Recent discussions
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Dr Ashwini R C
In LMICs, the issues that need to be highlighted are
1.Therapeutic hypothermia is to be done in only level III NICU with trained neonatogist so that only eligible neonates need to be cooled(criteria to be clearly defined) and only those NICU with hemodynamic monitors, adequate nursing ratio,Neurosonogram, Echo facilities can cool. Also when cooling mandatory hemodynamic, haematological, neurological monitoring to be mentioned.
Clarification is required regarding
1.Servo controlled vs Non servo controlled cooling devices results…. Servo would ensure more consistent mattress temperatures so the results mentioned here are contradictory
2.Guidelines regarding feeding regimen while being cooled
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Viraraghavan Vadakkencherry Ramaswamy
1. The control group event rate for mortality is 8.1%.. For a control group event rate of even 10%, we require at least total events of 350 - 400 for a RRR of 25%. (Figure 2 A). Could the evidence have been downrated for imprecision. I agree that OIS criterion varies for CPGs and SRs. But most of the ILCOR SRs and CPGs use the later. May be we should have a threshold set for critical and important outcomes a priori
2. In the supplementary file of NMA, pg 302, Table 1, for comparison, ICC:long DCC, the CoE is upgraded by one level. We rarely upgrade the evidence certainty in meta-analysis of RCTs. GRADE quotes “Indeed, although it is theoretically possible to rate up results from randomized control trials (RCTs), we have yet to find a compelling example of such an instance.”
page 278 Table 2 (League Table, outcome: death): ICC vs long DCC: 0.75 (0.41-1.43). ?qualifies for large effect
3. In the node splitting analysis for inconsistency evaluation for the outcome death (page 287, Table 19), there is inconsistency in the model for the comparison short deferral vs. ICC (p=0.038). This is the most difficult part for an author of an NMA. When inconsistency creeps in, it's not only the particular comparison that is suspect but all of the NMA effect estimates in the model. There is no proven way to deal with inconsistency. But an optimal way might be to downgrade the NMA evidence certainty by one level (even this is only a suggestion by some experts).
4. For many comparisons (Table 1, pg 302), imprecision is downrated by two levels. GRADE specifies circumstances where imprecision may be downrated by two levels. IGRADE “When there are very few events and CIs around both relative and absolute estimates of effect that include both appreciable benefit and appreciable harm, systematic reviewers and guideline developers should consider rating down the quality of evidence by two levels. For example, a systematic review of the use of probiotics for induction of remission in Crohn’s disease found a single randomized trial that included 11 patients. Of the treated patients, four of five achieved remission; this was true of five of six of the control patients. The point estimate of the risk ratio (0.96) suggests no difference, but the CI includes a reduction in likelihood of remission of almost half, or an increase in the likelihood of over 50%.”
My compliments to the team for the great work done.
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Shaimaa Ibrahim
I agree on recommendations, Knowledge gaps identified on long-term development and need for further evidence generation on long term outcome for development.
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Judith Finn
Useful scoping review - highlighting the need for further research in this field. Thanks, Judith
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Ken Tegtmeyer
i agree with these recommendations based on the studies available. It may be most fruitful to look at provider fatigue, particularly in the out of hospital setting where number of providers to do cpr are likely lowest. Such as single person rescuer at home awaiting for EMS.
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Jogender Kumar
I agree with the recommendations. The recent IPD definitely helps in improving the certainty of the evidence. The group may consider guidance on how to implement it.
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Jogender Kumar
This is one of the most contentious issue in LMIC especially after HELIX trial. There are few points which need further clarifications:
- As per subgroup analysis Servo-controlled devices seems to be inferior to the non-servo controlled devices. Which does not make any sense to me. Rather one would expect the results other ways around. The reader should not take a message that non-servo-controlled methods are better and start adopting them.
- There is need to clearly define the cooling criteria . The major problem is not with technique, but is with selection of the eligible infants. It will be beneficial if the same can be added in practice points.
- Feeding during therapeutic hypothermia is another aspect which requires guidance. I am not sure whether this comes under preview of this group or not but it requires clear guidance.
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Keiji Suzuki
I basically agree the reccommendation.
However, considering the contents that A, B, C, D, and E are dealing with, they had better be re-odered A, D, B, C, and E for easier understanding.
A: no resuscitation required D: resuscitation required
B: not less than 28 weeks C: less than 28 weeks
E: some pathologic conditions
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Renata de Araujo Monteiro Yoshida
I agree
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Renata de Araujo Monteiro Yoshida
I agree. There are a lot of knowledge gaps and opportunity for research on this topic.