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Mohammad K. Standardizing clinician training and patient care in the neonatal neurocritical care: A step-by-step guide. Semin Perinatol 2024; 48:151924. [PMID: 38897827 DOI: 10.1016/j.semperi.2024.151924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Neonatal neurocritical care (NNCC) has emerged as an important specialty to address neurological conditions affecting newborns including a wide spectrum of brain injuries and developmental impairment. Despite the discipline's growth, variability in NNCC service delivery, patient care, and clinical training poses significant challenges and potentially adversely impacts patient outcomes. Variations in neuroprotective strategies, postnatal care, and training methodologies highlight the urgent need for a unified approach to optimize both short- and long-term neurodevelopmental outcomes for these vulnerable population. This paper presents strategic blueprints for establishing standardized NNCC clinical care and training programs focusing on collaborative effort across medical and allied health professions. By addressing these inconsistencies, the paper proposes that standardizing NNCC practices can significantly enhance the quality of care, streamline healthcare resource utilization, and improve neurodevelopmental outcome, thus paving the way for a new era of neonatal neurological care.
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Affiliation(s)
- Khorshid Mohammad
- Section of Newborn Critical Care, Department of Pediatrics, University of Calgary, Canada.
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Giesinger RE, El-Khuffash AF, McNamara PJ. Arterial pressure is not reflective of right ventricular function in neonates with hypoxic ischemic encephalopathy treated with therapeutic hypothermia. J Perinatol 2023; 43:162-167. [PMID: 36460796 DOI: 10.1038/s41372-022-01567-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/29/2022] [Accepted: 11/15/2022] [Indexed: 12/03/2022]
Abstract
AIM to evaluate the correlation of recovery of arterial pressure with physiological recovery among patients with hypoxic ischemic encephalopathy undergoing therapeutic hypothermia. METHODS At 24 h postnatal age, we compared 53 neonates of whom 22 (41%) were inotrope-treated to those untreated with cardiovascular medications. RESULTS Inotrope-treated patients had persistent severe right ventricular (RV) dysfunction and evidence of abnormal brain tissue oxygen delivery, despite recovered arterial pressure. CONCLUSION Arterial pressure is not reflective of RV function and the need for inotropic agents may be reflective of abnormal brain tissue oxygen delivery.
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Affiliation(s)
- R E Giesinger
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
- The Hospital for Sick Children, Toronto, ON, Canada
| | - A F El-Khuffash
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - P J McNamara
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA.
- The Hospital for Sick Children, Toronto, ON, Canada.
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.
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Variations in care of neonates during therapeutic hypothermia: call for care practice bundle implementation. Pediatr Res 2023:10.1038/s41390-022-02453-6. [PMID: 36624286 DOI: 10.1038/s41390-022-02453-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/15/2022] [Accepted: 12/14/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Therapeutic hypothermia (TH) is the gold-standard treatment for moderate and severe neonatal encephalopathy (NE). Care during TH has implications for long-term outcomes. Outcome variability exists among neonatal intensive care units (NICUs) in Canada, but care variations are not understood well. This study examines variations in care practices for neonates with NE treated with TH in NICUs across Canada. METHODS A non-anonymous, web-based questionnaire was emailed to tertiary NICUs in Canada providing TH for NE to assess care practices during the first days of life and neurodevelopmental follow-up. RESULTS Ninety-two percent (24/26) responded. Centres followed national guidelines regarding the use of the modified Sarnat score to assess the initial severity of NE, the need to initiate TH within the first 6 h of birth, and the importance of follow-up. However, other practices varied, including ventilation mode, definition/treatment of hypotension, routine echocardiography, use of sedation, use of electroencephalogram (EEG), MRI timing, placental analysis, and follow-up duration. CONCLUSIONS NICUs across Canada follow available national guidelines, but variations exist in practices for managing NE during TH. Development and implementation of a consensus-based care bundle for neonates during TH may reduce practice variability and improve outcomes. IMPACT This survey describes the current HIE care practices and variation among tertiary centres in Canada. Variations exist in the care of neonates with NE treated with TH in NICUs across Canada. This paper Identifies areas of variation that are not discussed in detail in the national guidelines and will help to set up quality improvement initiatives. Elucidating the variation in care practices calls for the creation and implementation of a national, consensus-based care bundle, with the objective to improve the outcomes of these critically ill neonates.
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Risk factors for unfavorable outcome at discharge of newborns with hypoxic-ischemic encephalopathy in the era of hypothermia. Pediatr Res 2022:10.1038/s41390-022-02352-w. [PMID: 36272997 DOI: 10.1038/s41390-022-02352-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/19/2022] [Accepted: 09/25/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To re-visit short-term outcomes and associated risk factors of newborns with hypoxic-ischemic encephalopathy (HIE) in an era where hypothermia treatment (HT) is widespread. METHODS This is a prospective population-based cohort in French neonatal intensive care units (NICU). Neonates born at or after 34 weeks of gestational age with HIE were included; main outcomes were in-hospital death and discharge with abnormal or normal MRI. Associations of early perinatal risk factors, present at birth or at admission to NICU, with these outcomes were studied. RESULTS A total of 794 newborns were included and HT was administered to 670 (84.4%); 18.3% died and 28.5% and 53.2% survived with abnormal and normal MRI, respectively. Severe neurological status, Apgar score at 5 mn ≤5, lactate at birth ≥11 mMoles/l, and glycemia ≥100 mg/dL at admission were associated with an increased risk of death (relative risk ratios (aRRR) (95% CI) 19.93 (10.00-39.70), 2.89 (1.22-1.62), 3.06 (1.60-5.83), and 2.55 (1.38-4.71), respectively). Neurological status only was associated with survival with abnormal MRI (aRRR (95% CI) 1.76 (1.15-2.68)). CONCLUSION Despite high use of HT in this cohort, 46.8% died or presented brain lesions. Early neurological and biological examinations were associated with unfavorable outcomes and these criteria could be used to target children who warrant further neuroprotective treatment. TRIAL REGISTRATION Clinical trial registry, NCT02676063, ClinicalTrials.gov. IMPACT In this population-based cohort of newborns with HIE where 84% received hypothermia, 46.8% still had an unfavorable evolution (death or survival with abnormal MRI). Risk factors for death were high lactate, low Apgar score, severe early neurological examination, and high glycaemia. While studies have established risk factors for HIE, few have focused on early perinatal factors associated with short-term prognosis. This French population-based cohort updates knowledge about early risk factors for adverse outcomes in the era of widespread cooling. In the future, criteria associated with an unfavorable evolution could be used to target children who would benefit from another neuroprotective strategy with hypothermia.
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Malai T, Khuwuthyakorn V, Kosarat S, Tantiprabha W, Manopunya S, Pomrop M, Katanyuwong K, Saguensermsri C, Wiwattanadittakul N. Short-term outcome of perinatal hypoxic-ischaemic encephalopathy at Chiang Mai University Hospital, Thailand: a 15-year retrospective study. Paediatr Int Child Health 2022; 42:109-116. [PMID: 36649461 DOI: 10.1080/20469047.2022.2163135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 12/20/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND The outcome of perinatal hypoxic-ischaemic encephalopathy (HIE) in middle-to-low-income countries varies between regions. OBJECTIVES To determine the mortality and morbidity, and factors influencing the deaths of infants with perinatal HIE. METHODS A retrospective study was conducted at Chiang Mai University Hospital, Thailand. Perinatal HIE infants of >35 weeks gestation, birthweight ≥2000 g and admitted during 2005-2019 were reviewed. Baseline Characteristics, clinical course and outcome at discharge were compared between the period before and after initiation of therapeutic hypothermia (TH). Risk of death in HIE infants who underwent TH was identified. RESULTS A total of 162 HIE infants were included. Compared to the period before TH initiation, the mortality rate was significantly decreased in the TH period. (27% vs. 12.8%, p=0.04) Among 100 HIE infants who underwent TH, the mortality rates was 14%(14/100), of whom 2.5% (2/76) and 50% (12/24) were in the moderate and severe HIE groups. Apgar score at 5 mins ≤1, severe HIE, seizures, hypoglycaemia, organ involvement ≥ five sites, ammonia ≥100 umol/L, lactate ≥14 mmol/L, and requirement for two or more inotropic drugs were risks of death. Multivariate analysis demonstrated that severe HIE (aOR 732.8, 95% CI 4.7-114643, p=0.01) and a need for two or more inotropic drugs (aOR 45.7, 95% CI 1.5-1040, p=0.029) were significant factors for mortality. CONCLUSION In the period of TH, perinatal HIE infants had decreased mortality. Severe HIE and a need for two or more inotropic drugs were associated with death in the infant with HIE who underwent TH.Abbreviations: AED: anti-epileptic drug; BW, birthweight; CI: confidence interval; CMU: Chiang Mai University; EEG: electro-encephalogram; GA: gestational age; HIE: hypoxic-ischaemic encephalopathy; IQR: interquartile range; NICU: neonatal intensive care unit; SD: standard deviation; TH: therapeutic hypothermia.
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Affiliation(s)
- Thanatcha Malai
- Neonatology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Varangthip Khuwuthyakorn
- Neonatology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Shanika Kosarat
- Neonatology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Watcharee Tantiprabha
- Neonatology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Satit Manopunya
- Neonatology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Malika Pomrop
- Neonatology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kamornwan Katanyuwong
- Neonatology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chinnuwat Saguensermsri
- Neonatology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Natrujee Wiwattanadittakul
- Neonatology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Ovali F. Hemodynamic changes and evaluation during hypoxic-ischemic encephalopathy and therapeutic hypothermia. Early Hum Dev 2022; 167:105563. [PMID: 35248984 DOI: 10.1016/j.earlhumdev.2022.105563] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 11/03/2022]
Abstract
Multiorgan damage is a hallmark of hypoxic-ischemic encephalopathy and cardiovascular and hemodynamic changes during asphyxia contribute significantly to the brain damage. The main insult to the heart is myocardial damage and associated ventricular dysfunction, which is manifested by reduced preload and afterload. The immature myocardium reacts to asphyxia by bradycardia and reduced contractile capacity. Pulmonary hypertension aggrevates cardiac dysfunction. Hypothermia is the only effective treatment for HIE but it may also affect the heart and peripheral vascular system leading to bradycardia and peripheral vasoconstriction. In fact, these effects might be cardioprotective also. Rewarming after hypothermia may increase the heart rate and cardiac metabolism, augmenting the cardiac output. Monitoring of patient with HIE during and after hypothermia is possible by using near-infrared spectroscopy, echocardiography and electrocardiography. Cerebral effects may be monitored by magnetic resonance imaging also. Management should include the physiological status of the patient and appropriate treatments, including inotropes, vasopressors or rarely fluid boluses. Dopamine should not be used unless absolutely necessary. Drugs like melatonin and magnesium are under investigation. All treatments should be evidence-based and targeted echocardiography should be used more often in these vulnerable infants.
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Affiliation(s)
- Fahri Ovali
- Istanbul Medeniyet University, Medical Faculty, Department of Pediatrics, Division of Neonatology, Göztepe, İstanbul, Turkey.
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Alburaki W, Scringer-Wilkes M, Dawoud F, Oliver N, Lind J, Zein H, Leijser LM, Esser MJ, Mohammad K. Feeding during therapeutic hypothermia is safe and may improve outcomes in newborns with perinatal asphyxia. J Matern Fetal Neonatal Med 2022; 35:9440-9444. [DOI: 10.1080/14767058.2022.2041594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | - Fady Dawoud
- Alberta Health Services, Alberta Children Hospital, Calgary, Canada
| | - Norma Oliver
- Alberta Health Services, Alberta Children Hospital, Calgary, Canada
| | - Janice Lind
- Alberta Health Services, Alberta Children Hospital, Calgary, Canada
| | - Hussein Zein
- Alberta Health Services, Alberta Children Hospital, Calgary, Canada
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, Canada
| | - Lara M. Leijser
- Alberta Health Services, Alberta Children Hospital, Calgary, Canada
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, Canada
| | - Michael J. Esser
- Alberta Health Services, Alberta Children Hospital, Calgary, Canada
- Department of Pediatrics, Sections of Pediatric Neurology, University of Calgary, Calgary, Canada
| | - Khorshid Mohammad
- Alberta Health Services, Alberta Children Hospital, Calgary, Canada
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, Canada
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Wintermark P, Mohammad K, Bonifacio SL. Proposing a care practice bundle for neonatal encephalopathy during therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101303. [PMID: 34711527 DOI: 10.1016/j.siny.2021.101303] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Neonates with neonatal encephalopathy (NE) often present with multi-organ dysfunction that requires multidisciplinary specialized management. Care of the neonate with NE is thus complex with interaction between the brain and various organ systems. Illness severity during the first days of birth, and not only during the initial hypoxia-ischemia event, is a significant predictor of adverse outcomes in neonates with NE treated with therapeutic hypothermia (TH). We thus propose a care practice bundle dedicated to support the injured neonatal brain that is based on the current best evidence for each organ system. The impact of using such bundle on outcomes in NE remains to be demonstrated.
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Affiliation(s)
- Pia Wintermark
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada.
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, 28 Oki Drive NW, T3B 6A8, Calgary, AB, Canada.
| | - Sonia L Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, 750 Welch Road, Suite 315, 94304, Palo Alto, CA, USA.
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- Newborn Brain Society, PO Box 200783, Roxbury Crossing, 02120, MA, USA
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Cardiovascular management following hypoxic-ischemic encephalopathy in North America: need for physiologic consideration. Pediatr Res 2021; 90:600-607. [PMID: 33070162 PMCID: PMC8249436 DOI: 10.1038/s41390-020-01205-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/19/2020] [Accepted: 07/06/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Hypotension and hypoxemic respiratory failure are common among neonates with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). Right ventricular (RV) dysfunction is associated with adverse neurodevelopment. Individualized management utilizing targeted neonatal echocardiography (TnECHO) may enhance care. METHODS We evaluated the influence of TnECHO programs on cardiovascular practices in HIE/TH patients utilizing a 77-item REDCap survey. Nominated representatives of TnECHO (n = 19) or non-TnECHO (n = 96) sites were approached. RESULTS Seventy-one (62%) sites responded. Baseline neonatal intensive care unit characteristics and HIE volume were comparable between groups. Most centers monitor invasive blood pressure; however, we identified 17 unique definitions of hypotension. TnECHO centers were likelier to trend systolic/diastolic blood pressure and request earlier echocardiography. TnECHO responders were less likely to use fluid boluses; TnECHO responders more commonly chose an inotrope first-line, while non-TnECHO centers used a vasopressor. For HRF, TnECHO centers chose vasopressors with a favorable pulmonary vascular profile. Non-TnECHO centers used more dopamine and more extracorporeal membrane oxygen for patients with HRF. CONCLUSIONS Cardiovascular practices in neonates with HIE differ between centers with and without TnECHO. Consensus regarding the definition of hypotension is lacking and dopamine use is common. The merits of these practices among these patients, who frequently have comorbid pulmonary hypertension and RV dysfunction, need prospective evaluation. IMPACT Cardiovascular care following HIE while undergoing therapeutic hypothermia varies between centers with access to trained hemodynamics specialists and those without. Because cardiovascular dysfunction is associated with brain injury, precision medicine-based care may be an avenue to improving outcomes. Therapeutic hypothermia has introduced new physiological considerations and enhanced survival. It is essential that hemodynamic strategies evolve to keep pace; however, little literature exists. Lack of consensus regarding fundamental definitions (e.g., hypotension) highlights the importance of collaboration among the scientific community to advance the field. The value of enhanced cardiovascular care guided by hemodynamic specialists requires prospective evaluation.
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Roychoudhury S, Esser MJ, Buchhalter J, Bello-Espinosa L, Zein H, Howlett A, Thomas S, Murthy P, Appendino JP, Scott JN, Metcalfe C, Lind J, Oliver N, Kozlik S, Mohammad K. Implementation of Neonatal Neurocritical Care Program Improved Short-Term Outcomes in Neonates With Moderate-to-Severe Hypoxic Ischemic Encephalopathy. Pediatr Neurol 2019; 101:64-70. [PMID: 31047757 DOI: 10.1016/j.pediatrneurol.2019.02.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Despite the introduction of therapeutic hypothermia, infants with moderate-to-severe hypoxic-ischemic encephalopathy remain at risk of mortality and morbidity. A dedicated service with standardized management protocols and improved communication may help improve care. We aimed to evaluate the impact of a dedicated neonatal neurocritical care service on short-term outcomes in infants with hypoxic-ischemic encephalopathy. METHODS We performed a retrospective cohort study (July 2008 to December 2017) on term and near-term infants admitted to two tertiary neonatal intensive care units with moderate-to-severe hypoxic-ischemic encephalopathy, before and after neonatal neurocritical care service implementation. The primary outcome was brain magnetic resonance imaging findings consistent with those of hypoxic-ischemic encephalopathy. Secondary outcomes included the cooling initiation rate, hospital stay duration, antiseizure medication use, and inotrope use. Regression analysis and interrupted time series analysis were performed after adjusting for confounding factors. RESULTS In total, 216 infants with moderate-to-severe hypoxic-ischemic encephalopathy were analyzed-109 before and 107 after neonatal neurocritical care implementation. After adjusting for confounding factors, there was a significant reduction in primary outcomes (adjusted odds ratio: 0.3, confidence interval: 0.15 to 0.57, P < 0.001) after neonatal neurocritical care implementation. Average hospital stay duration reduced by 5.2 days per infant (P = 0.03), identification of eligible infants for cooling improved (P < 0.001), antiseizure medication use reduced (P = 0.001), and early inotropes use reduced (P = 0.04). CONCLUSION Implementation of a neonatal neurocritical care service associated with decreased brain injury shortened the hospital stay duration and improved the care of infants with moderate-to-severe hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Smita Roychoudhury
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Esser
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey Buchhalter
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Luis Bello-Espinosa
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Hussein Zein
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra Howlett
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Sumesh Thomas
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Prashanth Murthy
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Juan Pablo Appendino
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - James N Scott
- Departments of Diagnostic Imaging and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Metcalfe
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Jan Lind
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Norma Oliver
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Silvia Kozlik
- Section of Pediatric Neurology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
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