Not neonatology : the antipodes, week 6. Lake Tekapo and Christchurch

Week 6 was, too quickly, our final week in New Zealand, and we moved back to the interior of the North Island. Lake Tekapo is a Glacial Lake which gives it a milky turquoise colour. It is also in a Night sky reserve, where nocturnal lighting is very limited, and the views of the night sky are very clear, as clear as they used to be everywhere, I guess, until the invention of electric lighting. I don’t believe I have ever seen the Milky Way so clearly, most nights it is not visible at all in Montreal. I think the kids were surprised that there are so many stars. The second night there we had a guided description of the sky by an astronomer, who pointed out features using a laser pointer, surprisingly this worked very well for the whole group. The next day we walked up to the Observatory on Mount John (which is the reason for the night sky reserve) where at one point we could see lake Tekapo, and Lake Alexandra right next to it, which is not filled by glacial run-off, and so has a completely different colour, a dark green as a result of the algal growth. I haven’t adjusted the colours on this photo taken near the peak of Mount John, with Lake Tekapo on the right, and Lake Alexandria on the left, in person the contrast is even more striking.

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The mountain range behind includes Aoraki, Mount Cook. The highest mountain in New Zealand, and one that has 2 names. There is no record that James Cook ever saw, and he certainly never visited, the mountain that carries his name, so recently the old Maori name was given back to it, and the Europeans’ name kept for historical and guide book reasons. Our first view of the mountain was unusually clear over a lake. The Maori name may (or may not) mean something like Cloud Piercer, which, even if it isn’t true, would be appropriate as the summit is almost always hidden by clouds. So this view is rare.

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The walk to the glacial terminal lake was not very taxing, but well worth it, with many striking views.

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Our trip to New Zealand ended in Christchurch, a city in the middle of reconstruction after the devastation of the 2010, 2011 earthquakes. I was stunned by the extent of the destruction, remembering the images after the earthquakes I had not expected whole city blocks to be empty, but many buildings which were still standing after the quake had to be demolished as a result of structural damage, and it will take many more years (15 by some estimates) to rebuild. This is what remains of the Cathedral.

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Some businesses have set up in containers, placed in front of their damaged former premises while they wait to be rebuilt.

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Despite this, Christchurch is, like all of New Zealand in a gorgeous region; we had a walk in the hills around, and another in the estuary where there were thousands of Banded Godwits, Stilts, Gulls and Oystercatchers in the early evening, in this estuary very close to the center of town.

1-IMG_5058And this white-faced Heron, caught in the evening glow of the setting sun.

White-faced Heron

 

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Getting Better

Brett Manley, and a group of the CAP investigators, including yours truly, have just published an article about the long term cognitive testing results of the trial subjects. (Manley BJ, Roberts RS, Doyle LW, Schmidt B, Anderson PJ, Barrington KJ, Bohm B, Golan A, van Wassenaer-Leemhuis AG, Davis PG et al: Social Variables Predict Gains in Cognitive Scores across the Preschool Years in Children with Birth Weights 500 to 1250 Grams. The Journal of pediatrics 2015). The 5 year outcomes of the CAP trial, if you remember, were interesting in showing that only 18% of the babies who had a Bayley 2 score at 18 months corrected age which had been below 70 still had cognitive testing scores (on the WISC-R) less than 70 at 5 years of age. The babies who had the lowest scores on the Bayley had, overall, the greatest “improvement” in their scores at 5 years of age.

You may also remember that the primary outcome was no longer different between the caffeine and control groups at 5 years, although there were some differences between the groups, which still favoured the caffeine exposed infants. The average IQ score of the whole group of infants at 5 years of age was 98.9, almost identical to the population standardised mean.

We thought that the changes in scores, and the lack of difference between the groups when they reached 5 years, was probably evidence of the variable influences of environmental factors, which become much more important as babies age, so we used those social variables that we had collected in the CAP data set to see if they were associated with the changes in cognitive scores.

Obviously the tests that were used were not the same at 2 years and at 5 years, a developmental evaluation at 2 years, and a more formal test of “intelligence” at 5 years, but, with that proviso, we were able to show that much of the difference in test scores was explained by the contribution of a number of social variables, which actually all had additive effects. The most important social variables were paternal education, maternal education and parental employment. Having two parents in the home was important on individual analysis, but dropped out when combined with the other factors in the model.

Our data confirmed that developmental testing at 18-20 months is very poorly predictive for cognitive abilities at 5 years, among very preterm infants. Which is entirely consistent with other published data.

One important implication of this is that we need to be very circumspect making treatment decisions or therapeutic choices based on predictions of 18-20 month developmental outcomes.

It also strongly suggests that we should focus programs to try and improve the long term function of very preterm infants on those with more social limitations. Consistent with this suggestion is the recognition among several results of trials of early intervention programs that benefits are difficult to demonstrate, except among those with more social disadvantages. Presumably, families with more resources (of all kinds) may well already be able to provide the kind of environment which aids the very preterm infant to achieve their potential, those with more difficulties need more assistance to end up in the same place.

I think in the future we should find ways to screen families in neonatal follow-up to identify those that will most benefit from intervention aimed at improving outcomes, the families most likely to benefit are likely to be those who have more limited resources.

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Back to Blogging

Hello everyone, as we return slowly to Montréal, with a little stop-off on the way for an excellent conference in San Diego (Cool Topics in Neonatology, organised by my good friend Yvonne Vaucher), I am starting to see time and opportunities and topics for blogging.

While I was away the number of page views of this blog clicked over the 250,000 mark since inception. I have also met many individuals who claimed to read the blog and told me they found it useful. The feedback is much appreciated and helps me to be motivated to keep going.

Over the next few days I will be posting about some recent publications I have been involved with, about what is happening with probiotics, about suctioning for meconium, and other selected issues.

I will also post a steady stream of ‘not neonatology’ posts about my travels, with associated Photos.

In addition I have added a Photos page which you can reach from the top menu, with a few of my bird and wildlife photos, and occasionally others that I think are OK. When I post new photos on that page I will probably give a heads-up on the main page. Here, as a little taster is a photo of an Australian Parrot called a Galah. (To be more precise, as a budding ornithologist, I guess I should say that the Galah is a member of the Cockatoo family, the Cacatuidae. Species name is Eolophus roseicapilla). GalahOne of the things which struck me in Australia was the variety of the birds that could be seen easily with little effort, many which were strikingly attractive.

I hope you will enjoy them as much as I have.

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Internet Access Issues

Just a note to let everyone know that I have not fallen off the planet, even though we are on the bottom half, we are well stuck on. No internet access at the last place, and none next week either. I will restart the postings as soon as I have reliable access.

 

See you all soon!

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Not neonatology: the antipodes week 5. Te Anau, Mount Luxmore, and the Otago peninsula

We moved on again last week, spent a few days at Te Anau, which is just east of fiordland, in the southern part of the south island. From here we were able to go on a trip to cruise on Doubtful Sound, a long beautiful fiord which we cruised right to the ocean (to encounter Fur Seals, dolphins and albatross) and back.

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Doubtful Sound

The next day  we decided to hike the first, steep, part of the Kepler track. New Zealand is a great place for walkers, there are a number of Trails and Tracks which are very well maintained and signposted, and pass through glorious scenery. Several multi-day walks are now famous, including the 4 day Milford Track, which is usually very wet, and not recommended for children, and the 4-day Kepler track. This is a loop track of about 60 km total, which has 3 huts along the trail for overnight stops. It is actually a track which was designed as such from scratch, compared to most which have gradually developed over the years from the walking trails of multiple earlier hikers. The first part of the track is quite steep, rising about 900 metres in the first 8 kilometres, up to the Luxmore hut. We decided to do this first part of the walk with the kids, after crossing the lake in a boat to miss out the first 8 km from the town to the start of the climb, planning to walk the whole track back to the town when we got back down the slope.

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View from the summit of Mount Luxmore

After our lunch at the Luxmore hut we decided that it would be a shame to miss the last part of the climb to the actual summit of Mount Luxmore, so we decided to add the “little” extra to our hike. After a short, relatively, flat section the track started to climb again, with about another 300 meters up over a 5 km section of the track, ending with clambering over broken rocks to reach the summit at 1471 metres, having started the day at lake level, about 270 metres.  The views were glorious, and we were all feeling proud of ourselves, but it was maybe a mistake in the end, by the time we got back down the mountain and walked around the lake, we had covered over 31 kilometers in the day, which is the equivalent of completing the difficult half of the Kepler Track, in one day, with kids aged 7, 9 and 11 years old! The kids were exhausted, as you can see the picture at the end of the post on Violette’s blog, but they were all very proud of having climbed to the peak, and of covering such a long distance.

At the end of the week we moved on to Dunedin, to a house on the Otago peninsula.

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Otago Bay, from our window

With this great view over the Otago bay. The peninsula has some interesting easy walks (to compensate for Mount Luxmore) with great widlife viewing opportunities, including the only mainland nesting site of an albatross. The Royal Northern Albatross nests on the tip of the peninsula for the last 80 0r or so years, and you can also see Little Blue Penguins, and New Zealand Sea Lions. Getting close to abatross was great, they are huge, although not the biggest of the albatross apparently.  Here is one in flight, close to a gull, which I think was a black backed gull, already a very large bird.

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Albatross and Gull

We hadn’t been sure about the part of our trip, visiting the Otago peninsula, but in the end the visits to Dunedin (the Museum and the Cadbury chocolate factory being hits with the children) and the walks, with and without wildlife encounters, were really worthwhile.

I have been experimenting a bit with HDR photographs, here are 2 that I think were succesful, both from the region.

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Hooper’s Inlet, on the Otago peninsula

 

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Allans Beach

 

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Not Neonatology: Baby Birds! Aaaah..

Some of you may recently have seen a partially completed blog post, that accidentally got emailed out to people. It was actually a draft of a post for my son’s blog (I should add that apparently what Axel photographed as a Yellowhead is actually a Yellowhammer) . He and Violette are both intermittently blogging about our trip. Their blogs are at Tentacules.blog.com and at Violettebj.blog.com, Tai also supplies blog posts for Axel’s blog; he has been the most productive with his drawings of his favourite activities each day, accompanied by a text that he writes himself.

So, for anyone who likes bird pictures, here are a few of my own to satisfy your cravings. We have been lucky enough to be here when many birds are raising chicks, and have seen quite a few examples, starting with this stilt, whose baby is on the other side of the stream.

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This Variable Oystercatcher got quite noisy and agitated if you got too close to her (him?) and her chick.1-IMG_4425

The Red-Billed Gulls had many chicks in their colony1-IMG_4526

Yellow-Eyed Penguins are critically endangered; this was taken in a protected habitat. The chicks should soon fledge and set off on their own.1-IMG_4640

This is a juvenile Caspian Tern, who was being watched by a parent, who was about half a metre away. UPDATE* this is apparently a White-Fronted Tern, not a Caspian, thank you Brian Darlow, for the correction, and also for helping increase my lifetime list by one!

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And this pair of pretty Australasian Crested Grebes and chick were seen on lake Alexandrina, the chick has a zebra striped head and is soooo cute.

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This ungainly, but attractive bird is a Pukeko, its chick is in the long grass in front of it:1-IMG_4998-001

here is a close-up:

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All the birds above are native New Zealand species, I will end with an introduced bird, the California Quail. Many birds have been introduced for reasons that aren’t clear to me, who would bother introducing House Sparrows or Starlings? Quail chicks can’t help their origins though, I suppose, these were being shepherded by their parents.

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Shining a Light on Brain Oxygenation

A few years ago I was at a conference, where Gorm Greisen made a comment, after a talk I had given, that we really needed RCTs of new monitoring techniques, and specifically NIRS. Proving that a new technique actually improved outcomes was the best way to show that it was actually measuring something important, and that responding to the monitor was a good thing to do.

I admire people who will make comments like that, and then follow through on them.

A publication from a multi-center European group, led by Gorm, has accomplished the first stage of this evaluation. About 160 very preterm babies all had NIRS devices in place over the first 72 hours of life, they were randomized to either have the results displayed to the care staff, or hidden until the end of the study. The primary outcome was the percentage of time spent outside of the target range of 55-85%, which is thought to be a safe target range, based on prior data from some of the investigators. Having the NIRS data available reduced the out of range (and particularly the hypoxia) periods dramatically.

It is not immediately clear to me from this publication exactly what the investigators did when the NIRS was too low (or too high). But another publication includes the treatment algorithm, which includes suggestions of what to do when the the cerebral oxygen saturation is below 55% or above 85%. You could argue with some of the details of the responses suggested, but in general they seem reasonable.

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It seems therefore from this excellent trial, that knowing the value of the cerebral NIRS derived oxygention can help to stabilize the value within what are thought to be appropriate ranges. Hopefully the next stage in this evaluation will be to prove that this affects clinically important outcomes, in this trial mortality and severe brain injury were both less frequent in the NIRS visible group, but the differences, although large in relative terms, could well have been due to chance. A larger study focussed on these complications, with long term follow up, is now really needed, more than ever.

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