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Lighting the way to better baby care

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The brain injury technology University College London has been working on for eight years looks decidedly unremarkable.

Barely noticeable in the neonatal skyline of equipment is a trolley housing a laptop and what looks like a projector.

Yet the data it offers clinicians could accelerate improved care for brain injured babies in their crucial first few days. Currently, when babies suffer brain injury at or soon after birth due to lack of oxygen to the brain, doctors must wait several days until the newborn is stable enough for an MRI scan. Only then, usually at least four days after the birth, can they detect and assess the injury.

In these days before the MRI, there is poor visibility on whether treatments are working or how severe the injury may be.

But a new device, which has now passed a feasibility test involving over 50 babies with hypoxic-ischemic encephalopathy, could close this window of missed opportunity.

Dr Ilias Tachtsidis, biomedical engineer and team leader on the project, explains: “We wanted to know, from day one, what is happening to the biochemistry of the brain tissue in these babies. EEG shows how well the brain is doing in terms of the neuronal activity but it doesn’t show anything about how well the brain is getting oxygen or using it to produce energy.

“The other instrument at the doctors’ disposal is the MRI, but it is very difficult to take a sick, one-day-old baby for an MRI scan. The challenge was to develop a device that we can use immediately after the baby is born to inform the clinical team about the brain health of that baby.”

UCL engineers, doctors and scientists have combined forces in overcoming this challenge since 2010 – supported by funds from the Welcome Trust and access to UCL Hospital. The product of their endeavours is a seemingly transformative piece of cotside kit for neonatal intensive care wards.

Its magic is made possible through a technology that started life in the late seventies and has since emerged as a game- changer in internal body monitoring. Broadband near-infrared spectroscopy uses light with wavelengths just beyond the red end of the rainbow and is invisible to the eye. This near infrared light can travel far into the body – even through bone – while other colours with shorter wavelengths are absorbed and don’t pass through.

Light can reveal changing oxygen levels in the blood pumping through arteries and veins. Certain molecules in the brain, such as oxygen-carrying chemicals in the blood and cytochrome c oxidase in mitochondria, change colour depending on their activity and oxygen levels.

Different colour molecules absorb and reflect different colours of light, so by measuring the colours of the light passing through the brain, it is possible to work out the volume and activity of these molecules.

This data shows doctors which areas of the brain are working properly or have been damaged due to a lack of oxygen.

In the device, near-infrared light travels down optical fibres and is shone on the baby’s head. Some of it passes through the skull and brain and comes back to the surface.

This returning light is picked up by another optical fibre and travels to a spectrometer, which measures the relative amounts of different coloured light in the beams.

The light is then split into a spectrum of its constituent colours, using a prism or ‘diffraction grating’. Then a camera detects the amounts of each colour of light.

Finally, a computer calculates changes in the way certain parts of the brain are using oxygen and generating energy, giving a readout of brain metabolism and activity.

Tachtsidis says: “Our feasibility study has shown that the measurements can identify and classify newborn babies from day one; which ones are going to have a severe brain injury? Which will have severe or mild neuro- development issues?

“Our technology has shown a very high specificity in terms of classifying where the babies are going to be at two years old and five years old, for example. Are they going to have neurodevelopment issues, cerebral palsy or cognitive issues? We can identify this in babies from day one.”

Given that the device is cheap, cotside, non- invasive and harmless, industry parties are understandably circling; and Tachtsidis is hopeful of an eventual mainstream roll-out. It could take several years, however.

“Launching a medical device is a long process that requires a lot of regulation. We’ve had quite a few phone calls asking about
the device from various industry players, especially those interested in intensive care. I am hoping, with the help of UCL, we can manage to disseminate the value of this technology to the industry and get closer to a widely-available device.”

Next on UCL’s immediate agenda is figuring out how the data generated by the technology can influence better outcomes for brain injured newborns.

“We have a long way to go,” he says. “We still have to test how we can use this technology to manage treatment. We now have technology that, very early on, can prognosticate the impact of the brain injury on the baby.”

According to the National Neonatal Database, around three in 1,000 babies born in England suffer brain injury at or soon after birth, due to lack of oxygen during delivery. In the US, this figure is estimated at between one and six. More than half of affected newborns will develop disabilities, while one in 10 dies.

The risk is higher in babies born before 37 weeks, where up to 26 in 1,000 babies are affected. The standard approach in hospitals is to cool the baby’s body temperature to slow their metabolic processes.

Often, babies are placed on a water-filled cooling blanket and monitored over several days. An IV may help to further reduce body temperature. According to one prominent expert in the field, Dr. Inder of Washington University School of Medicine, “neonatal therapeutic hypothermia can reduce the chance of severe brain injury by 25 per cent in term-born babies with poor transition or low Apgar scores after birth”.

Since the treatment is not effective in every baby, however, Tachtsidis believes the new light technology could save time by quickly identifying which newborns are not benefitting from it.

“The clinical team needs to know very early on if this is not working for the infants to decide what else they can do about [the injury]. They need a measurement that enables this.”

There are various hurdles to get through before UCL’s technology is commercially available to hospital management. “Clearly we are looking at how we can disseminate our work and roll it out to more hospitals.

“We also need to build a demonstrator unit and, once we have that, we can move towards a clinical trial. There may also be some education required in terms of helping clinicians to understand the data and act on it.”

If UCL’s bright minds can prove to the world that their creation is a worthy addition to the hospital cotside, it could be a revelation in brain injury care.

The impact of a brain injury at birth due to decreased oxygen (hypoxia) and blood flow (ischemia) can lead to intensive, life-long care needs. Speeding up the immediate response time to unfolding events in the brain might change the life trajectory of newborns.

In the UK, the healthcare sector’s approach to baby brain injury risk has been a contentious issue in recent years. In some quarters, the drive for natural births has been blamed for a seeming rise in maternity ward injuries.

Last year the Royal College of Midwives formally announced it had discontinued its 12-year campaign for normal births without medical intervention.

Meanwhile, a 2017 study by the Royal College of Obstetricians and Gynaecologists suggests that most baby brain injuries in labour are avoidable.

It analysed 1,136 stillbirths, neonatal deaths and brain injuries on UK maternity wards in 2015. Three quarters of the babies – 854 of which suffered a brain injury – might have had a different outcome if they had received different care, researchers said.

While baby brain injury is a medical issue that can have a profound effect on families, their financial impact is also under scrutiny.

A report by NHS Resolution last year showed that compensation claims for new-borns with brain injuries or cerebral palsy soared 23 per cent in 2016/17 to 232. Their collective claim value was £1.9bn. It is predicted that the per- child claim value could soon hit £20m, NHS Resolution said.

For all concerned – families, the NHS, neonatal professionals and, of course, the tiny patients who will enter the world fighting for survival – much is riding on the success of UCL’s promising project.

Find out more at www.metabolight.org

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More retired rugby players report concussion than any other injury

Concussion is the most common injury among retired rugby athletes, according to new research.

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Researchers from Durham University and Auckland University of Technology compared the injuries of retired rugby athletes with retired non-contact athletes.

They found that retired elite rugby athletes reported up to seven times the number of injuries than those who played amateur rugby and non-contact sports, and concussion was the most commonly reported injury, and had the most common recurrence, for both groups of rugby players compared to non-contact athletes.

Among retired rugby athletes, 81 per cent of elite and 76 per cent of amateur players reported at least one concussion, and concussion injury had the highest recurrence.

The rugby athletes, who were all code athletes, which means they played rugby union or rugby league, were also up to 10 times more likely to report experiencing a lasting impact of previous concussion, among other injuries, including back and joint pain.

The researchers concluded that past participation in rugby union and rugby league, particularly at elite level, is linked to a higher risk of cumulative injuries and a continued impact of previous injuries after retiring from the game.

Retired elite rugby code players reported that previous concussions had a negative impact on their current health, the researchers found.

They urge that there should be more efforts to reduce injuries in rugby codes at all levels, given such a high number of concussions.

“The monitoring of injuries at the player level rather than at club level could be one approach to improving the management of injury for individualised player welfare,” the paper, published today in the journal Sports Medicine, states.

“This could include a system by which the individual player’s injury history can be followed as they move across professional club contracts, and specific strength and conditioning and sports therapy strategies prescribed to help prevent recurrence of injury.”

This is the first study to examine total injuries across entire careers of contact sport athletes, according to the researchers, and the reported effects on physical wellbeing post-retirement.

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Half of brain injury survivors lost access to rehab

More than half of brain injury survivors have lost access to rehab due to lockdown measures, and fear for their futures, according to research by Headway.

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Fifty-seven per cent of people surveyed, who had all sustained their injuries in the last two years, say their access to specialist treatment has been negatively impacted from lockdown measures.

Among those living with the long-term effects of brain injury, two thirds reported that their mental health has deteriorated due to government measures to control the spread of Covid-19, and the same number fear for their futures.

These findings highlight the importance of ensuring those affected by brain injury are provided with appropriate physical, psychological and social rehabilitation, says Headway.

Peter McCabe, the charity’s chief executive of Headway, says the findings are ‘deeply concerning’.

“The first two years following a brain injury are very important in terms of a patient’s long-term prognosis and any delay to receiving specialist rehabilitation can impact their ability to lead an independent life in the future,” he says. 

“Of equal concern is the short-term impact of the lockdown on survivors and their families.

“The effects of brain injury, such as problems with memory, a lack of insight or difficulties controlling behaviour and emotions, can mean that survivors face significant challenges in understanding and coping with the necessary safeguards put in place to deal with the pandemic.

“This can lead to conflict with other members of public as a result of not remembering the rules around social distancing, or excess pressure and emotional toil being placed on carers and family members.

“With local authorities under increasing financial pressure, local charities are facing an uphill battle to survive, exacerbating survivors’ fears for the future.

“Unless the government provides local authorities with adequate funding for community-based rehabilitation services, thousands of brain injury survivors and carers will either be left without support or be forced to rely on more costly state-funded care.”

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Delays in neurological treatment for seven in 10 patients

More than seven in 10 people with neurological conditions report delays to medical appointments due to Covid-19, according to new research.

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This means people with long-term neurological conditions could be missing out on vital tests and treatment, according to the Neurological Alliance.

More than 70 per cent of those who replied to the Neurological Alliance’s survey between 9 and 20 June said their NHS appointments had been delayed, and four in 10 did not know when their appointment would be rescheduled.

Due to the risk of infection and many staff being redeployed, most face-to-face neurology appointments have been delayed or cancelled.

“For some people with a neurological condition,” the Neurological Alliance states, “missing out on the right treatment at the right time can have life-changing consequences.

“For example, advanced drug therapies for Parkinson’s only have a short window during which they can be effective, so some people could already have lost their opportunity to have a life-changing therapy.

“Certain disease modifying treatments for multiple sclerosis, which reduce relapses and slow the progression of the condition, have also been delayed or cancelled in some NHS clinics.”

Without improved capacity across neurological services, the charity warns that people with neurological conditions risk facing further, potentially life-changing, delays.

Many people with neurological conditions were advised to ‘shield’ during the pandemic, due to being high-risk. The government relaxed guidelines around shielding on 5 July, and plan to pause of from 1 August. The report, however, found that people with neurological conditions who were shielding are concerned about the risks of going out more.

Half of respondents reported finding the government’s advice on shielding to be unclear, almost a third had difficulty accessing their normal food supplies and almost a quarter had experienced difficulties getting their regular medication.

Almost one in four respondents reported feeling lonely, and one in 10 felt hopeless.

The Neurological Alliance is urging NHS England to set out plans to ensure an immediate restart of services as soon as it’s safe to do so. The charity is also calling for:

  • Specialist neurology staff redeployed to COVID-19 wards to restore staffing in neurology departments to pre-Covid-19 levels
  • Adequate support within NHS mental health services to deal with the immediate mental health needs of people with neurological conditions who have been shielding or self-isolating
  • Patients discharged prematurely due to COVID-19 to be regularly reviewed to ensure their mobility and motor skills are not deteriorating

Georgina Carr, chief executive of the Neurological Alliance, says: “While health and care professionals have done all they can to retain some contact with people with neurological conditions during this crisis, our survey clearly shows that people with suspected and confirmed neurological conditions are being left in complete limbo while frontline services have been diverted to treat COVID-19 patients.

“This just isn’t acceptable and means thousands of people are not getting the life-changing treatment and support they so desperately need. People with neurological conditions must not be left in the dark any longer.”

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