Title of Program: What has Cochrane Neonatal Done For ...neonatal.cochrane.org/.../files/public/uploads/slides.pdf · The Basics ∙ Follow slides on the Internet ∙ Listen on your

Title of Program: What has Cochrane Neonatal Done For Babies?

Speakers/Moderators: Roger F. Soll, MD

Planning Committee: Jeffery D. Horbar, MD, Madge E. Buus-Frank, RN, MS, APRN-BC, FAAN, Roger F. Soll, MD

Date: September 2017

Learning Objectives:

Participants will be presented with evidence from clinical trials and systematic reviews and will be able to evaluate and translate the evidence in the field of neonatology to better serve their practices. Specifically, evidence from a variety of systematic reviews in Neonatal-Perinatal Medicine will be reviewed to evaluate their impact on practice and guidelines.

DISCLOSURE:

Is there anything to disclose? No financial interests to disclose

COMMERCIAL SUPPORT ORGANIZATIONS (if applicable): No Commercial Support

This activity has been planned and implemented by The Robert Larner College of Medicine at The University of Vermont and Cochrane Neonatal is

accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation

Council for Continuing Medical Education (ACCME), to provide continuing education for the healthcare team.

The University of Vermont designates this web seminar for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should claim only the

credit commensurate with the extent of their participation in the activity.

Trusted evidence. Informed decisions. Better health.

What has Cochrane Done for Babies?

Roger F. Soll, MD

H. Wallace Professor of NeonatologyUniversity of Vermont College of Medicine

Coordinating Editor, Cochrane NeonatalPresident, Vermont Oxford Network

Cochrane Neonatal Web SeminarSeptember 29th 2017

The Basics

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Cochrane Preparing, maintaining and promoting

the accessibility of systematic reviews

of the effects of health care interventions

Cochrane Neonatal Prepares and disseminates

evidence-based reviews of the effects

of therapies in the field of neonatal medicine

Editorial Team

Jennifer SpanoInformation Specialist

Roger F. SollCoordinating Editor

Colleen OvelmanManaging Editor

Michael BrackenYale University

Jeffrey HorbarUniversity of Vermont

Bill McGuireHull York Medical School

Gautham SureshBaylor University

Editorial Team

Editorial Team

Danielle Ehret, MD, MPHUniversity of Vermont

Support

Disclosure

Roger F. Soll is the Coordinating Editor of Cochrane Neonatal previously supported

by a contract from the NICHD andPresident of Vermont Oxford Network

Why These Webinars?

To develop an understanding ofthe evidence supplied by systematic reviews in

neonatal perinatal medicine(as well as other large well conducted trials)

and discuss how this evidence might influence your practice.

COCHRANE COLLABORATION

Cochrane Collaborative Groups

• Over 50 Collaborative Review Groups

• Most address specific disease entities/health problems

• The Cochrane Neonatal Review Group; one of the rare groups that address the needs of a population

COCHRANE NEONATAL

What do we do?

- prepare and disseminate evidence-based reviews of the

effects of therapies in the field of neonatal medicine.

- reviews follow a standard method:• a well formulated question• a comprehensive search for eligible trials• critical appraisal of trial quality• quantitative synthesis of the results using meta-analysis

- reviews are regularly updated as new trials are published.

SYSTEMATIC OVERVIEW

- Applies specific research strategies to identify, appraise, and synthesize data from all relevant clinical studies

Quantitative systematic reviews include meta-analyses:

- statistical methods to combine the results of similar randomized controlled trials to produce a typical estimate of the effect size

META-ANALYSIS

What’s the use of meta-analysis?

• increase statistical power

• increase precision of estimate

• explore differences between study results

• create structure for incorporating new evidence

These Cochrane systematic reviews are published in the Cochrane Database of Systematic Reviews which is contained

in the Cochrane Library.

COCHRANE NEONATAL

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COCHRANE NEONATAL:Published Reviews

What has Cochrane Neonatal done for me lately?

Or more importantly…

What has it done for babies?

COCHRANE NEONATAL

SOMETIMES COCHRANE REVIEWS CHANGE THE WAY WE PRACTICE

AND SAVE BABIES’ LIVES!

CORTICOSTEROIDS FOR PRETERM BIRTH

Since 1972,- there are multiple randomized controlled trials (N=18)- involving a large number of infants (3735 infants)

but…

Antenatal corticosteroidswere not utilized in the vast majority of patients until…

PROPHYLACTIC CORTICOSTEROIDS PRIOR TO PRETERM BIRTH

EFFECT ON NEONATAL DEATH

Typical relative risk 0.63 (95% CI 0.51 to 0.77)

Typical Relative Risk (95% CI)

Outcome (# of trials)

TypicalRelative Risk

( 95% CI ) 0.5 1.0 2.0 4.00.2

Decreased IncreasedRisk

0.5 1.0 2.0 4.00.2

PROPHYLACTIC CORTICOSTEROIDSPRIOR TO PRETERM BIRTH

RDS (14) 0.64 (0.56, 0.72)

OVERVIEW OF 18 RANDOMIZED CONTROLLED TRIALS

Periventricular hemorrhage (4) 0.57 (0.41, 0.78)

Necrotizing enterocolitis (4) 0.60 (0.33, 1.09)

Bronchopulmonary dysplasia (3) 1.38 (0.90, 2.11)

Neonatal death (13) 0.63 (0.51, 0.77)

Crowley (1992)


Outcome (# of trials)

TypicalRelative Risk

( 95% CI ) 0.5 1.0 2.0 4.00.2


0.5 1.0 2.0 4.00.2

Stillbirth (12) 0.84 (0.59, 1.21)

OVERVIEW OF 15 RANDOMIZED CONTROLLED TRIALS

Fetal/neonatal infection (15) 0.84 (0.60, 1.17)

Maternal infection (11) 1.26 (0.99, 1.60)

Neurological abnormality (3) 0.65 (0.39, 1.08)

Crowley (1992)

PROPHYLACTIC CORTICOSTEROIDSPRIOR TO PRETERM BIRTH

CORTICOSTEROIDSFOR PRETERM BIRTH

“Antenatal corticosteroid therapy is indicated for women at risk of premature delivery with few exceptions and will result in a substantial decrease in neonatal morbidity and mortality, as well as substantial savings in health care costs”

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VERMONT OXFORD NETWORK ANNUAL REPORTS 1991-2005

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NIH Conference

We’re so proud of this, we

made it part of our logo…

www.cochrane.org

←

SOMETIMES COCHRANE REVIEWS TELL US WHAT

WE ALREADY KNOW!


TYPES OF STUDIES (N)

Typical Risk Difference

( 95% CI ) 0.5 1.0 2.0 4.00.2


0.5 1.0 2.0 4.00.2

SURFACTANT THERAPY

PROPHYLACTIC SURFACTANT

EFFECT ON PNEUMOTHORAX

SYNTHETIC SURFACTANT (6) -0.05 (-0.09, -0.02)

NATURAL SURFACTANT (8) -0.15 (-0.20, -0.11 )

RESCUE SURFACTANT


Soll 1997

NATURAL SURFACTANT (12) -0.17 (-0.21, -0.13)


TYPES OF STUDIES (N)


( 95% CI ) 0.5 1.0 2.0 4.00.2


0.5 1.0 2.0 4.00.2

SURFACTANT THERAPY

PROPHYLACTIC SURFACTANT

EFFECT ON NEONATAL MORTALITY

SYNTHETIC SURFACTANT (7) -0.07 (-0.11,-0.03)

NATURAL SURFACTANT (8) -0.07 (-0.12, -0.03 )

RESCUE SURFACTANT


Soll 1997

NATURAL SURFACTANT (12) -0.09 (-0.13, -0.05)

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EXOGENOUS SURFACTANT TREATMENT

FDA APPROVAL

INTRODUCTION OF ANTENATAL STEROIDSAND POSTNATAL SURFACTANT TREATMENT

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ANTENATAL STEROIDS SURFACTANT THERAPY MORTALTY

EFFECT ON MORTALITY IN ELBW INFANTS

SOMETIMES COCHRANE REVIEWS REFINE HOW WE

PRACTICE!

Relative Risk and 95% CI

STUDY0.5 1.0 2.0 4.00.2


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DELIVERY ROOM vs. TREATMENT SURFACTANT

Dunn 1991

EFFECT ON NEONATAL MORTALITY

Egberts 1993

Kattwinkel 1993

Walti 1995

Bevilacqua 1996

Soll and Morley 2001

TYPICAL ESTIMATE

Kendig 1991

Bevilacqua 1997

PROPHYLACTIC SURFACTANT AND STEROIDS

EFFECT ON MORTALITY DUE TO RDS

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PROPHYLACTIC SURFACTANT vs. SELECTIVE TREATMENT OF RDSNEONATAL MORTALITY

PROPHYLACTIC SURFACTANT vs. SELECTIVE TREATMENT OF RDSDEATH OR BPD

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DR PRACTICES IN VLBW INFANTS

SOMETIMES COCHRANE REVIEWS STOP US FROM

DOING THINGS THAT MIGHT INJURE OUR

BABIES!

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ABSENT PRESENT

YOON AND COWORKERS. A SYSTEMIC FETAL INFLAMMATORY RESPONSE AND THE DEVELOPMENT OF BRONCHOPULMONARY DYSPLASIA.AM J OBSTET GYNECOL 1999;181:773-9

ROLE OF INFLAMMATION

CHORIOAMNIONITIS AND BRONCHOPULMONARY DYSPLASIA

POSTNATAL STEROID THERAPY: MECHANISM OF ACTION

• stabilize cellular or lysosomal membranes• decrease inflammatory response• decrease pulmonary edema

POSTNATAL STEROID THERAPY: POTENTIAL RISKS

• hypertension• hyperglycemia• infection• cardiomyopathy• gi bleeding/perforation• decreased somatic growth• decreased brain growth• neurodevelopmental problems

POSTNATAL STEROID THERAPY: SYSTEMATIC OVERVIEW

Early Steroid Treatment:• before or at 7 Days• studies 32• enrolled infants 4395

Late Steroid Treatment:• after 7 Days• studies 21• enrolled infants 1424

Doyle L, Cheong JL, Ehrenkranz RA and Halliday HL, Cochrane Library 2017

Typical Relative Risk and 95% CI

Outcome (N Studies)

TypicalRisk Difference

( 95% CI )0.5 1.0 2.0 4.00.2


0.5 1.0 2.0 4.00.2

EARLY (≤ 7 DAYS) POSTNATAL STEROID THERAPY

CLD @ 28 DAYS (17) -0.07 (-0.10,-0.03)

META-ANALYSIS OF 32 RANDOMIZED CONTROLLED TRAILS

CLD @ 36 WEEKS (24) -0.07 (-0.09, -0.04)

DEATH/CLD @ 36 WKS (25) -0.06 (-0.09, -0.03)

MORTALITY (30) -0.01 (-0.03, 0.01)

Doyle 2017


OUTCOME (N STUDIES)0.5 1.0 2.0 4.00.2


0.5 1.0 2.0 4.00.2

PATENT DUCTUS ARTERIOSUS (24)

EFFECT ON COMPLICATIONS OF PREMATURITY

INFECTION (25)

HYPERTENSION (11)

GI HEMORRHAGE (12)

SEVERE IVH (26)

Doyle 2017

SEVERE ROP (14)

PULMONARY AIR LEAK (16)



Outcome (N Studies)


( 95% CI ) 0.5 1.0 2.0 4.00.2


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LATE (> 7 DAYS) POSTNATAL STEROID THERAPY

CLD @ 28 DAYS (6) -0.11 (-0.17, -0.05)

META-ANALYSIS OF 21 RANDOMIZED CONTROLLED TRAILS

CLD @ 36 WEEKS (11) -0.15 (-0.22, -0.07)

DEATH/CLD @ 36 WKS (11) -0.18 (-0.25, -0.11)

MORTALITY (19) -0.03 (-0.07, 0.02)

Doyle 2017


OUTCOME (N Studies)


( 95% CI ) 0.5 1.0 2.0 4.00.2


0.5 1.0 2.0 4.00.2

NEURODEVELOPMENTAL OUTCOME IN SURVIVORS

BAYLEY MDI < 2SD (3) 0.01 (-0.06, 0.06)

BAYLEY PDI < 2SD (3) 0.02 (-0.02, 0.07)

DEVELOPMENTAL DELAY (1)

CEREBRAL PALSY (13) 0.02 (-0.00, 0.05)

Doyle 2017

MOD/SEVERE IMPAIRMENT (7) 0.01 (-0.02, 0.05)

PVL (15)

ABNORMAL NEURO EXAM (5)

0.00 (-0.01, 0.02)

0.10 (0.05, 0.15)

0.14 (0.03, 0.24)



Outcome (N)0.5 1.0 2.0 4.00.2


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BAYLEY MDI < 2SD (7)

NEURODEVELOPMENTAL OUTCOME IN SURVIVORS

BAYLEY PDI < 2SD (1)

ABNORMAL NEURO EXAM (4)

CEREBRAL PALSY (15)

MOD/SEVERE IMPAIRMENT (9)

Doyle 2017


(95%CI)

-0.03 (-0.10, 0.05)

-0.04 (-0.17, 0.09)

0.15 (-0.00, 0.30)

-0.02 (-0.08, 0.03)

0.03 (-0.03, 0.08)

LATE (> 7 DAYS) POSTNATAL STEROID THERAPY

POSTNATAL CORTICOSTEROIDS TO TREAT OR PREVENTCHRONIC LUNG DISEASE IN PRETERM INFANTS

RECOMMENDATIONS FROMTHE COMMITTEE ON THE FETUS AND NEWBORN 2002

On the basis of limited short-term benefits, the absence of long-term benefits, and the number of serious short-term and long-term complications, the routine use of systemic dexamethasone for the prevention or treatment of chronic lung disease in infants with very low birth weight is not recommended.

POSTNATAL CORTICOSTEROIDS TO TREAT OR PREVENTCHRONIC LUNG DISEASE IN PRETERM INFANTS

RECOMMENDATIONS FROMTHE COMMITTEE ON THE FETUS AND NEWBORN 2002

Outside the context of a randomized controlled trial, the use of corticosteroids should be limited to exceptional clinical circumstances (e.g., an infant on maximal ventilatory and oxygen support). In those circumstances, parents should be fully informed about the known short- and long-term risks and agree to treat.

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AAP Statement

Cochrane Review

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Doyle, L. W. et al.Pediatrics 2005;115:655-661

Risk Difference (%) for Death or CP among all participants vs. rate of CLD (%) in the control group

CLD

Cerebral palsy

SOMETIMES COCHRANE REVIEWS PROVIDE

RESULTS THAT MAY BE CONFUSING!

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Any Intraventricular Hemorrhage Severe Intraventricular Hemorrhage


OutcomeRisk Difference

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PATENT DUCTUS ARTERIOSUS (7) -0.27 (-0.32, -0.21)

Meta-analysis of 19 trials

EFFECT ON PATENT DUCTUS ARTERIOSUS (PDA)

SYMPTOMATIC PDA (14) -0.24 (-0.28, -0.21)

PDA LIGATION (8) -0.05 (-0.08, -0.03)

FOWLIE 2010: THE COCHRANE LIBRARY

Prophylactic Indomethacin



( 95% CI ) 0.5 1.0 2.0 4.00.2Decreased IncreasedRisk

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INTRAVENTRICULAR HEMORRHAGE (14) -0.04 (-0.08, -0.01)


EFFECT ON CENTRAL NERVOUS SYSTEM INJURY

SEVERE IVH (14) -0.05 (-0.07, -0.02)

PROGRESSIVE IVH (2) -0.08 (-0.29, 0.13)

PERIVENTRICULAR LEUKOMALACIA (5) -0.05 (-0.08, -0.01)

WHITE MATTER INJURY (1) -0.04 (-0.07, 0.00)



Long-Term Effects of Indomethacin Prophylaxis in ELBW InfantsSchmidt B and colleagues. N Engl J Med 2001; 344:1966-1972

Original Article

Long-Term Effects of Indomethacin

Prophylaxis in Extremely-Low-Birth-

Weight Infants

Barbara Schmidt, M.D., Peter Davis, M.D., Diane Moddemann,

M.D., Arne Ohlsson, M.D., Robin S. Roberts, M.Sc., Saroj Saigal,

M.D., Alfonso Solimano, M.D., Michael Vincer, M.D., and Linda L.

Wright, M.D., for the Trial of Indomethacin Prophylaxis in Preterms

Investigators*

N Engl J Med 2001; 344:1966-1972June 28, 2001DOI:

10.1056/NEJM200106283442602

Schmidt and colleagues randomly assigned 1202 extremely low birth weight infants to receive either indomethacin (0.1 mg/kg) or placebo intravenously once daily for three days.

The primary outcome was a composite of death, cerebral palsy, cognitive delay, deafness, and blindness at a corrected age of 18 months.

Secondary short-term outcomes were patent ductus arteriosus, pulmonary hemorrhage, chronic lung disease, ultrasonographicevidence of intracranial abnormalities, necrotizing enterocolitis, and retinopathy.

Secondary long-term outcomes were hydrocephalus necessitating the placement of a shunt, seizure disorder, and microcephaly within the same time frame.


Outcome

CompositeDeath or impairment

Components

DeathCPCognitive delayHearing lossBlindness

Indomethacin

47%

21%12%27%2%2%

Control

46%

19%12%26%2%1%

Adjusted OR (95% CI)

1.1 (0.8 to 1.4)

1.2 (0.9 to 1.6)1.1 (0.7 to 1.6)1.0 (0.8 to 1.4)1.0 (0.4 to 2.5)1.3 (0.5 to 3.6)




( 95% CI ) 0.5 1.0 2.0 4.00.2Decreased IncreasedRisk

0.5 1.0 2.0 4.00.2


MORTALITY AT FOLLOW UP (18) -0.01 (-0.04, 0.02)


STATUS AT LATEST FOLLOW UP

CEREBRAL PALSY (4) 0.00 (-0.03, 0.04)

SEVERE ND IMPAIRMENT (3) -0.01 (-0.05, 0.04)


Hierarchy of outcomes according to importance to patientsto assess effect of prophylactic indomethacin

Mortality

Neurodevelopmental outcome

Severe IVH

PDA ligation

PDA murmur

Prophylactic Indomethacin:Glass half full or half empty?

DOES NOT ALTERNEURODEVELOPMENTALOUTCOME

PREVENTS:SYMPTOMATIC PDASEVERE IVH

Indomethacin

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SOMETIMES WE IGNORE THE FINDINGS FROM

RANDOMIZED CONTROLLED TRIALS AND THE REVIEWS OF THESE

TRIALS!


OUTCOME (STUDIES)Risk Difference

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ELECTIVE HIGH FREQUENCY OSCILLATORY VENTILATION

IVH (12) 0.02 (-0.01, 0.05)

META-ANALYSIS OF 19 RANDOMIZED CONTROLLED TRIALS

SEVERE IVH (18) 0.01 (-0.01, 0.04)

PVL (17) 0.00 (-0.01, 0.02)

SEVERE RETINOPATHY (12) -0.04 (-0.07, -0.01)

CHRONIC LUNG DISEASE (17) -0.05 (-0.08, -0.02)

DEATH (17) -0.01 (-0.03, 0.02)

COOLS 2015

CLD/DEATH @ 36 WKS PMA (17) -0.05 (-0.08, -0.01)

PULMONARY AIRLEAK (13) 0.04 (0.01, 0.07)

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High Frequency Ventilation

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CHRONIC LUNG DISEASEIN VLBW INFANTS

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NITRIC OXIDE FOR RESPIRATORY FAILURE IN PRETERM INFANTS

EFFECT ON DEATH OR BPD AT 36 WEEKS PMA

NIH Consensus Development Conference Statement: Inhaled Nitric-Oxide Therapy for Premature Infants

Taken as a whole, the available evidence does not support use of iNO in early-routine, early-rescue, or later-rescue regimens in the care of premature infants of <34 weeks' gestation who require respiratory support.

There are rare clinical situations, including pulmonary hypertension or hypoplasia, that have been inadequately studied in which iNO may have benefit in infants of <34 weeks' gestation.

In such situations, clinicians should communicate with families regarding the current evidence on its risks and benefits as well as remaining uncertainties.

http://consensus.nih.gov/2010/ino.htm

http://consensus.nih.gov/2010/ino.htm

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Inhaled Nitric Oxide in VLBW Infants

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1st quartile

SOMETIMES THE COCHRANE REVIEW TELLS US THAT WE SHOULD BE

READY TO CONSIDER CHANGE

(AND NEW PRACTICES)

COOLING FOR INFANTS WITH HYPOXIC ISCHEMIC ENCEPHALOPATHY

DEATH OR MAJOR DISABILITY -0.16 (-0.23, -0.09)

MAJOR DISABILITY -0.18 (-0.29, -0.09)

DEATH -0.10 (-0.16, -0.04)

WHOLE BODY COOLING

DEATH OR MAJOR DISABILITY -0.09 (-0.21, 0.03)

MAJOR DISABILITY -0.09 (-0.24, 0.05)

DEATH -0.05 (-0.14, 0.04)


0.5 1.0 2.0 4.00.2

HYPOTHERMIA FOR HYPOXIC ISCHEMIC ENCEPHALOPATHY

WHOLE BODY COOLING AND SELECTIVE HEAD COOLING

Updated by Berg 2012

SELECTIVE HEAD COOLING

STUDY


(95%CI) 0.5 1.0 2.0 4.00.2Decreased IncreasedRisk

HYPOTHERMIA FOR THE TREATMENT OFHYPOXIC ISCHEMIC ENCEPHALOPATHY

ILCOR recommendations

“Intensive care nurseries should now consider adopting one of the validated protocols for the selection of term infants with HIE, be appropriately equipped and train staff to offer hypothermia according to the protocol of the currently published large hypothermia trials”

“Because HIE is a relatively uncommon condition, it would be highly desirable where possible to centralize this treatment to larger intensive care units.”

“With the data presently available, there is no longer any reasonable justification to deny this apparently efficacious treatment for those who most urgently need it.”

Hoehn and coworkers. Resuscitation 2008

COOLING IN HYPOXIC ISCHEMIC ENCEPHALOPATHY

What are we supposed to do?

DIFFICULTY OF TRANSLATINGEVIDENCE TO PRACTICE

Efficacy:

Mild hypothermia is a promising therapy in a highly selected population of infants with moderate to severe hypoxic ischemic encephalopathy when treated before 6 hours of age

DIFFICULTY OF TRANSLATINGEVIDENCE TO PRACTICE

Effectiveness and Efficiency:

• Does it work in the most affected infants? Does it provide a benefit to less severely affected infants?

• Does it work outside the restricted time window predicted by animal models and tested in clinical trials?

• Does selective or whole body hypothermia work better?

• What is the relationship of hypothermia to other therapeutic interventions?

ENCEPHALOPATHY REGISTRY:Hypothermic Therapy 2006 to 2011

• 99 participating centers

• 2457 infants treated with hypothermia

• 726 (30%) did not meet criteria from RCTs

– 40% with mild encephalopathy

– 60% treated after 6 hours

– 17% of all infants < 36 weeks gestation

Pfister. PAS. 2013

Whole Body 74%Selective Head 17%Both 9%

Only fair agreement between large clinical trials and meta-analyses

LeLorier 1997

PROBLEMS WITH META-ANALYSIS

Odds Ratio and 95% CI

CHARACTERISTICOdds Ratio

(95% CI) 0.5 1.0 2.0 4.00.2


0.5 1.0 2.0 4.00.2

META-ANALYSIS OF MULTIPLE SMALL STUDIESCOMPARED TO SINGLE LARGE STUDY

ASPIRIN FOR PREVENTION OF PRE-ECLAMPSIA

META-ANALYSIS 0.30 (0.20, 0.42)

SINGLE LARGE RCT 0.82 (0.72, 1.05)

META-ANALYSIS

Methodological flaws in meta-analyses

• Publication biasThe tendency for investigators to preferentially submit studies with positive results, and the tendency for editors to choose positive studies for publication

• HeterogeneityConcerning variation in the direction or the degrees of results between individual studies

PROBLEMS WITH COCHRANE REVIEWSAND META-ANALYSIS

Too many reviews that end with the conclusion that “more trials are needed.”

“You cannot makea silk purse

from a sow’s ear”

RCTs

Cochrane Reviews

TRIALS BASED (at least in part)on RESULTS OF META-ANALYSIS

• Prophylactic Indomethacin• Vitamin A• Emollient Ointments• DART Trial• Inositol• Caffeine

Search: “Neonate”Limit: all infants;

randomized controlled trial

7059 RCT identified

Cochrane Neonatal

1355 RCTs included

COCHRANE NEONATAL

SYSTEMATIC REVIEWS ARE USEFUL

• In guiding evidence-based practice

• To formulate research questions

• To create a context in which to view new evidence

So what is the fate of Cochrane Neonatal?

Bridging funds:University of Vermont

Cochrane Central

Possible future sponsorship:

Vermont Oxford Network

So what is the fate of Cochrane Neonatal?

Questions

For CME Credits use the following link:

https://www.surveymonkey.com/r/VS9CK2Z

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https://www.surveymonkey.com/r/FJPDJRZ

Future webinars!

Prevention and Treatment of Retinopathy of Prematurity

https://www.surveymonkey.com/r/VS9CK2Z

https://www.surveymonkey.com/r/FJPDJRZ

Documents

Title of Program: What has Cochrane Neonatal Done For ...neonatal.cochrane.org/.../files/public/uploads/slides.pdf · The Basics ∙ Follow slides on the Internet ∙ Listen on your