to see the data more like that by a but there's

Ben 1:09:12

only six cases. That's the problem. That's was I thought exactly the same thing. And then I had to like, look back, I was like, alright, that's right, because I look at the percentages, as I call it point. 5% I wish they had broken down in subgroups, but I'm like there's six babies.

Daphna 1:09:28

Yeah. And I think it tells you for sure that really being breached that last that last month May you know you ran out of room in there.

Ben 1:09:37

Absolutely. There was one last article that was quite interesting. I'm not going to go through it. It's just a quick review. It's called lower pass threshold for critical congenital heart disease screening at high altitude prevents repeat screening and reduces false positives. It's a paper obviously from a hospital called the Barton Memorial Hospital in South Lake Tahoe, which is pretty highly elevated. And they basically said because we're at high elevation, expecting a first pass of 95% or more is, is unrealistic, and we get maybe more echoes. And so they tested, they had a very cool study where they looked at two different centers at two different altitudes. And they see if lowering the threshold reduce the number of echoes babies were expected were exposed to. And did that change a bit of how the incidence of congenital heart disease and it turns out that if you're at high altitude, lowering the threshold is fine. By so they said the conclusion is that lowering the threshold by 2%, that more than 6000 feet significantly increased, first passed first screen pass rate. And it didn't really impact their missing of any congenital heart disease. I thought that was cool. Because that's something that's now very well accepted. And people are now having to make some tweaks to adjust for their specific circumstances. I thought that was.

Daphna 1:10:53

Yeah, okay. That means it feels like we should be calculating one of those equations.

Ben 1:10:59

Don't know that's for board review. Okay, okay. apologize to everyone for my voice again. But I thought it was I don't want to miss a week that though the podcast we take great pride in not having Mr. Week, so. So here we are. Thank you Daphna for the time and

Unknown Speaker 1:11:15

they're like, we're like the post office. That's right.

Ben 1:11:19

The mail never stops, as numina would say. Why did I want to say for? We have a very cool interview coming up this this next Sunday. Stay tuned. It's one of our giants of neonatology. And this is none other than one of my mentors, Professor Eduardo banchory. So it's a fun interview. He, he's chatty. So that's good. All right, everybody

Unknown Speaker 1:11:43

have a good?

Ben 1:11:45

Oh, one more thing. I wanted to say we've been receiving people sharing their stories about how the podcast has impacted their their not just their lives, but like the way they manage babies. We've had some very cool stories. And we wanted to share these stories on our end of your episodes. So we've received a few. If there's a story you want to share with us on how something you're listening on the podcast, or maybe a connection you've made through the podcast has helped you either with your research or with your clinical work. You can send us whatever you want, whether it's an audio file, and we'll play it on the show, whether it's just a text, and we'll read it. But just and obviously, we don't want to any personal like, we don't need to even say your name, we can just say your doctor or person from so and so. But just I think it's really neat.

Speaker 1 1:12:32

I love getting those messages. Oh my gosh, it just makes it makes all these late nights. Totally worth it.

Ben 1:12:41

Yeah. And we have an ETS, we decided that we're going to read them because there's, they're incredible. Some of them are like, holy moly, what was that? And so we're not going to spoil any of them. We'll leave them for the end of the year show. So, but yeah, start sending them. You have plenty of time. It's only October. So yeah. All right, guys.

Unknown Speaker 1:12:59

That was a good reminder. Okay.

Ben 1:13:00

Thank you. Thank you for listening to the incubator podcast. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcasts, Spotify, Google podcasts, or the podcast app of your choice. We would love to hear from you. So feel free to send us questions, comments or suggestions to our email address NICU You can also message the show on Instagram or Twitter, at NICU podcast or through our website at WWW dot d dash incubator debt report. This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns. Please see your primary care professional. Thank you

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