̽��ֱ�� of Cambridge - surgery

Team’s hip replacement surgery invention is set to be world first

sc604 — Fri, 13 Sep 2024 11:18:10 +0000

They have just won an award to develop their technology, which aims to make hip surgery more precise and deliver better and longer-lasting outcomes – which is good for patients and the NHS.

̽��ֱ��National Institute for Health and Care Research (NIHR) has awarded a £1.4 million Invention for Innovation (i4i) Product Development Award to advance work on the team’s “smart” joint “trial liner”.

̽��ֱ��sensors measure forces passing through the hip joint to help the surgeon assess and balance the soft tissues, which aids the accurate positioning of the implant.

Once measurements are complete using the wireless surgical aid, the surgeon marks the ideal position for the implant, removes the smart trial liner, and completes the operation.

There are currently no technologies that can deliver such readings during an operation and in real-time, and instead surgeons balance the joint based on feel and anatomical landmarks.

This is despite over two million total hip replacements being performed annually, with the number constantly rising due to increasing lifespans. Younger patients are starting to need hip replacements as well, so implants need to withstand higher stresses and last longer, to avoid spiralling into a vicious circle of revision surgery and higher rates of dissatisfaction.

Driving this clinical initiative is the chief investigator from Cambridge ̽��ֱ�� Hospitals (CUH) NHS Foundation Trust, Consultant orthopaedic surgeon, clinical and research lead of the Young Adult Hip Service, and Affiliate Associate Professor at the ̽��ֱ�� of Cambridge Vikas Khanduja.

̽��ֱ��technology development is being overseen by Professor Sohini Kar-Narayan from Cambridge’s Department of Materials Science and Metallurgy, together with Dr Jehangir Cama, who is leading on translational and commercialisation activities. They are joined by Consultant clinical scientist and CUH head of clinical engineering, Professor Paul White.

“We’re really looking forward to this next phase of product development that will see us move towards an actual product that is fit for clinical use, and that has the potential to revolutionise joint replacement surgery,” said Kar-Narayan.

“This funding will bring together wide-ranging expertise to help us further develop our prototype, bringing this technology closer to clinical use,” said Cama.

̽��ֱ��team currently has a prototype version of the device, which has been validated in the laboratory and in other tests. However, the NIHR award is important for further development and finalisation of the design and compliance with regulations before it can be tested in a living patient.

̽��ֱ��team’s underlying sensor technology intellectual property has been protected via a patent application filed by Cambridge Enterprise, the ̽��ֱ��’s commercialisation arm.

“This is a fantastic example of Cambridge’s entrepreneurial clinicians, academics and their institutions working together with forward-looking funders to create a positive impact for markets, society and importantly patients,” said Dr Terry Parlett, Commercialisation Director at Cambridge Enterprise.

Adapted from a CUH press release.

Technology that could transform the future of hip replacement surgery is being pioneered by a team of experts in Cambridge.

SEBASTIAN KAULITZKI/SCIENCE PHOTO LIBRARY via Getty Images

Illustration of a human hip joint

̽��ֱ��text in this work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Images, including our videos, are Copyright © ̽��ֱ�� of Cambridge and licensors/contributors as identified. All rights reserved. We make our image and video content available in a number of ways – on our main website under its Terms and conditions, and on a range of channels including social media that permit your use and sharing of our content under their respective Terms.

Yes

‘Wraparound’ implants represent new approach to treating spinal cord injuries

sc604 — Wed, 08 May 2024 18:01:25 +0000

A team of engineers, neuroscientists and surgeons from the ̽��ֱ�� of Cambridge developed the devices and used them to record the nerve signals going back and forth between the brain and the spinal cord. Unlike current approaches, the Cambridge devices can record 360-degree information, giving a complete picture of spinal cord activity.

Tests in live animal and human cadaver models showed the devices could also stimulate limb movement and bypass complete spinal cord injuries where communication between the brain and spinal cord had been completely interrupted.

Most current approaches to treating spinal injuries involve both piercing the spinal cord with electrodes and placing implants in the brain, which are both high-risk surgeries. ̽��ֱ��Cambridge-developed devices could lead to treatments for spinal injuries without the need for brain surgery, which would be far safer for patients.

While such treatments are still at least several years away, the researchers say the devices could be useful in the near-term for monitoring spinal cord activity during surgery. Better understanding of the spinal cord, which is difficult to study, could lead to improved treatments for a range of conditions, including chronic pain, inflammation and hypertension. ̽��ֱ��results are reported in the journal Science Advances.

“ ̽��ֱ��spinal cord is like a highway, carrying information in the form of nerve impulses to and from the brain,” said Professor George Malliaras from the Department of Engineering, who co-led the research. “Damage to the spinal cord causes that traffic to be interrupted, resulting in profound disability, including irreversible loss of sensory and motor functions.”

̽��ֱ��ability to monitor signals going to and from the spinal cord could dramatically aid in the development of treatments for spinal injuries, and could also be useful in the nearer term for better monitoring of the spinal cord during surgery.

“Most technologies for monitoring or stimulating the spinal cord only interact with motor neurons along the back, or dorsal, part of the spinal cord,” said Dr Damiano Barone from the Department of Clinical Neurosciences, who co-led the research. “These approaches can only reach between 20 and 30 percent of the spine, so you’re getting an incomplete picture.”

By taking their inspiration from microelectronics, the researchers developed a way to gain information from the whole spine, by wrapping very thin, high-resolution implants around the spinal cord’s circumference. This is the first time that safe 360-degree recording of the spinal cord has been possible – earlier approaches for 360-degree monitoring use electrodes that pierce the spine, which can cause spinal injury.

̽��ֱ��Cambridge-developed biocompatible devices – just a few millionths of a metre thick – are made using advanced photolithography and thin film deposition techniques, and require minimal power to function.

̽��ֱ��devices intercept the signals travelling on the axons, or nerve fibres, of the spinal cord, allowing the signals to be recorded. ̽��ֱ��thinness of the devices means they can record the signals without causing any damage to the nerves, since they do not penetrate the spinal cord itself.

“It was a difficult process, because we haven’t made spinal implants in this way before, and it wasn’t clear that we could safely and successfully place them around the spine,” said Malliaras. “But because of recent advances in both engineering and neurosurgery, the planets have aligned and we’ve made major progress in this important area.”

̽��ֱ��devices were implanted using an adaptation to routine surgical procedure so they could be slid under the spinal cord without damaging it. In tests using rat models, the researchers successfully used the devices to stimulate limb movement. ̽��ֱ��devices showed very low latency – that is, their reaction time was close to human reflexive movement. Further tests in human cadaver models showed that the devices can be successfully placed in humans.

̽��ֱ��researchers say their approach could change how spinal injuries are treated in future. Current attempts to treat spinal injuries involve both brain and spinal implants, but the Cambridge researchers say the brain implants may not be necessary.

“If someone has a spinal injury, their brain is fine, but it’s the connection that’s been interrupted,” said Barone. “As a surgeon, you want to go where the problem is, so adding brain surgery on top of spinal surgery just increases the risk to the patient. We can collect all the information we need from the spinal cord in a far less invasive way, so this would be a much safer approach for treating spinal injuries.”

While a treatment for spinal injuries is still years away, in the nearer term, the devices could be useful for researchers and surgeons to learn more about this vital, but understudied, part of human anatomy in a non-invasive way. ̽��ֱ��Cambridge researchers are currently planning to use the devices to monitor nerve activity in the spinal cord during surgery.

“It’s been almost impossible to study the whole of the spinal cord directly in a human, because it’s so delicate and complex,” said Barone. “Monitoring during surgery will help us to understand the spinal cord better without damaging it, which in turn will help us develop better therapies for conditions like chronic pain, hypertension or inflammation. This approach shows enormous potential for helping patients.”

̽��ֱ��research was supported in part by the Royal College of Surgeons, the Academy of Medical Sciences, Health Education England, the National Institute for Health Research, MRC Confidence in Concept, and the Engineering and Physical Sciences Research Council (EPSRC), part of UK Research and Innovation (UKRI).

Reference:
Ben J Woodington, Jiang Lei et al. ‘Flexible Circumferential Bioelectronics to Enable 360-degree Recording and Stimulation of the Spinal Cord.’ Science Advances (2024). DOI: 10.1126/sciadv.adl1230

A tiny, flexible electronic device that wraps around the spinal cord could represent a new approach to the treatment of spinal injuries, which can cause profound disability and paralysis.

Because of recent advances in both engineering and neurosurgery, the planets have aligned and we’ve made major progress in this important area

George Malliaras

SEBASTIAN KAULITZKI/SCIENCE PHOTO LIBRARY

Illustration of spinal cord

Yes

Robotic nerve ‘cuffs’ could help treat a range of neurological conditions

sc604 — Fri, 26 Apr 2024 08:55:34 +0000

̽��ֱ��researchers, from the ̽��ֱ�� of Cambridge, combined flexible electronics and soft robotics techniques to develop the devices, which could be used for the diagnosis and treatment of a range of disorders, including epilepsy and chronic pain, or the control of prosthetic limbs.

Current tools for interfacing with the peripheral nerves – the 43 pairs of motor and sensory nerves that connect the brain and the spinal cord – are outdated, bulky and carry a high risk of nerve injury. However, the robotic nerve ‘cuffs’ developed by the Cambridge team are sensitive enough to grasp or wrap around delicate nerve fibres without causing any damage.

Tests of the nerve cuffs in rats showed that the devices only require tiny voltages to change shape in a controlled way, forming a self-closing loop around nerves without the need for surgical sutures or glues.

̽��ֱ��researchers say the combination of soft electrical actuators with neurotechnology could be an answer to minimally invasive monitoring and treatment for a range of neurological conditions. ̽��ֱ��results are reported in the journal Nature Materials.

Electric nerve implants can be used to either stimulate or block signals in target nerves. For example, they might help relieve pain by blocking pain signals, or they could be used to restore movement in paralysed limbs by sending electrical signals to the nerves. Nerve monitoring is also standard surgical procedure when operating in areas of the body containing a high concentration of nerve fibres, such as anywhere near the spinal cord.

These implants allow direct access to nerve fibres, but they come with certain risks. “Nerve implants come with a high risk of nerve injury,” said Professor George Malliaras from Cambridge’s Department of Engineering, who led the research. “Nerves are small and highly delicate, so anytime you put something large, like an electrode, in contact with them, it represents a danger to the nerves.”

“Nerve cuffs that wrap around nerves are the least invasive implants currently available, but despite this they are still too bulky, stiff and difficult to implant, requiring significant handling and potential trauma to the nerve,” said co-author Dr Damiano Barone from Cambridge’s Department of Clinical Neurosciences.

̽��ֱ��researchers designed a new type of nerve cuff made from conducting polymers, normally used in soft robotics. ̽��ֱ��ultra-thin cuffs are engineered in two separate layers. Applying tiny amounts of electricity – just a few hundred millivolts – causes the devices to swell or shrink.

̽��ֱ��cuffs are small enough that they could be rolled up into a needle and injected near the target nerve. When activated electrically, the cuffs will change their shape to wrap around the nerve, allowing nerve activity to be monitored or altered.

“To ensure the safe use of these devices inside the body, we have managed to reduce the voltage required for actuation to very low values,” said Dr Chaoqun Dong, the paper’s first author. “What's even more significant is that these cuffs can change shape in both directions and be reprogrammed. This means surgeons can adjust how tightly the device fits around a nerve until they get the best results for recording and stimulating the nerve.”

Tests in rats showed that the cuffs could be successfully placed without surgery, and formed a self-closing loop around the target nerve. ̽��ֱ��researchers are planning further testing of the devices in animal models, and are hoping to begin testing in humans within the next few years.

“Using this approach, we can reach nerves that are difficult to reach through open surgery, such as the nerves that control, pain, vision or hearing, but without the need to implant anything inside the brain,” said Barone. “ ̽��ֱ��ability to place these cuffs so they wrap around the nerves makes this a much easier procedure for surgeons, and it’s less risky for patients.”

“ ̽��ֱ��ability to make an implant that can change shape through electrical activation opens up a range of future possibilities for highly targeted treatments,” said Malliaras. “In future, we might be able to have implants that can move through the body, or even into the brain – it makes you dream how we could use technology to benefit patients in future.”

̽��ֱ��research was supported in part by the Swiss National Science Foundation, the Cambridge Trust, and the Engineering and Physical Sciences Research Council (EPSRC), part of UK Research and Innovation (UKRI).

Reference:
Chaoqun Dong et al. ‘Electrochemically actuated microelectrodes for minimally invasive peripheral nerve interfaces.’ Nature Materials (2024). DOI: 10.1038/s41563-024-01886-0

Researchers have developed tiny, flexible devices that can wrap around individual nerve fibres without damaging them.

̽��ֱ��ability to make an implant that can change shape through electrical activation opens up a range of future possibilities for highly targeted treatments

George Malliaras

XH4D via iStock / Getty Images Plus

Illustration of the human nervous system

Yes

International study recommends replacing skull section after treatment for a brain bleed

cjb250 — Sun, 23 Apr 2023 19:30:09 +0000

̽��ֱ��RESCUE-ASDH trial, funded by the UK’s National Institute for Health and Care Research (NIHR), involved 40 centres in 11 countries and involved 450 patients. ̽��ֱ��results of the trial are published today in the New England Journal of Medicine and are announced at the annual meeting of the American Association of Neurological Surgeons.

One of the potentially life-threatening results of head injury is a so-called acute subdural haematoma – a bleed that occurs between the brain and skull and can lead to the build-up of pressure. Such haemorrhages require surgery to stem the bleeding, remove the blood clot and relieve the pressure.

At present, there are two approaches to such surgery. One approach is a decompressive craniectomy, which involves leaving a section of the skull out – which can be as large as 13cm in length – in order to protect the patient from brain swelling, often seen with this type of haemorrhage. ̽��ֱ��missing skull typically will need to be reconstructed and in some treatment centres, the patient’s own bone will be replaced several months after surgery, while at other centres a manufactured plate is used.

̽��ֱ��second approach is a craniotomy, in which the skull section is replaced after the haemorrhage has been stemmed and the blood clot removed. This approach will obviate the need for a skull reconstruction further down the line.

To date there has been little conclusive evidence and hence no uniformly accepted criteria for which approach to use. To solve this question, an international team led by researchers at the ̽��ֱ�� of Cambridge and Cambridge ̽��ֱ�� Hospitals NHS Foundation Trust carried out a randomised trial – RESCUE-ASDH – in which patients undergoing surgery for traumatic acute subdural haematoma were randomly assigned to undergo decompressive craniectomy or craniotomy.

A total of 228 patients were assigned to the craniotomy group and 222 to the decompressive craniectomy group. ̽��ֱ��researchers assessed the outcomes for these patients and their quality of life up to a year after surgery, as measured on clinical evaluation scales.

Patients in both groups had similar disability-related and quality-of-life outcomes at 12 months post-surgery, with a trend – which was not statistically significant – towards better outcomes with craniotomy.

Around one in four patients (25.6%) in the craniotomy group and one in five (19.9%) in the decompressive craniectomy group had a good recovery as measured on the scales.

Around one in three patients in both groups (30.2% of patients in the craniotomy group and 32.2% of those in the decompressive craniectomy group) died within the first 12 months following surgery.

14.6% of the craniotomy group and 6.9% of the decompressive craniectomy group required additional cranial surgery within two weeks after randomisation. However, this was balanced against the fact that fewer people in the craniotomy group experienced wound complications (3.9% against 12.2% of the decompressive craniectomy group).

Professor Peter Hutchinson, Professor of Neurosurgery at Cambridge and the trial's Chief Investigator, said: " ̽��ֱ��international randomised trial RESCUE-ASDH is the first multicentre study to address a very common clinical question: which technique is optimal for removing an acute subdural haematoma – a craniotomy (putting the bone back) or a decompressive craniectomy (leaving the bone out)?

“This was a large trial and the results convincingly show that there is no statistical difference in the 12 month disability-related and quality of life outcomes between the two techniques.”

Professor Angelos Kolias, Consultant Neurosurgeon at Cambridge and the trial's Co-chief Investigator, said: "Based on the trial findings, we recommend that after removing the blood clot, if the bone flap can be replaced without compression of the brain, surgeons should do so, rather than performing a pre-emptive decompressive craniectomy.

“This approach will save patients from having to undergo a skull reconstruction, which carries the risk of complications and additional healthcare costs, further down the line.”

̽��ֱ��researchers point out, however, that the findings may not be relevant for resource-limited or military settings, where pre-emptive decompressive craniectomy is often used owing to the absence of advanced intensive care facilities for post-operative care.

Professor Andrew Farmer, Director of NIHR’s Health Technology Assessment (HTA) Programme, said: “ ̽��ֱ��findings of this world-leading trial provide important evidence which will improve the way patients with head injuries are treated. High quality, independently funded research like this is vital in providing evidence to improve health and social care practice and treatments. Research is crucial in informing those who plan and provide care.”

̽��ֱ��RESCUE-ASDH trial was supported by the NIHR Global Health Research Group on Acquired Brain and Spine Injury, the CENTER-TBI project of the European Brain Injury Consortium, and the Royal College of Surgeons of England Clinical Research Initiative.

Reference
Hutchinson, PJ et al. Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma. NEJM; 23 Apr 2023; DOI: 10.1056/NEJMoa2214172

A major international trial has concluded that, where possible, surgeons should replace the removed section of the skull following surgery to treat a form of brain haemorrhage. This approach will save patients from having to undergo skull reconstruction further down the line.

This approach will save patients from having to undergo a skull reconstruction, which carries the risk of complications and additional healthcare costs, further down the line

Angelos Kolias

www.tredz.co.uk/

Bike Crash - Road Traffic Accident

̽��ֱ��text in this work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Images, including our videos, are Copyright © ̽��ֱ�� of Cambridge and licensors/contributors as identified. All rights reserved. We make our image and video content available in a number of ways – as here, on our main website under its Terms and conditions, and on a range of channels including social media that permit your use and sharing of our content under their respective Terms.

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Cambridge researchers change donor kidney blood type

fpjl2 — Mon, 15 Aug 2022 10:18:07 +0000

Researchers have been able to alter the blood type of deceased donor kidneys using “molecular scissors”.

Heart surgery delays will cost lives, warns research

sc604 — Fri, 17 Jun 2022 09:19:34 +0000

Urgent action is needed to clear the backlog of people with a common heart condition who are waiting for lifesaving treatment, according to research published in the journal BMJ Open. ̽��ֱ��researchers have warned that a lack of action could result in thousands of people dying while waiting for treatment.

̽��ֱ��COVID-19 pandemic has led to thousands of heart procedures being postponed and record waiting lists. Previous work has estimated that 4,989 people in England with severe aortic stenosis missed out on life-saving treatment between March and November 2020.

Aortic stenosis develops when the heart’s aortic valve becomes narrowed, restricting blood flow out of the heart. Prompt treatment is vital for people diagnosed with severe aortic stenosis, as around 50 percent will die within two years of symptoms beginning.

Now, an international team of researchers, including from the ̽��ֱ�� of Cambridge, has modelled the impact that increasing treatment capacity and using a quicker, less invasive treatment option would have on waiting lists. Even in the best-case scenario, they found that the waiting list would take nearly a year to clear and over 700 people would die while waiting for treatment. ̽��ֱ��research was funded by the British Heart Foundation and the EPSRC Cambridge Centre for Mathematics of Information in Healthcare.

̽��ֱ��traditional treatment for aortic stenosis involves replacing the narrowed valve, most commonly through open-heart surgery (a surgical aortic valve replacement, SAVR). However, a newer keyhole procedure called a transcatheter aortic valve implantation (TAVI) is increasingly being used and is now recommended for patients aged 75 and over.

̽��ֱ��researchers investigated the impact that increasing treatment capacity and converting a proportion of operations to the quicker TAVI procedure would have on the backlog. They looked at how long it would take to clear the backlog and the number of people who would die while waiting for treatment.

They found that the best and most achievable option involved a combination of increasing capacity by 20 percent and converting 40 percent of procedures from SAVR to TAVI. This would clear the backlog within 343 days with 784 deaths while people wait for treatment.

“This simple yet relevant model tackles the critical question of how to clear waiting lists and is easy to interpret in practice,” said study co-author Professor Houyuan Jiang from Cambridge Judge Business School.

̽��ֱ��team say they want to see greater collaboration at local and national levels to agree the changes needed that can ensure that people with severe aortic stenosis receive life-saving treatment as quickly as possible.

Before the pandemic around 13,500 SAVR and TAVI procedures were performed each year across the UK. Increasing capacity by 20 percent would represent one or two additional TAVI procedures each week per centre.

“We think that with local and national collaboration this increase is achievable,” said study co-author Professor Mamas Mamas from Keele ̽��ֱ��. “Furthermore, we have created an algorithm that NHS Trusts can use to work out the best approach locally.

“Since November 2020 the UK has been hit with further waves of COVID-19 which have led to extreme pressure on the NHS and additional delays to treatment. We expect that number of people waiting for treatment in recent months will be even higher than the figure we used in our study. Doing nothing is simply not an option. If we continue as we are currently thousands of people will die from untreated aortic stenosis.”

“Our approach does not put the onus on only management or doctors, but creates a joint solution that is easier to implement in practice,” said co-author Professor Feryal Erhun, from Cambridge Judge Business School.

“As this modelling study shows, even increased use of this quicker and less invasive procedure won’t be enough to overcome the impact of COVID-19 related delays and stop people with aortic stenosis dying while waiting for treatment,” said Dr Sonya Babu-Narayan, Associate Medical Director at the British Heart Foundation and consultant cardiologist. “Cardiac care can’t wait. ̽��ֱ��NHS desperately needs additional resources to help it tackle the backlog of care and ensure that heart patients receive the treatment and care they need.”

Reference:
Christian Philip Stickels et al. 'Aortic stenosis post-COVID-19: a mathematical model on waiting lists and mortality.' BMJ Open (2022). DOI: 10.1136/bmjopen-2021-059309

Adapted from a BHF press release.

Pandemic has delayed lifesaving treatment for thousands of people with severe aortic stenosis.

Our approach does not put the onus on only management or doctors, but creates a joint solution that is easier to implement in practice

Feryal Erhun

Thierry Dosogne via Getty Images

Surgeons performing heart surgery

̽��ֱ��text in this work is licensed under a Creative Commons Attribution 4.0 International License. Images, including our videos, are Copyright © ̽��ֱ�� of Cambridge and licensors/contributors as identified. All rights reserved. We make our image and video content available in a number of ways – as here, on our main website under its Terms and conditions, and on a range of channels including social media that permit your use and sharing of our content under their respective Terms.

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Cambridge team develops technique to ‘listen’ to a patient’s brain during tumour surgery

cjb250 — Mon, 15 Oct 2018 23:08:05 +0000

Patients with low-grade gliomas in their brains – a slow-spreading, but potentially life-threatening tumour – will usually receive surgery to have the tumour removed. But removing brain tissue can be risky as there is no boundary between the brain and tumour – the tumour infiltrates the brain. Removal of tumour can lead to removal of vital parts of the brain and resulting impairments in functions such as speech, movement and executive function (which enables the individual to plan, organise and execute tasks).

To minimise this risk, neurosurgeons open the patient’s skull and then waken them. A local anaesthetic means the patient will feel no pain, and the brain itself contains no pain receptors. ̽��ֱ��surgeon will probe the patient’s brain, applying mild electric pulses to tissue surrounding the tumour while asking them to perform a set of tasks. For example, the patient may be asked to count from one to five: if an electric pulse applied to a certain place in the brain affects their ability to perform this task, the surgeon will leave this tissue in place.

“As surgeons, we’re always trying to minimise the risk to patients and provide them with the best possible outcomes,” says Thomas Santarius, a neurosurgeon at Addenbrooke’s, Cambridge ̽��ֱ�� Hospitals. “Operating on brain tumours is always a delicate balance between removing as much diseased tissue as possible to give patients better prognosis, while minimising the risk of damage to brain functions that will have a potentially massively detrimental impact on the patient’s life.”

While the current approach is considered the ‘gold standard’, it is not perfect. It takes time to apply the pulses on different parts of the brain and it may miss out some areas that are important for certain functions. ̽��ֱ��current battery of cognitive tests that surgeons use is also limited and does not test for the essential executive function, for example.

Now, a team of scientists and clinicians from the ̽��ֱ�� of Cambridge and Addenbrooke's Hospital, led by Mr Santarius, Dr Yaara Erez and Mr Michael Hart, together with Pedro Coelho from Neurophys Ltd, has collaborated to develop a new approach that will enable patients to get a more accurate, personalised ‘read-out’ of their brain networks, and will provide surgeons with real-time feedback on the patient’s brain activity in theatre.

“At the moment, neurosurgeons only know about function in the average brain – they have no patient-specific information,” explains Dr Yaara Erez, a neuroscientist from the MRC Cognition and Brain Sciences Unit at the ̽��ֱ�� of Cambridge. “But there’s been huge progress in brain imaging and electrophysiology – our understanding of the electricity within our bodies – so why not use this information to improve brain surgery? We are aiming to bring all this knowledge into the theatre, providing surgeons with integrated data and the best tools to support their work.”

Under this approach, patients would undergo a number of neuroimaging examinations using magnetic resonance imaging (MRI) before surgery aimed at identifying not only the exact location of the tumour but also how different regions of their brains communicate with each other.

As part of this process, a 3D-printed copy of the patient’s brain will be used, showing where the tumour is located. This model is intended to help surgeons plan the surgery, discuss with the patient the potential risks from surgery and involve the patient in decisions over which tissue to remove.

“Doctors need to be able to talk through the options with patients, and we hope that using neuroimaging data and presenting this as a 3D model will help surgeons with the planning of surgery and ensure patients are better informed about the risks and benefits from surgery,” says Dr Erez.

During surgery, once the patient’s skull has been opened, the surgeon will place electrodes on the surface of the brain, to ‘listen’ to their brain activity. A computer algorithm will analyse this information as the patient performs a battery of cognitive tests, giving live feedback to the surgeon. This will enable the surgeon to predict more accurately the likely impact of removing a particular area of brain tissue.

In particular, executive function is difficult to test using electrical stimulation – in part because it involves networks of regions across the brain. Dr Erez hopes that a combination of improved cognitive tests and a more accurate understanding of an individual patient’s networks will enable surgeons to monitor potential impairment to executive function during surgery.

“This isn’t going to replace brain stimulation during surgery,” says Dr Erez, “but it will guide the surgeon and it will save time and make surgery more efficient, more accurate. It will also enable us to understand how patients’ brains adapt to the presence of a tumour and how well they recover from surgery. It involves equipment that is largely already in use in surgeries, so should be easy and cost effective to implement.”

So far, the team has obtained data from 12 patients, already providing a large amount of data to analyse, with a rich dataset from each patient, collected before, during and after surgery. Although they are currently analysing this information offline, the data will help them find the best measures to provide the required information – what the ideal tasks for patients to perform are – and then to optimise the analysis.

̽��ֱ��research has only been possible because of the interaction between researchers and clinicians from a variety of disciplines, says Dr Erez. “At Cambridge, we have different groups of neuroscientists with a range of expertise from psychology and imaging to computer science working with clinicians and surgeons at the hospital. Whatever we need, we can always find someone in Cambridge who knows how to do it!”

̽��ֱ��research is supported by the Medical Research Council, the Royal Society and ̽��ֱ��Brain Tumour Charity.

Surgeons could soon eavesdrop on a patient’s brain activity during surgery to remove their brain tumour, helping improve the accuracy of the operation and reduce the risk of impairing brain function.

There’s been huge progress in brain imaging and electrophysiology – our understanding of the electricity within our bodies – so why not use this information to improve brain surgery?

Yaara Erez

Kai Schreiber

Brains

Researcher profile: Dr Yaara Erez

Originally from Israel, Dr Yaara Erez is now a neuroscientist at the MRC Cognition and Brain Sciences Unit – a centre that not only has “a long history of great contributions to the theoretical and experimental foundations of cognitive psychology”, she says, but “is also famous for its truly lovely garden!”

Yaara’s background is in Computer Science and Psychology. She spent several years as a software developer before deciding to pursue a PhD in neuroscience, and she is now a Royal Society Dorothy Hodgkin Research Fellow. Her background is proving essential for understanding the inner workings of the brain.

“We process the information around us in an active way – we pay attention to what is relevant to us and filter out what we don’t need. We do that all the time, effortlessly and efficiently, but from a computational perspective it is a very complicated problem. We only have hints about how this is done in the brain.”

Yaara’s interest lies in the brain systems that allow us to behave flexibly, adapt our behaviour to changing circumstances, and select only the information that we need. These systems are involved in a wide range of cognitive function known as ‘executive function’, including problem-solving, keeping focus, switching focus and planning, all of which are essential to normal healthy life. “It’s important to understand these brain mechanisms because it may help us develop treatments for patients with different brain disorders that affect cognitive function, such as stroke, brain tumour, depression, and many more,” she says.

While Yaara’s research is basic science, she is interested in its clinical application and how the knowledge might be used to improve healthcare and treatments for patients. “I believe we can improve existing procedures so patients can have a high quality of life after brain surgery. We can and we should use our knowledge from basic neuroscience to improve treatments for patients.”

Her work uses a variety of techniques that involve different types of brain signals that she collects from healthy volunteers and patients with brain tumours. “This data is very complex, so requires detailed analysis, which I like. ̽��ֱ��combination of the data from the different techniques, and what we can learn from each of them, makes my work exciting and enables me to get the full picture.

Yaara recalls the day she first saw a live brain surgery on an awake patient. “As a neuroscientist, I study the brain and know quite a lot about it, but seeing a real brain and how brief pulses of electrical stimulation immediately affect behaviour was a different level of experience and truly eye-opening.”

Cambridge, says Yaara, is the perfect place for her research. “There are people from all over the world, and they all bring their expertise, knowledge, and perspective. My research is multidisciplinary in its nature, and the combination of the different expertise of people in Cambridge makes it work. We also have great facilities here and are very fortunate to have such a great ̽��ֱ�� Hospital as Addenbrooke’s as our local hospital.

“I enjoy meeting and working with people from all around the world, and the international community in Cambridge is amazing.”

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Keyhole surgery more effective than open surgery for ruptured aneurysm

cjb250 — Wed, 15 Nov 2017 09:32:25 +0000

This is the first randomised trial comparing the use of keyhole (endovascular) aneurysm repair versus traditional open surgery to repair ruptured aneurysm, with full midterm follow-up.

Abdominal aortic aneurysm is a swelling of the aorta – the main blood vessel that leads away from the heart, down through the abdomen to the rest of the body. If the artery wall ruptures, the risk of death is high, and emergency surgery is needed.

Three recent European randomised trials showed that keyhole repair does not reduce the high death rate up to three months after surgery compared with open repair. However, mid-term outcomes (three months to three years) of keyhole repair are still uncertain.

An international research team set out to assess three year clinical outcomes and cost effectiveness of a strategy of keyhole repair (whenever the shape of the aorta allows this) versus open repair for patients with suspected ruptured abdominal aortic aneurysm who were part of the IMPROVE trial.

Dr Michael Sweeting from the Department of Public Health and Primary Care at the ̽��ֱ�� of Cambridge, who was involved in the trial, says: “More than 1000 people a year in the UK require emergency surgery to repair a ruptured abdominal aortic aneurysm. Without repair, ruptured aneurysm is nearly always fatal. However, surgery is not without its own significant risks, so we are always looking at ways of reducing the risk to the patient. One option is keyhole surgery, but until now not enough was known about how its outcomes compare to regular, open surgery beyond one year after repair.”

̽��ֱ��trial involved 613 patients from 30 vascular centres (29 in the UK – including at Addenbrooke’s Hospital, Cambridge - and one in Canada) with a clinical diagnosis of ruptured aneurysm, of whom 316 were randomised to a strategy of keyhole repair and 297 to open repair.

Deaths were monitored for an average of 4.9 years and were similar in both groups three months after surgery. At three years, there were fewer deaths in the keyhole group than in the open repair group, leading to lower mortality (48% vs 56%). However, after seven years there was no clear difference between the groups.

̽��ֱ��need for repeat surgery (‘reinterventions’) related to the aneurysm occurred at a similar rate in both groups, with about 28% of each group needing at least one reintervention after three years.

Average quality of life was higher in the keyhole group in the first year, but by three years was similar across the groups. This early higher average quality of life, coupled with the lower mortality at three years, led to a gain in average quality adjusted life years or QALYs (a measure of healthy years lived) at three years in the keyhole versus the open repair group.

̽��ֱ��keyhole group also spent fewer days in hospital (14.4 versus 20.5 in the open repair group) and had lower overall costs (£16,900 versus £19,500 in the open repair group).

̽��ֱ��researchers point to some study limitations, such as sample size and midterm data focusing on aneurysm-related events, which may have led to some bias. Nevertheless, they say compared with open repair, there are clear benefits associated with keyhole surgery.

“These findings show that, in the first three years after repair, keyhole surgery can improve outcomes and quality of life for patients compared to open surgery, and is more cost effective and requires less time in hospital – important factors to consider for our stretched health services,” adds Dr Sweeting.

Reference
Comparative clinical effectiveness and cost effectiveness of endovascular strategy v open repair for ruptured abdominal aortic aneurysm: three year results of the IMPROVE randomised trial. BMJ; 15 Nov 2017; DOI:

Adapted from a press release from ̽��ֱ��BMJ.

̽��ֱ��use of keyhole surgery to repair ruptured abdominal aortic aneurysm is both clinically and cost effective and should be adopted more widely, concludes a randomised trial published by ̽��ֱ��BMJ today.

More than 1000 people a year in the UK require emergency surgery to repair a ruptured abdominal aortic aneurysm. Without repair, ruptured aneurysm is nearly always fatal

Michael Sweeting

Arindam Chaudhuri

Abdominal aortic aneurysm

̽��ֱ��text in this work is licensed under a Creative Commons Attribution 4.0 International License. For image use please see separate credits above.

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