This line is totally fucking appalling.
But paramedics’ guidelines, such as facial paralysis or slurred speech,
do not offer a foolproof diagnostic tool:
up to 50% of all pre‑hospital
stroke diagnoses turn out to be inaccurate.
What are the statistics about that from your hospital? Do they even know? If not, that is pure incompetency.
https://www.theguardian.com/science/2017/jan/22/stroke-detector-biosensor-diagnosis-nicholas-dale--breakthrough
Stroke,
or “brain attack”, is the third biggest killer in the western world,
after cancer and heart failure. The life-changing effects associated
with this simple, Anglo-Saxon word are readily explained: a stroke
occurs when the blood supply to the brain is disrupted by a blood vessel
either bursting or blocking, so that the part of the brain supplied by
this blood vessel dies.
The brain is a much more complex organ than the heart. While strokes
are a common feature of everyday life, precisely how and why they occur
is far from straightforward.
Each year in the UK, there will be
about 50,000 brain attacks.
One-third of those affected will die; one-third will be left severely
disabled; and about one-third will make some kind of recovery. In the
time it takes to read this article, approximately nine people in
Britain, from across all age groups, will have suffered a stroke.
Or did they? For the brain is not only super-sensitive territory – as
the human animal’s command HQ – it is also top secret. Despite
extraordinary progress in MRI scans, the brain remains essentially
mysterious and the symptoms of its dysfunction can be hard to diagnose
with certainty. An elderly man presenting himself at A&E with
unsteady gait and a slurring of his words could be suffering a stroke –
or he might just be intoxicated. Treat him for the former, and you’ll
save his life; treat him as a drunk, and he might die.
This is not the only way in which stroke sufferers find themselves
trapped in a medical lottery. From the beginning of a stroke, every
minute, even every second, becomes a matter of life or death in which
the patient’s response is crucial. The onset of a brain attack is
bewildering and confusing. For patients in the midst of a medical
emergency, the key to the best recovery is rapid recognition of the
attack followed by the prompt implementation of brain-saving treatment.
But rapid recognition is easier said than done.
All
strokes are unique, with a multiplicity of symptoms ranging from a
drooping facial muscle to total unconsciousness. But paramedics’
guidelines, such as facial paralysis or slurred speech, do not offer a
foolproof diagnostic tool: up to 50% of all pre‑hospital stroke
diagnoses turn out to be inaccurate.
The diagnostic predicament is also bedevilled by the phenomenon of
“mimics”. For example, a patient might come to A&E with a very bad
migraine, exhibiting all the symptoms of stroke. Devoting the resources
of stroke treatment to such a mimic is costly in both time and
resources, the last thing a cash-strapped
NHS can afford.
In A&E, one of the biggest – and potentially most expensive –
problems faced by doctors and nurses is how to weed out the mimics and
decide if a patient has or has not suffered a stroke. This decision can
be fateful. Send the patient for immediate treatment, and all kinds of
good outcomes might follow. Delay an hour, and the patient might be on
the road to severe disability, even death.
As long ago as 1998, the complex challenges of stroke diagnosis began
to intrigue an inquisitive Scottish neuroscientist named Nicholas Dale.
He takes up the story: “Some strokes are really obvious. The brain scan
shows exactly what’s happened, and everyone is in agreement. But then
there are those strokes where the brain scan doesn’t really show
anything, even though the symptoms are there. Those are what you might
call ‘possible strokes’. What is a clinician supposed to do?” To this
last question, Dale would come eventually up with an answer about the
size of a thumbnail: the
SMARTChip.
Twenty years on, Dale’s tortuous journey into the dark maze of
neurological emergency is reaching a climax. After a series of
nationwide clinical trials, the
Observer can report exclusively that Dale and his biosensor company,
Sarissa, an
offshoot of Warwick University, are on the threshold of a remarkable breakthrough in stroke diagnosis.
Dale’s pioneering contribution to stroke medicine is a classic tale
of scientific innovation replete with accidental discoveries, chance
meetings and frustrating setbacks. Add this to the sheer slog of a
determined neuroscientist who seems professionally addicted to finding
bees in his bonnet, and you begin to approach the story of the smart
chip that saves lives.
Dale’s breakthroughs in stroke prevention had mundane beginnings. “My
original work,” says Dale with a wry smile, recalling his graduate
years in Bristol and St Andrews, was “on how tadpoles swim”.
We need not dwell on Dale’s career in the society of the tadpole.
Suffice to say that by 1997, he needed to invent a biosensor to measure
the substance adenosine. “I wanted to measure adenosine,” he says,
“because I thought that its gradual accumulation in the tadpole’s spinal
cord controlled how its swimming slowed over time and ultimately
stopped.”
Dale duly published his tadpole findings. It was then, in 1998,
articulating a vague thought in the back of his mind, that he uttered to
himself the sentence – “This biosensor must be useful for other things”
– that would not only change his life, but profoundly influence the
fates of many UK stroke patients. At this stage, his aspirations were
half-formed, and he had no plan. All he knew was: he was done with
tadpoles.
Dale
admits that he wanted to do work that did not – as tadpoles always did –
provoke smiles of disbelief. “I wanted to find an application for these
sensors that was real and important.”
He pauses to recall another turning point. “One of my colleagues in
Scotland said: ‘The person you need to talk to is Bruno Frenguelli. He’s
interested in models of stroke.’ So I met Bruno,” says Dale, with
disarming simplicity, “and told him about my biosensor.”
Dale and Frenguelli were a perfect match. Dale was becoming a master
of biosensor technology, whose microchips could measure anything.
Frenguelli, a neuroscientist at the University of Dundee, had things he
wanted to measure, but no way to make the measurement. Soon, Dale was
ferrying his biosensor kit in his car across the Tay Bridge to Dundee,
and setting up in Frenguelli’s lab. “We both vividly remember our first
joint experiment,” says Dale, “because it was so exciting.”
But then what? The bees in Dale’s bonnet began buzzing again.
His biosensor was too cumbersome and fragile for any serious medical
applications. “I started to think: could we not make something smaller?”
In 1999, Dale was puzzling over how he might do this – “I realised I
would need polymers” – when there was a knock at his door. “And in came
this guy I’d never seen before.”
“Hello”, said the newcomer. “I’m Enrique Llaudet.”
Llaudet, a Spanish organic chemist, was a whiz with polymers. Just
what Dale needed to create new ways of making tiny biosensors.
So began an eight-year relationship, partly sponsored by seed money
from a small Scottish charity, and later by the Wellcome Trust. Now Dale
and Llaudet, with Frenguelli in the background, began to develop a tiny
biosensor, the ancestor of Sarissa’s smart chip.
There were, inevitably, setbacks. At times, the technology let them
down; at times, the funding dried up. But Dale, a natural team player,
continued to develop his group, which now included Chris Imray (a heart
surgeon at University Hospitals Coventry and Warwickshire NHS Trust),
Christine Roffe (a stroke specialist at University Hospitals of North
Midlands), Gary Ford (Oxford Academic
Health
Science Network), Everard Mascarenhas (Sarissa’s CEO), and Faming Tian
and Shabin Joshi (both also at the Coventry and Warwickshire).
By now Dale had moved to Warwick to take up a chair in neurosciences.
In 2004, Sarissa filed its first biosensor patent, but then Dale found
himself in a blind alley. “We had the means, and we had the ideas, but
we were getting nowhere. We tried to raise funds for treating foetal
hypoxia.” He laughs: “I soon realised that the middle-aged white males
who controlled the purse-strings just aren’t interested in babies.”
Finally, Dale returned to stroke. He had puzzled over its mysteries
for years, but had never really grappled with the practicalities. Now he
began to advance a brilliant hypothesis, developed in collaboration
with Chris Imray. This – the measurement of purines in the blood – had
the elegance of simplicity. Imray and Dale had begun to prove that,
at
the onset of stroke, the brain releases a detectable quantity of purines
into the blood. If Dale’s smart chip could measure this surge, it could
provide positive proof of stroke. For Dale, “elevated purines” would be
the criterion by which he would definitively determine the onset of a
brain attack.
Today,
in the stroke units where Dale’s hypothesis is being tested, nurses
have come to recognise that a high purine reading immediately indicates
that stroke is a probable diagnosis.
In 2004, that was all in the future. First, Dale had to persuade the
medical profession to undertake a clinical trial. It was his contention
that Sarissa’s biosensor could weed out the “mimics” that bedevil stroke
treatment.
Sarissa made its first commercial sales in 2005. Its biosensors (aka
Sarissaprobe) had potential in clinical diagnosis, but, says Dale “we
still didn’t have a product that was close to being useful for
clinicians and nurses”. In simple terms, Dale’s biosensor would not work
in blood.
Blood is the one thing that medics the world over like to test. But
blood, as Dale puts it, “is a complex environment. We had to make our
sensors a whole lot more selective if we were to measure a surge in
purine levels. This was Faming Tian’s brilliant contribution.”
At the same time, Dale was stepping up the presentation of his biosensor to funding bodies. In 2013, he made a pitch to
Invention for Innovation, a committee of the National Institute for Health Research. He will probably never forget this moment:
“I made my presentation, and then this clinical biochemist launched
into a statement – it was nowhere near an inquiry – which became so
hostile that I felt as if I were a delinquent teenager. There was, he
told me, no need for this kind of technology. I was stunned by the
aggression and the hostility. When this man had finished, I could not
think initially how to respond, so I just said, ‘Was there a question?’”
The committee burst out laughing. Dale left the meeting with a sense of
failure, but he was wrong.
The committee decided to take a punt on his smart chip, after all.
Three years ago, Dale and his colleagues began clinical trials in three
UK hospitals, Salford, Coventry and Stoke-on-Trent.
Royal Stoke University Hospital, on the west of the city, is just
over 10 years old, and a showcase of New Labour’s commitment to a
revitalised NHS. Once, in the bad old days, Stoke was served by two
separate, Victorian hospitals, with patients ferried between A&E and
the stroke unit, which were in different buildings. Now, with A&E
just a lift ride away, everything is under one roof with acres of
parking space for doctors, nurses, patients and their families.
Inside, long shiny corridors and blinking tiers of lifts take the
visitor into the heart of an impressively modern teaching hospital that
caters for a population of about 600,000 in Stoke and Stafford. Add
Derby, Macclesfield, Wolverhampton, Walsall, and Telford and you are
looking at a catchment of 1.5 million. This is Nick Dale’s designated
stroke laboratory, and it’s here, for the past three years, that his
biosensor has been tested, under Professor Christine Roffe, a dynamic,
highly practical director who has placed her team at the forefront of
stroke research in the UK, especially as a
pioneer of mechanical thrombectomy. She has been here since 1996, heading a unit that consists of six consultants, two specialists and 10 research nurses.
