Volume guarantee, does it guarantee volume?

I published an abstract somewhere, a while a go, that was called “Volume guarantee does not guarantee volume”. It was a summary of the results of a short-term cross-over trial which showed that tidal volumes stays quite variable when you switch from pressure limited ventilation to volume-guarantee, using the Babylog.

The reason of course is that respiratory efforts vary from breath to breath, so a system designed to measure the tidal volume delivered and then adjust the pressures for the next breath, is bound to be always playing catch-up. Sometimes the variability is small, sometimes, when the baby is irritable or crying, for example, the variability can be quite substantial.

In true volume-controlled ventilation the machines deliver a fixed volume into the ventilator circuit for each breath; there actually was at one time a neonatal ventilator that did this, the old Bourns LS104, which I am old enough to have actually used (in my animal lab). The problem with such machines is that the compressible volume of the ventilator circuit is substantially greater than the volume of a baby’s lungs, so any minor change in lung compliance (the ventilator circuit has, of course, an unchanging compliance) can lead to dramatic changes in the actual pulmonary tidal volume received by the infant. If compliance deteriorates significantly you can end up ventilating just the ventilator circuit, and not the baby. In contrast improvements in compliance can lead to dramatic increases in the volumes delivered to the baby, and excessive, damaging inhalational volumes. The Bourns LS104 was associated with worse pulmonary outcomes and went off the market.

Safe volume ventilation in newborns must be determined by the volume actually entering (or leaving) the lungs of the baby, and measured at the endotracheal tube. Some of the trials of “volume targeted ventilation” (including the 2 of the largest ones included in the Cochrane review) in the newborn have used the Siemens Servo 300c in PRVC mode, which measured the volume delivered at the ventilator end of the circuit. Volumes selected for those trials were determined by watching the babies chest move and selecting a volume which gave good chest movement, which varied between 5 and 15 ml/kg. You really cannot call that volume targeted ventilation, and such studies should be considered separately in systematic reviews of volume targeted ventilation in the newborn. In fact if you take those trials out of the systematic reviews, the evidence base for a clinically significant benefit of volume targeted ventilation is rather weak with not many more than 100 patients on volume ventilation and 100 with pressure limited ventilation (even though I personally think it is likely to be an improvement over pressure limited ventilation).

So a system that adjusts pressures in order to get the target volume, will always have tidal volumes which are variable (unless your patient is apneic or paralyzed). In contrast, a system which targets a particular pressure (standard neonatal ventilators that is) will likely have even higher variations in volume, including potentially damaging breaths with excessive inspiratory volumes.

Overall, volume guarantee systems should therefore have fewer breaths which are seriously excessive (or indeed breaths which are much too small). Is that really true? There are numerous small short-term cross-over studies that demonstrate that indeed there are fewer excessive tidal volumes with the babylog or VN500 systems. In part this is also likely to be due to another safety feature in VG ventilation, at least with the Drager systems, that once the volume passes a particular threshold (for the babylog/VN500 that is 130% of the set tidal volume) the inhalation is terminated, and circuit pressure returns to the set PEEP.

How good are the machines at consistently delivering the desired tidal volume? A new publication from David Tingay and his group from the children’s hospital in Melbourne examined this with the SLE 5000.

Farrell O, et al. Volume guaranteed? Accuracy of a volume-targeted ventilation mode in infants. Archives of disease in childhood Fetal and neonatal edition. 2017.

They showed with an extensive data collection in 100 babies, with millions of inflations recorded, that tidal volumes were close to the desired tidal volumes with narrow confidence intervals.

One thing I noted that seemed a bit strange however, is from their figure 1.

(A) Bland-Altman plot of VTset and expiratory tidal volume (VTe) . Solid black line denotes the bias, dashed black lines denote the 95% CI of the limits of agreement. (B) Relationship between VTset and VTe; y=0.736x+1.073 (r=0.34, p<0.0001; linear regression). Solid black line represents the line of best fit and dotted black lines represent 95% CI bands. To ease visual interpretation of figures, and after seeking statistical advice, symbols represent the average values for each infant rather than all values analysed (maximum 90 000/infant)

The dots on the graphs represent the average values from individual patients, who had a median of over 80,000 inflations per patient. Therefore over a large number of inflations some babies had average delivered tidal volumes that were up to 3 mL/kg less, or nearly 2 mL/kg more, than the desired tidal volume, if I interpret graph A correctly. I can understand that sometimes the pressure limit is being hit frequently, limiting the administered pressures and therefore the tidal volume, and that this could lead to smaller average tidal volumes than the set volume; but I find it hard to understand why tidal volumes would be consistently larger than the set volume over a large number of inflations, shouldn’t the ventilator have reduced the pressures to lead to smaller tidal volume? I guess it is possible that the ventilator had reduced the peak pressure down to a minimum (PEEP) and the baby was spontaneously generating volumes higher than the set volume. It would be nice to know if these explanations are correct.

Other findings were that it seems that CO2 is probably truly more stable during volume targeted ventilation, and that the latest algorithm for leak adjusting the inflations seemed to work better that the older algorithm, and indeed worked quite well up to an ETT leak of 30%.

Posted in Neonatal Research | 1 Comment

When good journals print nonsense. (And good doctors too).

It is hard to believe the drivel some people are prepared to countenance just because it is supposed to be very old drivel. Chen KL, et al. Acupuncture in the neonatal intensive care unit-using ancient medicine to help today’s babies: a review. J Perinatol. 2017;37(7):749-56.

Starting with the questionable premise that acupuncture has been in use for ‘thousands’ of years (a brief summary of the recent history of Acupuncture can be found here)., the authors of this article promote its investigation for pain control in the newborn’. Even if the earliest known possible references to acupuncture (which date from about 100 BCE) do really refer to what we now know as acupuncture, the fact that it is an old system is not necessarily in its favour. For it is based on pre-scientific theories of how bodies work, and the manipulation of non-existent energies (Xi) that flow through non-existent meridians, we would be better to remain extremely sceptical that sticking needles anywhere in the body would have distant effects on specific illnesses, or indeed any reproducible effect at all.

Fortunately we have ditched just about all of “traditional western medicine”, which was also based on a similarly profound lack of understanding of anatomy and of physiology.

What is clear from published research is that there are sometimes small effects of acupuncture, which are reproduced regardless of the site that the needles are stuck into, and that you can get the same effects without sticking the needle in at all. The better a study is designed, the lesser the effects of acupuncture. In studies with complete blinding, using sham acupuncture at random sites in control groups, the small effects of acupuncture are usually identical to the small effects of sham controls. (See here for a review of systematic reviews of acupuncture for pain control which concludes “Numerous reviews have produced little convincing evidence that acupuncture is effective in reducing pain. Serious adverse events, including deaths, continue to be reported”).

Some people have promoted these small effects as evidence that acupuncture harnesses the “placebo effect” (as if that was a good thing) what it really is, is evidence that it does not have a real effect.

Using acupuncture, of any variety, including shining lights on “acupuncture points”, is a totally unethical thing to do in an investigation of pain control in the newborn. To perform a painful procedure and test acupuncture against a known effective analgesic is an idea that should horrify anyone who cares about pain in babies.

The articles quoted in this review include ridiculous nonsense such as the “demonstration of active acupuncture points” in the ears of babies with neonatal abstinence syndrome. The demonstration of these non-existent points is often made with a “machine that goes ping”,

which is what was done in the study they refer to. These are galvanometers of various designs, which are used as  supposed identifiers of acupuncture points, they have never been shown to do anything except go “ping”. It is hard to believe that anyone could swallow the idea that there is a specific point in the ear that can be needled to create specific effects elsewhere in the body, based on totally imaginary “homunculi” like this one.

Far from being thousands of years old, auricular acupuncture was made up in France in the 1950’s. The “machines that go ping” measure electrical conductivity of the skin, which varies according to the angle of the implement, the pressure applied, and how much the skin is stretched: such machines have never been demonstrated to detect any real structure or phenomenon.

Despite its total lack of scientific justification there are unfortunately a couple of studies in newborn infants that have been performed. They, not surprisingly, showed no effect of laser acupuncture or of acupuncture accompanied by electrical stimulation. One of the studies, examining the analgesic effect of laser acupuncture, compared laser acupuncture alone to sucrose alone before heel lancing in newborns, the infants in the sucrose group had less pain; that is a truly unethical trial.

We must not start exposing newborn infants to painful procedures in order to investigate the impact of this nonsense. Acupuncture is nothing more than a theatrical placebo, which is unlikely to impress a newborn infant. As Colquhoun and Novella note “A small excess of positive results after thousands of trials is most consistent with an inactive intervention. The small excess is predicted by poor study design and publication bias…The best controlled studies show a clear pattern, with acupuncture the outcome does not depend on needle location or even needle insertion. Since these variables are those that define acupuncture, the only sensible conclusion is that acupuncture does not work.”

If you can get this nonsense published in a normally high quality journal, maybe I should write a review article about ear candling, or the benefits of homeopathy: or maybe I should set up an “alternative medicine NICU”, it would probably be as effective as Mitchell and Webb’s emergency room.

Posted in Neonatal Research | Tagged | 1 Comment

Not neonatology; trip to Western Canada.

I have just returned from summer vacation, we were very fortunate with the weather and with the wildlife viewing. I have put 2 new pages up of my photos under the “Photos” item on the menu at the top of this page. Wildlife of the Canadian Rockies, and Wildlife of the West Coast, Vancouver Island.

One photo I am quite pleased with is of a Purple Martin mother feeding her chick, that had grown to be a similar size to her. It was the first time I had seen Purple Martins, (unfortunately there were no males around), and I caught the moment when the mother deposited the meal right at the back of the young ones mouth. In this sequence  you can see her approaching the noisily demanding chick, then, with the nictitating membrane over her eye, plunging her beak into the chick’s mouth, and then, without pausing, she flew off again to find more food for her hungry charge. Exhausting being a new parent.

Posted in Not neonatology | 4 Comments

Using less antibiotics

Most newborns who receive antibiotics are not infected. This is true of full term babies in normal newborn care, and preterms in the NICU. For most infants antibiotics can be stopped after 36 hours if cultures are negative at that point (for the few which are positive between 36 and 48 hours, antibiotics can be restarted without missing a dose). Duration of treatment of those with positive cultures, or of those who are thought to have culture negative sepsis, is quite arbitrary.

Stocker M, et al. Procalcitonin-guided decision making for duration of antibiotic therapy in neonates with suspected early-onset sepsis: a multicentre, randomised controlled trial (NeoPIns). Lancet. 2017.

In this large international RCT of infants who had antibiotics started for suspected early onset sepsis (<72 hours of age) and who were term or late-preterm were randomized. Infants were evaluated with a reasonably objective risk scoring system, and could score 1 point for risk factors, 1 point for clinical findings, and 1 point for lab values.

The 2 randomized groups either had duration of therapy determined by Procalcitonin levels, or by an arbitrary duration, as shown in the figure. Babies who had positive cultures had at least 7 days of antibiotics, regardless of procalcitonin levels.

The group who used procalcitonin levels had shorter duration of antibiotics, a mean of 55 hours versus 65 hours. But of the 1710 babies included in the trial 47% were determined to be “infection possible”, and 41% were “infection unlikely”.  Only 27 babies had proven infections or about 1.5%.

My main problem with this trial is that the duration of antibiotic use in infants who are not infected is much too long. Any infant with a risk factor, even with no clinical signs, no other supportive evidence and with negative cultures at 36 hours receives between 36 and 72 hours of antibiotics. Any infant with a risk factor and one other point on the risk scale (for example for respiratory distress, or an elevated CRP) will receive 5 to 7 days of antibiotics. So any infant born before 37 weeks who has respiratory distress will have got at least 5 days of antibiotics in the non-procalcitonin group.

A baby with a history of chorioamnionitis or 20 hours ruptured membranes, respiratory distress, and an elevated CRP would be considered to be “infection probable” and would get 7 to 21 days of antibiotics, even if they improved rapidly, and had negative cultures. The clinical sign that was the most frequent was indeed respiratory distress.

I think that the authors have not shown that procalcitonin reduces duration of antibiotic use compared to a more reasonable approach, in which they would be stopped in the large majority of infants at 36 hours if cultures are negative.

I think most babies in this study should have had their antibiotics stopped at 36 hours, so the results of 55 and 65 hours of treatment that they found are both too long.

Overuse of antibiotics is a big problem, when less than 2% of treated babies can be proven to have an infection. Under-treating a baby who is truly infected is the concern that drives these numbers; the authors tried to evaluate that by looking also at deaths within the first month of life, and re-infection with 72 hours of stopping antibiotics. However, the numbers of those events was tiny (less than 1%) so there is no significant difference between the groups, the actual numbers are identical between the groups.

Many of the infants enrolled in this study, especially those in the ‘infection unlikely” group would not even have qualified for antibiotics if the evidence-based neonatal sepsis risk calculator, that I discussed previously, had been used. (It obviously wasn’t available when these authors were planning theire trial, but it is easily available now!)

Mukhopadhyay S, Puopolo KM. Clinical and Microbiologic Characteristics of Early-Onset Sepsis Among VLBW Infants: Opportunities for Antibiotic Stewardship. Pediatr Infect Dis J. 2017.

There is clearly room for improvement among preterm babies also. It has long been my practice to not perform cultures or give antibitoics to preterm babies born by Cesarean delivery with intact membranes to mothers who were not in labour.If there isn’t a route for a baby to get infected they aren’t likely to be infected!

This new publication confirms that practice to be safe. They reviewed over 5000 VLBW infants admitted to the Brigham and Women’s hospital, of which 109 had culture positive sepsis. There was only 1 case of a positive culture among an infant delivered with the characteristics that I mentioned, and that was almost certainly a contaminant (1 of 2 bottles grew a coagulase negative staph, which was negative on repeat culture despite the antibiotics not covering the germ).

The study also confirmed that cultures were very often positive before 36 hours, and 98% before 48h, so a 36 duration of initial antibiotic prescription is appropriate.

Being preterm is not an infectious disease. Some babies are at very low risk of actually being septic and we can avoid giving them antibiotics.

Posted in Neonatal Research | Tagged , | 2 Comments

Life, and medicine, with a disability

I met the author of this article at a CPS meeting a few years ago, she immediately impressed me with her unique perspective. Paige is a developmental pediatrician who does long-term follow-up of preterms, and is involved in developmental evaluation and intervention of children with other challenges, including Spina Bifida.

Church P. A personal perspective on disability: Between the words. JAMA Pediatrics. 2017.

As you will see if you read the article, Paige has a form of Spina Bifida herself, a Lipomyelomeningocele, with a neurogenic bladder and neurogenic bowel, requiring life-long interventions. She discusses the poor tolerance many medical people have of disability, and such how things are often discussed as black or white, whereas having a profound personal experience of disability has made her much more nuanced.

She recounts being involved in a discussion regarding a “selective reduction” of a twin pregnancy where the twin being considered for “reduction”, i.e. abortion, had a similar lesion to her own.

That is an experience that I can barely understand: how would I react if a family was considering terminating  a pregnancy because of a condition that I had? Paige recounts the episode with tact and humanity.

I can imagine, as I have heard them many times, the words of the other physicians involved in such a decision, I am sure they talked about handicaps and limitations, poor quality of life, pain, and restrictions on family life. Most of which is said with good intentions but with no real knowledge of the literature, or of the range of experiences of families living with the challenges.

Just as with similar discussions regarding extreme preterm infants, a list of complications, interventions, disabilities, and long-term problems is often presented, but with no similar list of benefits, achievements, abilities, long-term adaptation, and happiness.

Near the end of her moving piece Paige writes:

Like most things in life, and medicine, disability is sharp, painful, humbling, as well as tremendous, giving, awe-inspiring. It is human. It is not easily distilled to an all or none discussion. Medicine sets the tone for this discussion and, to date, has done a miserable job. More is needed to appreciate the incredible opportunities that disability poses. More education is needed to provide the counselling families deserve: balanced, sensitive, thoughtful, and individualized rather than “objective.”

I sincerely hope that this piece by Paige will be part of a new discussion about these issues.

(Of note, even though the article is behind a paywall, JAMA lets you see the first page of the article before buying, in this case there is only one page, so you can read the whole thing for free!)

Posted in Advocating for impaired children, Neonatal Research | 1 Comment

A shiny new test

I have invented a shiny new test, which detects brain injury in preterm infants just before they go home. It can be used at discharge to predict whether a former extremely preterm baby will have developmental delay or neurologic impairment. The test has a threshold of 1 unit for increased risk of poor outcome, and 2 units is a really abnormal test.

When the result is below 2 (that is normal or mildly abnormal) about 5% of babies will have cerebral palsy, and 25 to 35 % will have delay in various domains. When the result is above 2 (moderately or severely abnormal) about 25% will have cerebral palsy, and about 40 to 45% will have developmental delay.

In other words, when the test is severely abnormal, most of the babies will not have delay or movement disorder (even though there is a statistically significant difference in outcomes between groups); I can express the results differently to try and convince you to use my shiny test: there is a highly significant linear correlation between test results and developmental screening test results at 2 years.

What I want to know is; are you buying? It only costs about 600$ (Canadian) per test.

Hopefully in the era of modern neonatology, before doing this test you would discuss it with the parents of each baby, they might well ask “Do you recommend the test, doctor?”

Well?

Extremely preterm infants have increased long term problems, and need to be followed up in focussed programs. Parents are generally aware of the increased risks of their babies by the time they are about to go home. For a pre-discharge test to help families it should reliably inform them of the likely outcome of their infant. In other words it should be both sensitive and specific. Most extremely preterm babies do well, but a test with low sensitivity will have a low positive predictive value for important long term outcomes.

For some outcomes (relatively rare outcomes such as critical congenital heart disease) a screening test with low positive predictive value is acceptable, there are more false positives than real positives (even though many of the positive results of pulse oximetry screening actually have problems that need addressing) and a 0.5% false positive rate, for a condition with an incidence of 1:10,000 does not create huge problems. Especially when the patients who are truly positive need urgent intervention to prevent serious complications.

But when the risk of a particular outcome is moderately common, a test with the same characteristics is much less acceptable, large numbers of families will be identified as being at risk, and most of them will end up OK. Plus, in the case of former preterm infants at discharge, you actually don’t change your intervention based on the test results.

You could actually get almost as good discrimination by sitting in the waiting room of the test station, pointing at all the babies and saying “You will probably be OK”.

Are you takers for my shiny new test?

What I am trying to get at, is just because a test slightly improves prediction of delay or motor issues, does not necessarily mean that all of our patients should have that test. To be useful you need a test that discriminates between babies who will need follow-up and intervention, and those that do not. I think my shiny new test might not be so useful after all.

What is my shiny new test?

It will be obvious to many of my readers that my shiny new test is a term-equivalent cerebral magnetic resonance image.

What I have described is where we are with predischarge MRI (and probably term equivalent head ultrasound also). Most babies with abnormalities on the MRI have good outcomes. The positive predictive value of anything seen on the MRI is less than 50%. MRIs are really good at finding imaging abnormalities, they are relatively useless at finding developmental problems! Which is as it should be… surely, MRIs can be spectacularly succesful at showing brain structure, mapping tracts and developing connections and showing how some brains are different to others, including the brains of former preterm babies.

A new publication from Melbourne of 186 babies under 30 weeks gestation (or under 1250 g) who had pre-discharge MRI illustrates much of this. (Anderson PJ, et al. Associations of Newborn Brain Magnetic Resonance Imaging with Long-Term Neurodevelopmental Impairments in Very Preterm Children. The Journal of pediatrics. 2017).

This group of infants had the usual amazing high quality follow up from Peter Anderson and their team, and it shows a statistically significant association between abnormal MRI and various aspects of their cognitive abilities at 7 years of age.

But because there is a significant association, that does not mean that it is useful to parents, or that everyone should have the MRI.

This new publication doesn’t present the data in a way that you can calculate the PPV or specificity. What it does show is that if you have a semi-objective MRI scoring system, in a group of former very preterm babies who are now 7 years of age, the mean IQ of those with a normal pre-discharge MRI is 100 (SD 15) those with moderate to severe abnormalities on the MRI it is 89 (SD 15). (For those with mild abnormalities the IQ was 97 (SD 15)).

To show it graphically here are the mean plus or minus 2SD, to show the range of results of 95% of the babies in each group (about).

I think these data are amazing, they show, perhaps a bit surprisingly, that pre-discharge MRI findings at 40 weeks PMA have a statistically significant association with standardized testing 8 years later, after 8 more years of growth and development and stimulation and education and love and warmth in a family, there are still measurable impacts of how the brain developed in those first few weeks of life.

But,  I fail to see how this information is of any value for individual parents, although the authors try to use their results to promote routine pre-discharge MRI. What are you supposed to say to parents when you have a moderate to severe abnormality on the term-equivalent pre-discharge MRI?

Here is an evidence based suggestion for what to say to a parent when you get back the MRI with severely abnormal scores.:

“Your babies predicted IQ at 8 years of age is 95% likely to be somewhere between 59 and 119, if the MRI had been normal the predicted IQ at 8 years of age would have been 95% likely to be between 70 and 130.”

Now if the pre-discharge MRI predicted a response to early intervention programs, for example, then maybe they would be of value, but I don’t think there is any evidence of that; what does seem to correlate with an advantage from early intervention is poorer social circumstances. Perhaps if the sensitivity and the negative predictive value were high enough, you could decide not to follow-up some babies, but, although the NPV is high for cerebral palsy in a few studies, it is not very good for developmental delay. Which means, I think, that all very preterm babies should be in focussed follow-up programs regardless of MRI findings.

The authors of the article state the following in the discussion:

This study confirms that newborn MRI identifies brain abnormalities in CWM, DGM, and CBL that have long-term impact on neurodevelopmental outcomes, independent of perinatal and social risk factors. Thus, quantitative evaluation of structural MRI obtained at term equivalent age provides valuable information for clinicians. Because discussion of neurodevelopmental prognosis with families before neonatal intensive care unit discharge is standard of care, and brain abnormality on MRI is the strongest neonatal predictor of long-term outcome, prognostic discussions with families should be informed about MRI findings alongside other clinical indicators.

As should be clear by now, I really disagree with these statements. Doing a screening test with low specificity in a lowish risk population leads to frequent conversations with parents about the fact that, despite these findings, their baby will probably be fine, I still don’t think that we have answered the question of whether this test (alongside many others that we do, such as term equivalent head ultrasound, especially in babies whose US was previously normal) and that conversation, actually helps families.

Posted in Neonatal Research | 5 Comments

Thanks for Canadian Medicare and Tommy Douglas

I recently had an acute medical event, took myself off to a local emergency room, received excellent immediate attention. After about 8 hours of care, an expensive drug that I had never heard of before, multiple disposables and several high tech investigations, I was able to go home. I got back home in the early hours of Canada Day, the 150th anniversary of the convention that created Canada. Two days later I was seen by a specialist, and had further expensive high tech tests.

When I got home from that, I thought I had better figure out my bill to make sure I could afford it all:

Taxi to hospital $14, taxi home from hospital $14, outpatient prescription drugs $1.84 (outpatient drugs are not completely covered for most people), parking for the specialist appointment $12.

Total cost $41.84

That’s it.

Everything else was covered by the provinical healthcare system, paid for by taxes.

Tommy Douglas was a former professional boxer, who was also a baptist minister, and is the father of Canadian Medicare. He was from the Canadian Prairies, has been referred to as the ‘greatest Canadian of all time’ and worked tirelessly to start a Canadian Health Care system which provides care to all, regardless of ability to pay. It is an interesting contrast to me, the attitude of someone like Tommy Douglas, a committed baptist who believed in creating a just and equal society where all are cared for when they are in need, to some of the attitudes of some christian groups in the USA today.

Our system (actually systems, there are significant differences between provinces that are responsible for administering health care) is far from perfect, acute and emergency care tends to be favoured, so neonatal care, for example, is in a privileged position. Central management makes regionalization quite effective, so we have almost no avoidable deliveries of very preterm babies in non-tertiary hospitals. Central management also creates problems, with the size of medical school intakes oscillating as the government tries to decide if we have too many physicians or too few, and keeps changing its mind.

Chronic care, and domiciliary care are the big losers in our system, as it is politically easier to cut budgets when the adverse effects are slowly cumulative rather than acutely visible. Non-urgent surgery is another place where our system does relatively poorly, so a hip replacement might be quite delayed, with consequent avoidable pain and disability. Although, in fact, some type of waiting list is an important way of containing costs, if everyone can get a hip replacement within a few days of qualifying for one, there has to be a great deal of redundancy in the system.

One interesting comparison with the US system was made a few years ago by John Ralston Saul. The cost of US Medicare and Medicaid, divided by the entire US population, (even though they only cover a smallish part of the US population) was substantially greater than the cost  of Canadian Medicare, divided by the entire Canadian Population; but the Canadian system covers everybody. A system with a layer of administration dedicated to making a profit has to be more costly.

I am certainly grateful for the Canadian health care system, both as a patient and as a part of the system, no-one find themselves in debt because of medical costs, those who pay taxes pay for the medical care of those who pay little or no taxes. In a relatively just society, that is how it should be.

Happy belated 150th Canada Day!

Posted in Neonatal Research | 1 Comment