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#173 - Journal Club - 📑 Normal Saline Boluses, Long term effects of nitric oxide, Oral surfactant and more..







Hello Friends 👋


The time has arrived for the last episode of the year 😢 We conclude 2023 with an episode of journal club where we discuss a few interesting topics. Oropharyngeal surfactant, normal saline boluses, and long-term effects of inhaled nitric oxide, among other things. We also take some time to announce the new and exciting shows that will be coming to the incubator network in 2024. The team at the incubator podcast would like to wish you a happy holiday season and best wishes for the upcoming new year. We will be back with a brand new interview on Sunday, January 7th. See you then!


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


Sehgal A, Gauli B.Am J Physiol Lung Cell Mol Physiol. 2023 Dec 1;325(6):L819-L825. doi: 10.1152/ajplung.00179.2023. Epub 2023 Nov 7.PMID: 37933458

 

Murphy MC, Miletin J, Klingenberg C, Guthe HJ, Rigo V, Plavka R, Bohlin K, Barroso Pereira A, Juren T, Alih E, Galligan M, O'Donnell CPF.JAMA Pediatr. 2023 Dec 11:e235082. doi: 10.1001/jamapediatrics.2023.5082. Online ahead of print.PMID: 38079168 Free PMC article.

 

Gurram Venkata SKR, Lodha A, Hicks M, Jain A, Lapointe A, Makary H, Kanungo J, Lee KS, Ye X, Shah PS, Soraisham AS; Canadian Neonatal Network and Canadian Neonatal Follow Up Network; Canadian Neonatal Network and Canadian Neonatal Follow Up NetworkTM.Arch Dis Child Fetal Neonatal Ed. 2023 Oct 27:fetalneonatal-2023-325418. doi: 10.1136/archdischild-2023-325418. Online ahead of print.PMID: 37890983

 

Fusch G, Mohamed S, Bakry A, Li EW, Dutta S, Helou SE, Fusch C.Eur J Pediatr. 2023 Dec 14. doi: 10.1007/s00431-023-05335-z. Online ahead of print.PMID: 38095715


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Ben's Notes are below:

174_oropharyngealsurf
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Download PDF • 508KB

 

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


Ben Courchia MD (00:00.93)

Hello, everybody. Welcome back to the VADER Podcast. Uh, Daphne and I were trying to figure out how to start this episode, and we haven't come up with a good one yet.

Daphna Yasova Barbeau, MD (she/her) (00:08.448)

It ready and you started with it.

Ben Courchia MD (00:11.466)

You gave me a few indications at some point that you were ready, then not ready. I was not ready, but that's okay. Uh, welcome back everybody. The last episode of the year, 2023, is coming to a close. It's a, how's it feeling?

Daphna Yasova Barbeau, MD (she/her) (00:14.171)

Hehehe

Daphna Yasova Barbeau, MD (she/her) (00:27.091)

Well, it's been a weird year. Let's just say it's been a weird year, and the end of the year is coming faster than I anticipated, I guess. But we've got some things to recap from the podcast, you know, this year. I mean, there's a lot going on in the world, right? Obviously.

Ben Courchia MD (00:36.385)

Yeah.

Ben Courchia MD (00:42.483)

Why are you saying it's been a weird year?

Ben Courchia MD (00:47.806)

Okay. I thought you were going to say something like that. And so that's why I wanted to then quantify this by saying, I agree. And, um, I also want to say that the podcast in and of itself has been doing very well, we cannot thank the community enough for rallying behind the podcast. And as you said, considering what's going on in the world, it feels so rewarding to be able to put out something out there in, in a lot of

Daphna Yasova Barbeau, MD (she/her) (01:02.288)

Yeah.

Daphna Yasova Barbeau, MD (she/her) (01:15.137)

Yeah, I mean...

Ben Courchia MD (01:16.318)

And a lot of negativity, something quite positive that is meant to help people that is committed to values that I think are very noble about accessibility, about excellence, about care. So, so yeah.

Daphna Yasova Barbeau, MD (she/her) (01:31.795)

Yeah, no, I mean, I think this is I hope everybody has found something this year that kind of buoys them. And this, I mean, the podcast really does for us to be able to engage with our community and talk about all the amazing stuff people are doing. And just hear people's stories and what everybody's going through. And it's been a real source of inspiration for me this year, for sure.

Ben Courchia MD (01:37.678)

Mm-hmm for us. Yeah for sure

Ben Courchia MD (02:00.938)

Yeah. I mean, from a performance standpoint, we could not be happier with what the podcast is doing. It's kind of intimidating almost that this endeavor is becoming so big. But this is cool. And we have a lot of announcements coming for you at the end of this episode about what to look out for in 2024. So stay tuned. We have a sort of a short journal club trying to just wrap up the year. And...

Daphna Yasova Barbeau, MD (she/her) (02:07.623)

Hmm.

Daphna Yasova Barbeau, MD (she/her) (02:12.37)

Yeah.

Ben Courchia MD (02:27.646)

And just so you guys know, many of you are aware of the Neonatology Review podcast that we do with the collaboration with Dr. Cammy Martin and Dr. Derabrodsky. This is fairly disseminated at this point, really easy to access on our website. And there's a subscription there. It's kind of a different format because it is proprietary content. But

As we've said on Mende Show many times, if you have any issues paying for that subscription, email us. We'll gift it to you. This is not a money-making endeavor by no means. And actually, some people have taken us up on this. So I just want to say that we're not just blowing smoke up people's butts. If you text me and you say, hey, I cannot pay for this subscription, believe me, within the day, you'll get an email with that subscription. So

Daphna Yasova Barbeau, MD (she/her) (03:10.361)

Mm-hmm.

Daphna Yasova Barbeau, MD (she/her) (03:13.735)

But just not saying stuff.

Ben Courchia MD (03:26.25)

We're very happy about that. And if you are looking for board review content as well, we still have this partnership with StatPearls. It's not really a partnership. It is sort of a referral code. We don't use any of the content from StatPearls. We're not really allowed to use their content. I think they were originally giving us permission to use their free questions, but we never really did. However,

Daphna Yasova Barbeau, MD (she/her) (03:38.451)

Mm-hmm.

Daphna Yasova Barbeau, MD (she/her) (03:43.347)

Mm-hmm.

Ben Courchia MD (03:55.498)

we do have a coupon code. So like if you want to use their questions for the board review, which by the way, I don't know if they're good. I didn't use them when I was reviewing. So I cannot comment on how valuable, good, accurate, I don't know any of this. I just know that it is a resource that's out there. And I know that.

Daphna Yasova Barbeau, MD (she/her) (04:05.226)

Me either.

Daphna Yasova Barbeau, MD (she/her) (04:15.375)

Yeah, what I can tell from the questions is that they're potentially good for like the quick fire review facts type things. But I also did not use them. But we can tell that the community is still looking for more questions to use to study for the test. So this could be an opportunity if people are interested.

Ben Courchia MD (04:24.506)

Mm-hmm. Yeah.

Ben Courchia MD (04:35.534)

I have to say that one of our issues in neonatology is that we don't have enough questions. There's not enough questions. When you think about USMLE world where we had thousands of questions, 2,000 question bank, that was something. You go to take the boards and you have the Bratty and Martin review book, which has hundreds of questions. But then you have the neo prep questions, which have maybe like what, eight a month. So like what?

Daphna Yasova Barbeau, MD (she/her) (04:39.537)

Yeah.

Ben Courchia MD (05:03.342)

20 at best every, like maybe 100 questions a year. And that sometimes you're like, man, I want more questions. So that's a resource. I think they're fairly well established. I mean, you access that pros on PubMed and so on. So yeah, I mean, I think that's good. So go and if you want, you can get 20% off their subscription and you use the coupon code, what is it Daphna? Podcaster20. Yeah, podcaster, P-O-D-C-A-S.

Daphna Yasova Barbeau, MD (she/her) (05:04.145)

Yeah.

Daphna Yasova Barbeau, MD (she/her) (05:11.673)

Yeah.

Daphna Yasova Barbeau, MD (she/her) (05:28.947)

Exactly.

Ben Courchia MD (05:32.93)

T-E-R and then 2-0-20. So yeah, I mean, whatever we can do to help the community, whatever, yeah. So yeah, these are the announcements. Anything else? We'll go over the 2024 stuff at the end of the episode because I don't wanna...

Daphna Yasova Barbeau, MD (she/her) (05:46.525)

Um.

Daphna Yasova Barbeau, MD (she/her) (05:49.907)

Yeah, I think the only other announcement is that if you're on Neo Twitter, that the EB Neo article that your campaign is ongoing through the 29th, so that means there's still some voting to be done. And if you've submitted a bracket or you have one in mind and you want your article to come out on top, then you got to vote on Neo Twitter. Neo X? We still can't figure it out. That's right.

Ben Courchia MD (06:10.314)

Yeah, the EBneo team has made this very simple. Yeah, ex formerly known as Twitter, I guess that's how I usually do it. I mean, Twitter was kind of a nice name. I don't know why X sounds like it's just such a anyways, regardless, the EBneo team has made it very convenient to vote. So it's like one click so you can go and keep voting. And then if you want to post a bracket, then like take a piece of paper, take a picture and then post it. That's, that's the Daphne way. I like that way. It's, it's low friction, low tech.

Daphna Yasova Barbeau, MD (she/her) (06:19.871)

Yeah.

Daphna Yasova Barbeau, MD (she/her) (06:23.271)

Anyways.

Daphna Yasova Barbeau, MD (she/her) (06:37.797)

That's right. We did receive many brackets this way. That's right.

Ben Courchia MD (06:40.448)

I like that.

Mm-hmm. Yeah, yeah. I was thinking originally, like, how can I make a customizable file? And Tafna was like, just put a piece of paper and take a picture. I was like, she's right. That's easier. That's easier. But anyway, should we? Should we? Yeah. That's a reference to something. If people listen to sports radio, they will know where that's a reference to. Anyway, let's begin, I guess. What do you think?

Daphna Yasova Barbeau, MD (she/her) (06:57.176)

Anywell, that's a new one.

Ben Courchia MD (07:12.446)

All right, I guess I'm beginning Journal Club today. There was one paper that I really wanted to review before the end of the year. It was a fun paper for me. I'm picking end of year papers are for me, like just like the fun ones to read. Right. This one was fun to read. I was actually not super familiar with this concept, so it was a, it was a riveting read for me. It was published in JAMA Peeds. First author is Madeline Murphy and Abdul Razak.

posted it, posted the little summary on Twitter. It's called prophylactic oropharyngeal surfactant for preterm newborns at birth, a randomized clinical trial. The background of the, so what are we talking about? The background of the paper talks about all the ways that we can give surfactant. So it talks about INSURE and what are the benefits of giving surfactant through this intubation, surfactant extubation process. Then it talks about LISA, this sort of less invasive surfactant administration, where you give it through a thin catheter,

when you insert that catheter into the trachea while the baby is on CPAP. And it talks about all the things that have been demonstrated when it comes to the beneficial effects of giving surfactant this way as well. However, it does mention something that we were discussing with some of the EB-Neo group when we reviewed the OPTIMIST trial, which will air in the coming weeks, where Lisa...

is certainly maybe less invasive, but it's not like that much less invasive. Technically, you're still using a laryngoscope, you're still doing laryngoscopy, and you are still passing a catheter through the vocal cord. Granted, a much smaller one, but I mean, right? It's sort of like you're just using a very undersized tube. So how much less invasive is this? Um, they also talk about even less invasive ways of giving surfactant, like nebulized surfactant.

But it also shows how really the data hasn't really panned out for the use of nebulized surfactant in addition to CPAP. So their idea is to talk about the process of giving surfactant into the pharynx in a very non-invasive manner. Which, practically speaking, what does that mean? Well,

Ben Courchia MD (09:26.166)

you would put a catheter in the baby's throat. You would not even try to look. You would just try to pass it where you're in the pharynx and then just instill surfactant in there. Yes, some of it will make it to the stomach, but some of it may make it to the lungs, and maybe that's sufficient. And that is truly not invasive. So they are quoting in the background some studies that were done on preterm rabbits that received pharyngeal surfactant and that were allowed a

And it showed a higher lung thorax compliance compared with those just who were just ventilated. And they showed how much, right? The question is like, well, how much of it is going to get to the lungs? Well, in these rabbit studies, they found that about half of the surfactant reached the lungs, which I trust, but I don't know if I believe.

Daphna Yasova Barbeau, MD (she/her) (10:17.347)

Yeah, how does one measure that?

Ben Courchia MD (10:17.61)

It sounds, I mean, I'm sure that when you're doing, I mean, fortunately, unfortunately for the animals, like when you're doing animal study, I'm sure there's a way for you to, to invasively look at that. But that sounds, I'm like, no way, but I'm sure I'm reporting the data accurately, but it sounds like man.

Daphna Yasova Barbeau, MD (she/her) (10:24.859)

That's true.

Daphna Yasova Barbeau, MD (she/her) (10:32.847)

Well, and if you only get half, could you give twice as much? I don't know.

Ben Courchia MD (10:38.562)

Mm-hmm. They're not gonna answer that question in this paper, unfortunately. Then they mentioned one more thing in the background, one randomized clinical trial that compared artificial surfactant with saline for preterm newborns who received their first dose via the oral fangs with subsequent doses given via an ET tube. And they showed that in this study, it significantly reduced mortality, the need for respiratory support, but the outcomes of the newborns who received only pharyngeal surfactant were not really reported. So I don't know, there's not much data.

Daphna Yasova Barbeau, MD (she/her) (10:42.191)

Mm-hmm.

Ben Courchia MD (11:07.574)

The point here is, what about if we give surfactant to newborns in their oropharynx at birth, in addition to CPAP compared to kids who just get straight CPAP? Would you reduce the rate of intubation in the first 120 hours of life? So, let's talk more about what that question looks like. This is the POPART trial, love that name. Prophylactic oropharyngeal surfactant for preterm infants, a randomized trial. It's investigator-led, unblinded.

kind of obviously parallel group randomized clinical trial in nine university hospitals in six European countries. They looked at infants that were born before 29 weeks of gestation. If they had major congenital anomalies, they were excluded. They were randomized one-to-one and either you receive the oropharyngeal surfactant or just CPAP. The intervention itself, because I think this is, to me, that was a novel concept. They used poractant alpha.

And the dose that they used was 100 milligram as recommended, because the dose can be 100 milligram per kilo to 200 milligram per kilo. And that's if you're receiving prophylaxis. If you are having established RDS, then you should use 200 milligrams per kilo. So in this case, because it was given right at the time of birth, that was considered prophylactic. So they were not weighed prior. Like they gave this surfactant immediately after the baby was born.

And so they basically used an empiric measurement to give an empiric dose for these babies. So if you were born and you were less than 26 weeks, you got like 120 milligrams. If you were 26 to 28 weeks, you got 240 milligrams because the surfactant was given to the baby between 30 seconds to 60 seconds of life, ideally before the cord was clamped, before the baby was placed on CPAP. So when I say like,

immediately after birth. That's really immediately after birth. They used a flexible thin catheter, five centimeter long, that was attached to a syringe and then the surfactant was instilled into the oropharynx as soon as possible after delivery. And the babies who were randomly assigned to the control group did not have anything instilled in their oropharynx, they were just stabilized on CPAP. And if a newborn was determined to need an endotracheal tube surfactant following

Ben Courchia MD (13:33.942)

How did they give it, whether they did insure or not? That was at the discretion of the team. The primary outcome was, will these kids need endotracheal intubation for some form of respiratory failure within the first 120 hours of life? So that's like what, four days? About four days, right? My math is okay. Which I think is interesting, right? I think that's interesting.

they reached, how do they reach this primary outcome is that if they were intubated with an endotracheal tube for mechanical ventilation, intubated with an endotracheal tube for surfactant administration and mechanical ventilation, or intubated with an ET tube for surfactant administration and extubated to CPAP, like in an inshore form. Or if they had laryngoscope-guided thin catheter surfactant administration, which means if you get Lisa, you meet the primary outcome, okay?

Secondary outcomes, I'm not going to go through the list. It's insane. It's like a long, long list of things. They have a power calculation, which I wrote down, but for the interest of time, I'm going to skip right now. The results of the study are the following. They had 251 newborns with an mean gestational age of 26 weeks. So again, some pretty small babies. 126 were assigned to the oropharyngeal surfactant group, 125 to the control one.

60% of participants were enrolled outside regular daytime working hours. I love that little tidbit, because I'm like, this is quite difficult, but the consents were done prenatally. So it's very likely that they probably consented the parents during the daytime, and maybe the babies were born later in the evening. The characteristics of the two groups to control the intervention were similar. The babies who were assigned to the oropharyngeal group had a mean birth weight of 858 grams.

compared to 829 grams in the control. 10 newborns in the study were weighing less than 500 grams, three less than 400. So they were not shy about including even some of these very small babies. Let's get into some of the results. The proportion of newborns intubated within the first 120 hours of life was not different between the two groups. 64% in the oropharyngeal surfactant group versus 65% in...

Ben Courchia MD (15:56.534)

the control group. The rate of the primary outcome was, so the need for intubation, was higher in the younger gestational age stratum. Kind of not surprising. 85% versus, 85.4% versus 79.5%. And what do we mean in the younger gestational age stratum? They looked at it from, if you were less than 26 weeks,

or if you were 26 to 28 and six weeks. So that's sort of the categorization that they used for these gestational age babies. Among the 80 newborns randomized to the oropharyngeal surfactant and who were intubated, the plan at the time of the first intubation was to intubate and continued ventilation for 78.8% of the babies. It was to give insurance 15% of cases, and it was to give Lisa in 2.5%. So I think.

that was interesting that for a lot of the babies that were receiving this oropharyngeal surfactant, it was not for repeat dosing. It was for continued ventilation and many, many of them. For those who were in the control group, that's 80 babies who were then randomized to control to just CPAP, who then needed to be intubated. And the plan at the time of the intubation was 82%

for 82.7% of them was to continued ventilation, 7% for Insure, 7% for Lisa. So kind of a similar story there. Let's look at some of the secondary outcomes because I think those were interested. The oropharyngeal surfactant group had more pneumothorax. The other secondary outcomes were relatively similar.

But I thought that was an interesting difference. That was statistically significant. More newborns randomized to the oropharyngeal surfactant were diagnosed with a pneumothorax and were treated with needle aspiration or chest strain insertion. 17% versus 6%. All newborns diagnosed, so maybe, so what? So, okay, maybe at baseline, these kids were similar, but maybe there were other factors that put them at risk for a pneumothorax. But not really. All newborns diagnosed with a pneumothorax were exposed to antenatal steroids. The incidence and duration of preterm

Ben Courchia MD (18:15.446)

premature rupture of membranes were similar in the newborns diagnosed with pneumothorax in both groups. Among the newborns diagnosed with the pneumothorax, the mean gestational age and the proportion of newborns who received positive pressure ventilation and were intubated in the delivery room were similar between the groups. So that's kind of concerning. The conclusion of the article are that the administration of surfactant in this new manner in the oropharynx immediately after birth in addition to CPAP

did not reduce the rates of intubation among newborns before 29 weeks and in the first 20 hours of life. And that trial suggests that this technique should not be routinely used. So it's interesting that is not the solution. So yeah, that is not the solution. So sad, but I learned something new today about this new methods because it's true. Yeah.

Daphna Yasova Barbeau, MD (she/her) (19:10.643)

I mean, I think it's interesting. I think it speaks to the fact that the surfactant's getting in there, right? Because how else do you explain, like, what was the cause for increased pneumo-authorities? Like, I think it means the surfactant is getting there. So, I don't know. In all this discussion about surfactant and surfactant administration, you know, I think there's a key component about this management about like, okay, well.

how do we respond to the hopeful change in compliance after we give surfactant? And I mean, I don't know about you, but when I give surfactant, I'm decreasing settings, like as soon as I'm giving surfactant, because I don't want a pneumothorax. And nobody talks about that in the study design about how they are managing changing compliance. So I don't know. I wonder if people felt like, wow, this isn't the same as giving surfactant the regular way and...

Ben Courchia MD (20:02.922)

Right. Yeah.

Daphna Yasova Barbeau, MD (she/her) (20:10.451)

I'm not so worried about it. I don't know. It's interesting. But I was hopeful that it would be a slam dunk. Nope. I still think there's something there. So I'm not gonna disregard it altogether.

Ben Courchia MD (20:11.98)

Mm-hmm.

Ben Courchia MD (20:20.608)

Nope.

Ben Courchia MD (20:28.383)

I don't disregard all these things. I don't really disregard. I think there's a strong quest from our field to find the best way to administer surfactant in the least invasive way, in the manner that delivers it in the best possible fashion to the distal alveoli. And I do think that we're sort of fumbling around with some very mechanical things where it's like, well, if I put smaller tube or tube a bit higher, like it's very mechanistically, it's very crude.

Daphna Yasova Barbeau, MD (she/her) (20:35.407)

Yeah, right.

most effective way here.

Ben Courchia MD (20:55.734)

but I am sure that there's gonna be some, it has to come from engineers, in my opinion. Some engineer is gonna find that the molecule can be aerosolized or some other way, and they're like, and you just do this, and it just goes. And it's like, and we won't think about it anymore. I don't know, I don't know if as neonatologists, we do have the technical know-how to, like it seems sounds like an engineer's problem. How do you get this little molecule from point A to point B?

Daphna Yasova Barbeau, MD (she/her) (21:03.153)

Mm-hmm.

Daphna Yasova Barbeau, MD (she/her) (21:18.163)

Mm-hmm. I mean...

Ben Courchia MD (21:23.086)

taking into consideration the constraints of the airway, of this and that, of physiology. And I think maybe a physician will figure this out. I'm not saying we can't, but it sounds like a very mechanical engineering problem.

Daphna Yasova Barbeau, MD (she/her) (21:37.907)

I think it speaks to the fact that we'd probably get things done faster if we really had this cross-discipline communication, right? Because they don't know we are having this problem. We may not have the technical sense in that arena to solve the problem. I'm sure somebody in our community does. I'm looking forward to meeting them. But just saying. I think the more we talk to people not in neonatology, not in medicine.

get we get more done that you know that's my soapbox.

Ben Courchia MD (22:11.158)

That's fine. And that's also a good reminder that the tickets for the Delphi conference are available for purchase where we do bring people from a variety of backgrounds to have these kinds of discussions. So that's it. So bucks. Acknowledged.

Daphna Yasova Barbeau, MD (she/her) (22:16.306)

That's right.

Daphna Yasova Barbeau, MD (she/her) (22:21.043)

That's right. Okay. I acknowledge. Okay, do you have more you wanna talk about?

Ben Courchia MD (22:28.642)

Do you want me to do one more? I can do one more.

Daphna Yasova Barbeau, MD (she/her) (22:30.843)

Uh, sure. I had three things I wanted to talk about. So you can do yours.

Ben Courchia MD (22:35.934)

OK, I have a paper that was published in the let me let me pull it up. I it's published in the American Journal of Physiology, Lung Cellular and Molecular Physiology, so not our typical. But again, it's the end of the year. So I'm taking some liberties with the papers. It is a paper called Changes in Respiratory Mechanics and Respond to Crystalloid Infusions in Extremely Preterm Infants.

The first author is Arvind Sehgal. It's a paper that talks about RDS, how basically the primary underlying pathogenesis is inadequate pulmonary surfactant manifesting as diffuse alveolar atelectasis, pulmonary edema, and cell injury. If you want to learn more about RDS, go back to last week's series of episode on managing respiratory distress, where we hosted a group of experts to talk about managing RDS.

And the recovery from RDS is characterized by spontaneous diuresis, right? So, and which is not surprising considering that we have noted that baby who are getting some fluid restriction do better when it comes to RDS. However, they mentioned how the use of normal saline boluses in preterm infants may slow down then the spontaneous recovery and affect lung compliance. They talk about

volume kinetics and how giving normal saline bolus in preterm neonates really is something that should not be taken lightly. We'll get into that in a second. But the hypothesis is that giving a normal saline bolus in these infants may adversely affect respiratory physiology. The objective of the study is to evaluate the evolution of pulmonary compliance when normal saline boluses are given to babies who are on the ventilator.

This is an observational study. It's going to be a very small study. I'm just warning you ahead of time. And they're including babies who are 28 weeks of gestation or less, who are given a normal saline bolus, 10 ml per kilo over an hour for reasons determined by the clinical team. So they don't care why you give it. Just let's see what happens. The infants had to be less than a week of age and ventilated on basically volume controlled ventilation. What they ended up doing is that.

Ben Courchia MD (25:00.61)

They explained their setup in terms of the vent, but they downloaded all the pulmonary mechanics data from the vent over a period of 30 minutes before the infusion, 60 minutes during the infusion, followed by 30 minutes post-infusion for a total of two hours. Self-ventilating infants, those on other modes of ventilation, those who were older than a week old, all these kids excluded. So they were able to, this is preliminary data that they're reporting, and they're reporting this data on 16 extremely preterm infants.

from this cohort, the gestational age at birth was 25.2 weeks, 620 grams. So, I am, I mean, again, don't discard small studies. None of the infants had an obvious cause of hypovolemia, such as fetal maternal hemorrhage, twin to twin transfusion, pulmonary hemorrhage. So like there was nothing really overt that could explain a state of hypovolemia. None of the infants were on inotropes.

Daphna Yasova Barbeau, MD (she/her) (25:44.388)

Mm-hmm.

Ben Courchia MD (26:00.138)

before or during the two-hour period that they looked at. So that's an important point as well. What was the reason then for giving a normal saline bolus? The most common documented reason for a saline bolus was hypotension. And how did people say that they evaluated hypotension? Just having a mean blood pressure that was below the gestational age. Again, I know some people are listening to me right now and they're like, oh my God, this is...

BS, right? Like you shouldn't give the bolus, you should not assess. I know, but the fact of the matter is, and we will go over the discussion, many, many people still practice this way. So it's important for us to, and there's not a lot of data either. So let's look at this, because I think it's very interesting. The net volume of normal saline infusion was 10 ml per kilo and was on average about 6.4 ml. There were no significant improvement in the mean blood pressure on reassessment.

And that was statistically significant. The set volume, the set volume, the long volume, the volume guaranteed volume in the cohort was a median of five ml per kilo. What they noticed is a significant reduction in the compliance that was noted from pre-infusion to post-infusion. And to be able to deliver the set title volume.

via volume guarantee, the volume generated higher peak inspiratory pressures. Alongside a trend in increased oxygen requirement, an increase in respiratory severity score was noted. So they have a lot of graphs that depict the trend. They have a very good central figure that talks about the findings that they observed. And

And the discussion is fascinating. The discussion is probably the one that takes the bulk of the paper. And again, I know I don't usually review the discussion, but I think it's just a theoretical conversation that we should have where they talk about the fact that even though there's no consensus has to best treat hypotension in preterm inference, the use of saline boluses remains the initial intervention for many clinicians. Their study demonstrates adverse effects on the preterm lung mechanics in association with saline boluses.

Ben Courchia MD (28:16.058)

related to the redistribution into the extravascular space. They talk about the fact that most clinicians still use amine blood pressure below the gestational age to define and to treat hypotension in preterm infants. Normal saline being the most commonly used crystalloid to address this. They talk about surveys because I think that we may think that some neonatologists who are under rocks are the only ones who are doing this, but...

I feel like this is something that is quite prevalent. They mentioned a Canadian survey of 95 neonatologists who reported that clinicians routinely treated suspected hemodynamic compromise in premature infants with a fluid bolus most commonly using 0.9% sodium chloride. An international observational study in preterm infants who received fluid boluses for the management of hemodynamic compromise noted the most common fluid use was again normal saline at a most common dose of 10 ml per kilo.

Daphna Yasova Barbeau, MD (she/her) (28:45.295)

Mm-hmm.

Ben Courchia MD (29:11.586)

The most common indication was hypotension followed by poor perfusion and metabolic acidosis. Minimal or no clinical improvement was reported by clinicians in 40% of cases. These data echo the findings in our study of indications, choice, and the amount of fluid and the lack of response to numerical hypotensions. The investigators have previously noted that infants who receive more than 30

of volume expansion in the first 48 hours of life are more likely to die versus those who receive less fluid volume. They mentioned a few of the Cochrane reviews that have been published on this topic. And then they go into some of the physiology of this and they talk about how experimental studies in piglets indicate the lack of efficacy of crystalloid towards volume expansion. And I think that some of the data that they are...

presenting is fascinating to me from a physiologic standpoint. And that they're saying how Ebola is ineffective, because there's rapid leakage of saline out of the systemic vasculature. And that normal saline rapidly distributes as the membrane between the vascular and the interstitial space is permeable to most electrolytes. They talk about a study in adults that noted that one liter of crystalloid resulted in an increase in plasma volume of only 194 mLs.

They're talking about the distribution within the extracellular fluid, and they're talking about how the loss of the bolus can happen within about like 30 minutes. And they're talking about how the use of normal saline could contribute to iatrogenic fluid overload. And they're talking about how this is even more pronounced than the fact that our preterm

So they're saying that in contrast to an adult heart that has 60% of the myocardium as muscle, extremely preterm infants contractile tissue only accounts for about 30% with over-representation of relatively disorganized mitochondria. So the ability of the myocardium to respond to additional stress may be severely compromised. I'm not gonna read you the whole thing. Obviously you see, I was quite happy about this discussion.

Ben Courchia MD (31:34.302)

They're talking about time constant and then talk about like what is the way to move forward. And obviously they are not completely clueless to what the path forward looks like. Hemodynamic management of preterm infants required appreciation of the aforementioned physiology, point of care echocardiography could enhance the diagnostic accuracy and select physiologically appropriate medications. And what they're saying is that reliable indicators of assessment of volume status in these cohorts are lacking.

and the use of subjective estimation of volume status, eyeballing to the site administration of saline boluses is not evidence-based. The conclusions of the paper are that this preliminary data is showing adverse influence on pulmonary mechanics in preterm infants and is cause for scientific pause before liberal slash routine use of saline boluses in the absence of hypovolemia. Similar evaluations in populations shows as babies with perinatal asphyxia, septic shock,

may give further physiologic information and a better understanding of the alteration in neonatal respiratory physiology in response to common interventions may allow physiology based approach in decision making. I think this is very interesting. I think they are not completely clueless about the fact that some babies do need volume expansion. How we deliver this volume expansion is something that we can discuss, but how do we determine the need for volume expansion is what is the key. And this idea that I've used in the past, what do you say?

The baby is 25 weeks. The mean blood pressure is 23. So then the baby is technically hypotensive. So I have to address this. This is, this is not the way to go. And there's so much adult data about the use of boluses and how that affects the myocardium. So I thought this was a very interesting paper. It's 16 babies. Uh, and to me, it's not saying anything dramatic that will, uh, alter my practice

I try to avoid normal saline boluses already, but I just love when a paper does this so eloquently. And yeah, so I like that little study.

Daphna Yasova Barbeau, MD (she/her) (33:41.103)

Yeah, no, I mean, I think it's a really good review of what we already know and what the concerns are. And I think it's just a good reminder that like, unfortunately, we all went to medical school that was really adult focused, right? And even child, the care of children, older children is so different than the care of the neonate. And so it's like ingrained to us, like, I think this is hypotension, whatever you decide is hypotension.

I have to, I must treat with fluid. Like that must be the most common reason or cause. But I think it just underscores this, like really this need for hemodynamic evaluation and saying like, is this enough for this baby? And if it's not enough, what is the reason for babies? It's not always hypovolemia. So I loved it. Yeah.

Ben Courchia MD (34:33.378)

Yeah, it underscores our poor understanding of babies' blood pressure assessment. It underscores our sometimes ignorance and maybe amnesia of the critical aspects of a newborn physiology, especially when you talk about the myocardium. So it's a great reminder of, and even the adult literature is rethinking boluses. Like, I mean, you want to piss off my wife, tell her about just giving blind boluses to people.

Daphna Yasova Barbeau, MD (she/her) (34:56.486)

Yeah.

Daphna Yasova Barbeau, MD (she/her) (35:00.624)

Give a bolus.

Ben Courchia MD (35:02.17)

Oh my God, she will fly off the handle. But yeah, I mean, they know that as well. So.

Daphna Yasova Barbeau, MD (she/her) (35:07.503)

What I also really like about this discussion is, okay, when I was a trainee, when I was a fellow, I was like, what could I possibly study? Like, what is left to study? But like, the truth is that like, there's a lot of stuff that we do not know. It's funny to study, so.

Ben Courchia MD (35:21.37)

Yeah, and there's so many things we do actually do that still is not evidence-based. Look at these authors. They basically took a practice that's still used and they just said, hey, we're just gonna download the data from the vent and we're gonna look at what happens. I mean, this is very simple. And look, they have preliminary data that's probably gonna lead them to a bigger study. That's awesome.

Daphna Yasova Barbeau, MD (she/her) (35:31.999)

Mm.

Daphna Yasova Barbeau, MD (she/her) (35:35.652)

Mm-hmm.

Daphna Yasova Barbeau, MD (she/her) (35:39.119)

A bigger study. Yeah. Very cool. Okay. Well, I had a few things and we have things to get through. So I'm going to try to move through these quickly, more quickly than I usually do. Mine I've had in my folder for some time. It's the neurodevelopmental outcomes of preterm neonates receiving rescue inhaled nitric oxide in the first week of age. A cohort study. Lead author, Sujith Venkata.

This is coming from the Canadian Neonatal Network and the Canadian Neonatal Follow-Up Network. It was published in the Archives of Disease, fetal neonatal edition, and obviously it's coming to us from Canada. So basically their question was, in preterm neonates less than 29 weeks who receive rescue, so pretty sick.

group of babies, nitric oxide for hypoxic respiratory failure. Is there a difference in the neurodevelopmental impairment at 18 to 24 months corrected age when compared with propensity matched controls? So this is a multi-center retrospective cohort study, including the neonates born less than 29 weeks admitted to Canadian NICUs participating in the study. This was between January, 2010 and December, 2018. And

of course, as part of the inclusion criteria, the children had to have a neurodevelopmental assessment at 18 to 24 months at one of the neonatal follow-up clinics affiliated with the follow-up network. Neonates were excluded if they received palliative care, were quote unquote moribund at birth, received nitric after the first week of age, and those who had major congenital anomalies. Infants were evaluated for neurodevelopment between 18 and 24 months.

and the diagnosis and severity of cerebral palsy were classified based on the gross motor function classification system. And the third edition of the Bayley was used to evaluate cognitive motor and language development. So the primary outcome they were looking at was really what was a neurodevelopmental impairment at 18 to 24 months corrected age defined as a presence of any of the following.

Daphna Yasova Barbeau, MD (she/her) (37:54.315)

or higher, a Bayley-3 composite score of less than 85 on any of the individual components. The secondary outcomes included death, significant neurodevelopmental impairment, and significant individual components of the primary outcome. And they define severe neurodevelopmental impairment as the presence of any one or the more of the following. Oh gosh. CP with a GMF CS3, 4, or 5.

A Bayley 3 composite score less than 70 on any of the components. Hearing impairment requiring hearing aids or cochlear implant and bilateral visual impairment. They had 6,324 neonates born at less than 29 weeks admitted to participating sites. 712 neonates were excluded of the 5,612 eligible neonates. 8.2% 460 received rescue nitric oxide during the first week of age.

Ben Courchia MD (38:53.154)

That's interesting, right? So basically 8% of their less than 29-weekers received nitric in the first week of life. That's not, I mean, I don't know. I would have guessed less if I had to think of how many babies do get nitric in the first week of life. I don't know what you think about that. I was kind of shocked by that.

Daphna Yasova Barbeau, MD (she/her) (38:54.351)

Yeah.

Daphna Yasova Barbeau, MD (she/her) (39:10.651)

Well, I think that's because, truthfully, most of the babies we see in the NICU are not less than 29 weeks, right? So we have to remember that still the NICU population is made mostly of late preterms and even term infants. So I think proportionally for all the babies we see, we don't give a lot of nitric. And truthfully, I mean, the data for nitric in the ELBW population is not very good, right? So I think the community has moved away from using nitric.

Ben Courchia MD (39:19.976)

True.

Daphna Yasova Barbeau, MD (she/her) (39:39.687)

but there's still some of these sick babies where we say like, what do I have in my arsenal to offer to this baby? Okay. So 8%, like you said, received rescue nitric during the first week. A total of the group, 723, 13% of neonetes died. Of the 460 infants in the nitric group,

Ben Courchia MD (39:49.752)

Mm-hmm.

Daphna Yasova Barbeau, MD (she/her) (40:08.679)

43.6% died. 187 neonates died during the hospital stay. 14 died after discharge, but before the follow-up assessment. A total of 522, 10% of neonates in the no-nitric group died. Of course, remember this was not a randomized study. So just keep that in mind.

Ben Courchia MD (40:11.466)

Oof.

Daphna Yasova Barbeau, MD (she/her) (40:34.907)

500 died during the NICU stay, 22 died after discharge, but before follow-up. About 70% of mortality occurred during the first two weeks of birth. Of the 4,889 survivors, 77% had follow-up assessments at 18 to 24 months. Among these in follow-up, 213 were in the nitric group, 3,541 were in the no nitric group. This is important to note compared with the no nitric group

Neonates in the nitric group had lower birth weights, had lower gestational aids, had less antenatal steroid coverage. They had higher illness severity scores, they used a SNAP2, and more rates of prolonged premature rupture of membrane, and more likely to be small for gestational age. This was definitely a much sicker cohort, the babies who got rescue nitric, than the babies who didn't.

even though they did this kind of propensity score matching. Even after the propensity score match analysis, neonates who received nitric had higher odds of severe brain injury, BPD, and mortality during the NICU stay. In addition, the overall mortality was significantly higher in the nitric group, an adjusted odds ratio of 2.11. Infants...

The good thing about the follow-up is that the infants that were lost to follow-up had higher gestational age and birth weight. They were less severely ill on day one. And compared with the nitrate group, infants who were lost to follow-up from the no nitrate group also had higher gestational age, birth weight, and lower SNAP2 scores. So the overall punchline here is that after propensity score matching, neonates who received

of neurodevelopmental impairment. This was an adjusted odds ratio of 1.34 or severe neurodevelopmental impairment, an adjusted odds ratio of one. I did want to note though that in the individual components CP, there was an adjusted odds ratio of 1.56, visual impairment and adjusted odds ratio of 1.62, hearing impairment was 0.81.

Daphna Yasova Barbeau, MD (she/her) (42:54.279)

The Bayley 3 cognitive score less than 85 and adjusted odds ratio of 1.35. Bayley 3 motor score less than 85 and adjusted odds ratio of 2.16. And the Bayley 3 language score adjusted odds ratio of 1.17. So I think this is interesting. Obviously, the mortality was higher in that group and they were a much sicker group of babies. But it's interesting that the developmental outcomes...

were not so different even though they were a much sicker, smaller group. Thoughts?

Ben Courchia MD (43:31.414)

I mean, yeah, lots of thoughts on this study. I mean, I think this is interesting to, I think it's interesting to report this data. Any data is worth looking at, but practically speaking, it's very difficult to do retrospective stuff when babies are so sick, because how much can you truly correct for everything? Also, I mean, the mortality rates alone are so different.

Daphna Yasova Barbeau, MD (she/her) (43:47.719)

Mm-hmm.

Daphna Yasova Barbeau, MD (she/her) (43:52.092)

Right.

Daphna Yasova Barbeau, MD (she/her) (43:59.955)

Hehehe

Ben Courchia MD (44:00.834)

that it's very tough. And at the end of the day, I am not exactly sure if this changes anything from the management standpoint. Because if the babies are so sick, and by the time you reach the point of starting a nitric oxide on a small baby like this in the first week of life,

Daphna Yasova Barbeau, MD (she/her) (44:13.607)

Mm-hmm. Great.

Daphna Yasova Barbeau, MD (she/her) (44:21.371)

That's right.

Yeah, you think that baby is not going to make it, I think, when you start nitro.

Ben Courchia MD (44:29.346)

Yeah. And it's not like you have a million other interventions in your back pocket. Like, usually, this is like kind of a Hail Mary situation where you say, hey, let's just give this a try. So, yeah, I mean, it's tough. But I guess you could look at the study from the standpoint of the way it could have presented itself. Like, what if the kids in the nitric group had dramatically worse? And you can say...

Daphna Yasova Barbeau, MD (she/her) (44:55.483)

worse. Yeah.

Ben Courchia MD (44:56.706)

But then even then, could you have said, oh, it's because of the nitric? I don't know. So I think I like that we reviewed this paper because I saw the title and I was like, oh, interesting. But then the retrospective nature, I think, limits the authors quite a lot, unfortunately. It is what it is, but it's good data. And it's good data also, again, I like when these networks come up with these numbers. Because if you're not going to take

Daphna Yasova Barbeau, MD (she/her) (45:00.985)

I don't know. Right.

Daphna Yasova Barbeau, MD (she/her) (45:07.472)

Yeah, very interesting. Yeah.

Ben Courchia MD (45:23.862)

the propensity score matching and the adjusted odds ratio, fine, but then 44% of these babies died once they start on nitric. I think that's interesting. That's interesting that when you compare these infants from not nitric to nitric, like the fact that it jumped four times, that's something that parents may be interested in.

Daphna Yasova Barbeau, MD (she/her) (45:36.312)

Mm-hmm.

Ben Courchia MD (45:51.199)

These are the sort of epidemiologic data that could be helpful when we're managing babies.

Daphna Yasova Barbeau, MD (she/her) (45:51.792)

Yeah.

useful.

Um, on the totally different, uh, end of things, I had this interesting paper in the European journal of pediatrics, uh, analysis of noise levels in the neonatal intensive care unit, the impact of clinical microsystems. And I'm not going to go through the whole study. I just think, um, as we roll into the new year, we think about the small changes, the low-hanging fruit that we can, uh, pick off in our units, um, to, to make improved developmental outcomes.

Ben Courchia MD (46:02.783)

Yeah.

Daphna Yasova Barbeau, MD (she/her) (46:27.447)

So basically what they did was they looked at their noise levels in their unit. They did a six months pre and post implementation of microsystems, in which all they did was cohort infants of similar acuity. So basically they put the babies, they had a before period where they had babies, this is babies that are sick and not sick.

high acuity and feeder growers right next to one another versus just cohorting them. So putting the sickest, most acute babies together and then putting the feeding and growing babies on some other place, which I think most units are already doing, but I think that was still useful. So

Ben Courchia MD (47:14.667)

Mm-hmm.

Daphna Yasova Barbeau, MD (she/her) (47:16.219)

They looked at the daily profiles from continuous noise level measurements and then calculated the length of exposure to predefined noise levels. So compared to baseline daytime measurements, noise levels were three to six decibels higher during physician handover. Noise levels are two to three decibels lower on weekends and three to four decibels lower at night, independent of the organizational model. So independent of how they cohorted the babies.

The introduction of these clinical microsystems slightly increased average noise levels for the high acuity pods, but produced a much more substantial decrease for the low acuity pods. And overall, this led to a reduction in unit-wide noise levels. But what is interesting though is that the baseline noise levels in both models, regardless of the cohorting, still exceeded the standard permissible limits.

But I think my takeaway from this is like, we do, you know, there's some major noise changing things you can do, like change the unit design, work on the technology, things that are very expensive, but some of these are just human factors. Like handover time is really noisy. And that's something we could probably fix without a lot of effort.

time or money and that, you know, why is it that the weekends and the nights are much less noisy and can we emulate some of those things during the highest noise hours? So those were my takeaways for that paper.

Ben Courchia MD (48:50.347)

Very cool.

Daphna Yasova Barbeau, MD (she/her) (48:51.943)

The only other thing I wanted to kind of point out is before we do our exciting predictions for 2024 is that the British Association of Perinatal Medicine put together this quality improvement toolkit for BPD. They just released it this month. I think that it is a great overview of BPD, what we know about BPD, what we do know about interventions that...

help reduce BPD. So I think it's a great learning tool for one, for people who are just wanna know more about BPD. And then certainly if you're a unit who's looking to reduce BPD, I think it is a great way to help predict some of your PDSA cycles. So I thought that was really useful. I wanted to take people's attention to it.

Ben Courchia MD (49:47.274)

Yep, some very nice graphs in that document. All right, well, as we wrap up the year, should we give people a glimpse into 2024? Yeah, you're excited. Yeah. That's awesome.

Daphna Yasova Barbeau, MD (she/her) (49:48.399)

Okay, yeah, okay.

Daphna Yasova Barbeau, MD (she/her) (50:00.919)

I think so. I think it's time. I'm very excited. I mean, first and foremost, we're going to keep doing what we're doing first, right? As we're going to keep bringing exciting new interviews. There's a lot of interviews we already have recorded for next year that are really, really good, if I could say so.

Ben Courchia MD (50:08.749)

Yeah.

Ben Courchia MD (50:17.27)

Yeah, absolutely. I think we always try to keep the content of the podcast relevant and of high quality, so that will continue. We did experimenting with miniseries, so there may be another one or two next year, just trying to delve into maybe one specific topic in a bit more depth.

So that's very exciting and Journal Club will continue to happen on a regularly scheduled basis. But the exciting thing about the Incubator for 2024 is that we are expanding to not just being a podcast anymore but being more of a podcast network. And what that means, practically speaking, is that we will be bringing you new shows on this channel.

that will touch on a variety of topics. So Daphna and I do realize that there are many aspects of neonatal care that deserve attention, that deserve to be highlighted, and that we may not be the best people to do that. And so we're very happy to give these...

subjects, these areas, more attention, and we're very fortunate to have identified and have the opportunity to collaborate with the right people to do these subjects justice. So without further ado, let's talk about some of the shows that will be coming to you on the incubator for 2024. I think the first show we're very excited about is the Global Neonatal Podcast.

This is a podcast that is going to be solely dedicated to global health, specifically, obviously, in neonatology. This will be a show that's hosted by Dr. Shelley-Ann Williams-Dakarai, and she is a neonatologist herself, and she will be interviewing physicians from around the world working in low- and middle-income countries. And...

Ben Courchia MD (52:25.45)

And this promises to be a very, very interesting show. We've done some interviews this year discussing a little bit global health. People were very interested to find out more about that. So yeah, so the Global Neonatal Podcast will be coming in 2024. It will be a monthly show. And please look out for these interviews where we talk to physicians in Africa, where we talk to physicians around the world and talk about...

What does their reality look like? What are some of the obstacles? What are the things that matter to them? So this will be very, very interesting. Another show that we're very excited to bring you for 2024 is a podcast called At the Bench. It is a neonatal physician scientist podcast, and it basically delves into the reality of being a neonatal physician scientist in today's day and age. Our amazing hosts include Dr. Misty Good, Dr. Elizabeth Crouch, Dr. David McCauley, and Dr. Gaston Hoffman. We are very excited for them to bring to you.

the latest research in basic science, and to talk to you about some of the things that your little physician scientists deal with on a day-to-day basis, grant application, grant funding, maybe career choices. And we could not be happier to have stumbled and found this amazing group of people to host this podcast. So this is another show that will be coming to the Incubator Network in 2024.

And so we're very, very excited about that. Definitely. Do you want to, I feel like I've been hogging the mic. Do you want to tell us about our third show coming in 2024?

Daphna Yasova Barbeau, MD (she/her) (55:43.923)

Sure, sure. We really, we heard the need in the community and from the families that we serve that we needed an outlet, let's say, for kind of resource for families that was at a high level, but for parents, by parents. And so we're really excited to be partnering with the team at ICU Baby.

to bring yet another show to the Incubator Network that I think not only families will learn from, but I think professionals will learn from and hear about what's really important to the families in our units, so.

Ben Courchia MD (56:28.178)

Yeah, we're very excited about this show. The title, maybe the NICU Family Podcast. I'm not exactly, we haven't really settled. We're still arguing about this, but we're not arguing. We're discussing this. But the great thing about this podcast will be that it will be hosted by parents. It will invite parents and the clinicians will be at the service of the parents to try to help with either answering questions or breaking down some medical concepts.

Daphna Yasova Barbeau, MD (she/her) (56:44.339)

Mm-hmm.

Daphna Yasova Barbeau, MD (she/her) (56:49.651)

Mm-hmm, that's right.

Ben Courchia MD (56:57.898)

I think that, like Daphne said, one of the feedbacks that we received, obviously, about the incubator podcast is that it is, you kind of have to know a lot about neonatology to be able to keep up with the episodes. So we're hoping that this can actually bring more families along. And maybe Leah and Elizabeth, our hosts, are going to talk about a subject, I don't know, like the PDA, and maybe families will know enough about the PDA after these episodes to maybe delve into more details through either...

Daphna Yasova Barbeau, MD (she/her) (57:23.057)

Mm-hmm.

Ben Courchia MD (57:25.122)

the incubator or journal clubs or the interviews, and maybe wanna listen to, I don't know, a FIFS interview about the PDA and stuff like that. So, it creates a continuum.

Daphna Yasova Barbeau, MD (she/her) (57:33.039)

Yeah, we're hoping that these can serve as an introduction to families and then they can use some of the other content to learn more about the things that are affecting their babies. So we're excited.

Ben Courchia MD (57:44.766)

Absolutely. So we're very excited about these shows. The Tech Tuesday episodes will continue to be airing. The journal clubs will continue to be airing. The interviews are going to continue to come out. We continue to be very thankful to our international colleagues who are producing the shows in Portuguese, in Spanish. The Spanish podcast has been killing it in the past few weeks. We have a brand new set of hosts with physicians from Spain, from the US, from Mexico. Go check them out if you're Spanish speaking. It's been phenomenal.

Daphna Yasova Barbeau, MD (she/her) (57:58.119)

Mm-hmm.

Ben Courchia MD (58:14.014)

The French podcast is including more and more interviews, some very prominent researchers are French speaking as well. And it's so cool to be able to interview them. And Miriam and Ilar in Iran doing amazing work in the Farsi podcast. So go give them some love if you are, if you speak multiple languages and you'd be interested in hearing the content in different languages.

Daphna Yasova Barbeau, MD (she/her) (58:21.651)

Mm-hmm.

Ben Courchia MD (58:38.622)

And it's not a direct translation, which is what's great about it. Every podcast has its own flavor and highlights the work that is done locally in these parts of the world. We're hoping more languages will be available soon. We're also working on making the podcast available for now in China so that people in China can actually access for now the current sets of podcasts and maybe one day we'll have a podcast in Mandarin.

Other things coming to you in 2024 from the incubator podcast will include the Delphi conference, which will take place from September 23rd to September 25th. An amazing lineup. The agenda will be released in January of this year and we will continue to have our dedicated TEDx event. Our partnership with the TED conference is going well. And so we are very excited that our license was happily renewed by the team.

They were very impressed with the first iteration of the TEDx conference. Everybody that attended has had only but great feedback. All the talks are available for free on the TEDx YouTube page or on our TEDxNewRiver.com website. And the board review podcast will continue throughout the boards. So stay tuned with us. We're doing a couple of questions every day, every other week to try to help you study for the boards when you are not at the desk.

looking at textbooks, I hope that this provides value to you all. And we will be doing some traveling this year as well. I think that we will be visiting our friends at Nationwide Children, we'll be visiting our friends at CHOP. And so if you are in these parts of the US, please come say hello. And yeah, and if you...

Daphna Yasova Barbeau, MD (she/her) (01:00:11.762)

Mm-hmm.

Ben Courchia MD (01:00:31.43)

and we'll be at a multitude of conferences this year, PAS obviously and others. So we'll keep you posted as to where we will be so that you can engage with the team and maybe get some swag and so on and so forth. Anything else that we forgot, Daphna?

Daphna Yasova Barbeau, MD (she/her) (01:00:48.927)

That was a lot. No, I think the only other thing we wanted to do on this end of year episode was really thank our team. You did part of that with our international colleagues. We have a very small but mighty administrative team. We wanted to thank everybody who does the behind the scenes work at the incubator. We've got a small but mighty Delphi planning committee, and they are really hard at work to give you a kind of...

Ben Courchia MD (01:00:50.156)

Yeah.

Daphna Yasova Barbeau, MD (she/her) (01:01:16.967)

dynamic transformational type conference. And we wanted to thank everybody who tunes in and listens. We couldn't do this without the whole community. We take a lot of, we take all of your recommendations seriously, people you wanna hear about on the podcast, things that you want us to talk about on the podcast. So keep sending those messages and emails. We love getting them and interfacing with the community. So thanks to everybody.

Ben Courchia MD (01:01:43.958)

Yep. Wanted to then conclude by thanking our sponsors, most notably KeyAzy, and wanted to thank also Wreck-it-Me Johnson. I think these are people that have really grasped the vision for the podcast and who are allowing us to do all this without having the pressure of financial burden so that we can continue to expand and not have to worry about, my God, how we're gonna pay for this. So.

This has not been a lucrative endeavor for us, but our ability to continually expand with the support of Kiese is just really something that is something we cannot underscore. So thank you to all the team at Kiese. Thank you to all the people that are helping us make this content possible for you. So yeah, I just wanted to give our friends a shout out.

And I think that with this, we will be concluding 2023. Woo, that's exciting.

Daphna Yasova Barbeau, MD (she/her) (01:02:47.799)

It is, it's exciting.

Ben Courchia MD (01:02:49.814)

We are coming back to you in January. Obviously, we will be taking a break for the holidays. Let me see. So this episode is airing on the 24th. And obviously, Christmas is upon us. So we will be off. And we will be off during the week of New Year. So you can expect the Incubator Network to resume on January 7th with a brand new interview.

I believe that we will be kicking off the new year with the brilliant Dr. Terry Major Kinkade. So stay tuned for that and see you then!

Daphna Yasova Barbeau, MD (she/her) (01:03:34.171)

Bye everybody.

Ben Courchia MD (01:03:35.586)

Thank you. I was waiting for that.

Daphna Yasova Barbeau, MD (she/her) (01:03:38.614)

Hahaha!

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