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And coupony. Next, we have Christian Aquilina who's consultant neurosurgeon and Clinical Lead for Neuro Oncology and Great Ormond Street. And he's going to speak on Drift and brainwashing. Not so much the brainwashing, but well, it's, it's really good to be here today. It's, it's great to see so many people after 10 years. And uh as you know, I was in French up to about 10 years ago and I want to talk a bit about Drift and I realize some of my talk has been gone through already. So I'll try and hurry up the next slide, please. So, um my um pretty much like bone eating away. My, my first introduction to the journey to Bristol was an sho interview with Mister Malcolm and Mr Poeple in October um to 1999. And I got the job and returned back in January that year, next year to try and navigate this landscape which we have talked about already today. Next slide please. And after my one year of, of being an sho which was a great year. It was for me. I think the best introduction to neurosurgery could have had. There was no question I was going back afterwards to do anything else. Um After that, I uh went back to French a in 2005, finished some research with Ian mostly on hydrocephalus. And then finished my training and then spent an amazing year in uh in Memphis with Rick Boop and Alex Sanford and Mike Muhlbauer. And then I went back and was appointed as a consultant in 2010. And then I went to Great Ormond Street in 2012. Next slide, please. So um I think it's difficult to, to not say what I got out of French. I think it was an amazing time. It's as if the infrastructure and the ruggedness of it all creates a certain belonging to the to the institution. Uh The mentorship, especially in my early consultant areas was amazing and patient and caring. Um And obviously made many colleagues and friends which I still keep in touch with it. But we've been talking about so much today's innovation. We still has a very strong sense of innovation. You know, I've worked in a few units now and you can see many units are very good at doing what needs to be done but not everybody, not everywhere. Do you find that spirit, that spirit of innovation that is, you know, where people actually happy to try something new and not be scared to fail and try again if some something doesn't go right. But Christie clearly has all of that and it's something which has been very inspiring to all of us. Next slide, please. We've all been to these uh examples today. Just go through them very quickly. So it was the second city scan in the UK and not only was it just a CT scan, but there was even a paper on uh cost effectiveness of CT scanning. Two years later. Next slide please. This was in 1976 which reflected on use of the scan er from 1970 for next slide. And we've talked about image guidance today, a simple trajectory guidance device which of course now is ubiquitous and neurosurgical practice. Next slide and on the vascular side coiling including MC A aneurysm, total balloon occlusion and revascularization surgery. Next slide, the artificial joint we've talked about today, next slide uh DBS of course, doing MRI guided DBS uh in patients who are asleep using guide you. This was very innovative at the time and has been taken up so widely throughout the world. Now, next slide injection of GDNF and eventually convection hands delivery, which is still being investigated so widely in so many branches of neurosurgery. Next slide uh next again and next again. So in in pediatrics, there were two particular things which made a big difference. Um One is endoscopy which has already been described this morning, next slide and next slide. And you can see here how it was described as a fairly simple procedure using endoscopy to coagulate the chorioplexus chorioplexus coagulation, which really this these were the first papers to describe the technique properly and also to evaluate its results. Next slide and next slide again. So this was uh slide, it was given to him by E and actually some time ago, there's a video there of CPC which is quite old, but using a television cameras had been predicted. And you can see how using CPC in the right situation can actually reduce communicating hydrocephalus and reduce um the progressive macrocephaly in that child as an example. Uh next slide and then we'll come to drift, which hasn't really been talked about much today. It's, it's very much a pediatric uh problem. Posthemorrhagic hydrocephalus is now the communist cause of hydrocephalus and marinades. Next slide, we're dealing with very small babies, typically weighing about 800 to 1000 200 g. Often uh born at around 25 weeks gestation and the posthemorrhagic hydrocephalus problem really becomes a significant issue at around three weeks of age. Next slide. And this is some work we had done a great Ormond Street related to um nominated shunts. And you can see that the ones with posthemorrhagic hydrocephalus there with zero are the ones have the worst cognitive outcomes and these are really those who require highest levels of education and support and they have the highest levels of learning disability, more than any other type of nominated hydrocephalus. Next slide and drift as you probably know, stands for drainage, irrigation and fibrotic therapy. Um It's involves insertion of two categories in the neonatal unit at the bedside. Uh So they don't need to go to theater. There's an injection of tea pee in the beginning and then the irrigation starts over about five days. Next slide and over a period of time, usually about 4 to 5 days, the blood actually washes out and it's important to try and do this as early as possible when hydrocephalus first develops and it probably works in many ways. But we think that blood and it's breakdown products probably is toxic to developing white matter. And also there's an increased pressure raised ICP problem as well as free iron and clearing those out early on when hydrocephalus develops is must be beneficial for these Children. Next slide. That's what it looks like with an inflow and outflow and ICP measurement in the inflow all the time. Next slide. And you can see here the inflow there with the red fluid, sorry, the inflow of the clear fluid going in and the outflow with the red fluid coming out. And over time over about four or five days, the redness reduces to a more um uh pink color. Next slide. And these are the pioneers of drift and the white loney in Poeple, an amazing collaboration between a pediatric neurosurgeon and an academic neonatologist and this is where it all started from next slide. This is a couple of pictures showing um insertion of the catheters in the neonatal units and a child who's anesthetized next slide. And this is a scan, ultrasound scan, pre drift and next slide. This is supposed rift. You can see how the ventricular blood has disappeared and the ventricles are slightly smaller next slide. So these papers here would um show the progress of the drift story. Initially, it was a small trial, preliminary phase, one trial went on to a bigger trial which recruited about 75 babies. And the initial results um uh the the initial follow up presents at two years showed that there was no change in uh the requirement for a ventriculoperitoneal chance, which was thought to be disappointing. It was thought to be that the main reason for doing drift is to reduce chance requirements. But actually the second paper then showed that the cognition at two years is significantly better. And those Children who had drift compared to those who received standard therapy and this was replicated at 10 years, which is quite an important result if you go to the next one and the next one, next one again. So on the next slide. So this is the key that in 10 years or 10 years of age. So 10 years after drift was done, the Children who had the drift therapy had a much better cognitive outcome than those who did not. So six or 6% survival without severe cognitive disability. For the drift, patient's compared to 35% for those had standard treatment. These are really good results. Nobody before had ever shown any technique which showed improvement in cognition and premature Children with posthemorrhagic hydrocephalus. Next slide. So the problem with drift, even though it works for cognition is that it is quite difficult to replicate. It requires very um quite significant intensive care and skills which are difficult to disseminate and teach. And so over the last few years, there have been some studies which showed uh small populations of babies having endoscopic washouts for um for posthemorrhagic hydrocephalus. Next slide. And these are some of those papers. They're usually small numbers, um often less than 40 or so. And of course, nobody has actually compared them to standard Children, Children treated in the standard way next slide. And it's, it's not quite an easy procedure. I'm sure many of the pediatric surgeons have done them. So initially you put the scope into these ventricles are very small Children. Um And you put the scope and you see nothing for about five minutes, you have to irrigate and then you start getting some vision and over time you start getting a sense of the normal anatomy and you try and navigate through the ventricles to try and wash out as much of the clot as you can. Next slide. This is some of the pictures on the left there. You can see hematoma and that one doesn't the one on the right doesn't reflect very well, but it's a small video on the next slide. So this is just particular blood collections over the Ependyma. Next slide we can play this video and then maybe go back and try again. Yeah. Yeah, it doesn't play unfortunately. But anyway, what, what that video shows not pretty at all by any means, but the point is to show that there's all these fronts of blood and some red blood as well as old blood. And it's really including all your ventricular anatomy. So, working your way to the ventricles is actually quite challenging. And this is one of the cases we did showing a pre uh washout scan on the left and the post washout scan on the right. You can see smaller ventricles and most of the hematoma has gone next slide. So of course, a randomized trial hasn't been done yet, but in the spirit of drift and in the spirit of French, eh, we thought it was important to try and develop a randomized trial to see whether and the scopic lavage actually makes a difference to cognition. Um It's uh an operation that can be done and it may remove the blood clot, but it is risky. These Children are very small and very fragile and it's easy to cause electrolyte disturbances, seizures and, and secondary bleeds. And so a trial would be important and we developed a big team. Um We have now got an IH are funding and have collaborated with the clinical trials. You know that you see L and one of our trainees has been very creativity coming up with the name Dolphin, which is a developmental optimization with lavage for preterm hemorrhage and infants. Next slide. And the aim is to try and recruit 100 patient's in multiple centers uh as soon as possible after hydrocephalus develops and two randomized them to standard treatment with an access device or subgaleal shunt against um standard treatment plus lavage. Next slide and the next slide again. And what we'll be looking at the primary outcome is the cognitive score at two years. We're not really going to be that interested in requirements for shot because that's not that important, but the cognition is the most important aspect and we'll be measuring Bailey four scores at two years of age next slide. And it's quite a big team with a large number of centers taking part we're very excited about. And the study involves a number of, of uh when non experts in the field who will be involved in the trial steering committee including and the White Law, Neil Marlo, who's a uh an academic neonatologist at UCL, uh John Kessel from HCRN in the US and Europe tomorrow, who probably has the largest experience in the world of lavage and also some of our UK try lists including Peter Hutchinson, Mike Jenkinson and Nick Fremantle from the CT you at UCL. And we've also worked hard with patient bodies like shine and ban Fu to define the primary outcomes of the study. Next slide. It's the timeline. So we're hoping to, at the moment we're setting this study up, we're hoping to recruit from September October onwards and we recruit for three years, 100 patients' and then hopefully have results about three years later, next slide. So in conclusion, I think all of this comes from the initial mentorship And as everyone else has said today, working in franchise and in Bristol for the first few years, well, for me, I suppose the first eight years of my neurosurgical life was incredibly important. And certainly for me, it has really made me more time today, I think and the innovative spirit needs to live on wherever we are. Thank you very much getting to the next.