Taking the lead with patient monitoring

Patients are currently monitored using wired leads (electrocardiographic cables). This decreases patient mobility and comfort. Studies have shown that it can also lead (pun not intended) to long-term skin damage, especially with newborns. A team of researchers from the University of Malta (UM) are examining whether some of this data can be extracted through digital cameras, removing the need for cables.

What if hospitals could use ordinary digital cameras to monitor patients’ vital signs?

While monitoring patients wirelessly sounds like an almost futuristic idea, it’s precisely the line of research being investigated by an interdisciplinary team of six scientists and medical professionals at the University of Malta and Mater Dei Hospital. The formidable team, consisting of Dr Owen Falzon, Prof. Ing. Kenneth Camilleri, Dr Abdelkader Helwan, Prof. Jean Calleja Agius, Dr Nicole Grech and Dr Stephen Sciberras, is currently spearheading what they call the NIVS Project: Non-Invasive Vital Signs monitoring project.

‘Monitoring vital signs like heart and respiratory rates is essential for various reasons,’ explains anaesthesia trainee Dr Nicole Grech over a coffee one morning. ‘It’s particularly important in wards like the Intensive Care Unit (ICU) where patients are more likely to be unstable, so continuous monitoring can be a matter of life and death.’

Grech explains that heart and respiratory rates can often show that all is not well with a patient even when they are feeling fine; a situation that was quite common with COVID-19 patients over the past months for instance.

‘ECG monitor leads are considered the gold standard in terms of providing that data in real time, but they also come with a lot of issues,’ she explains. ‘First of all, there is a practicality issue, in that they tend to fall off patients and hamper their movement when they are trying to move about or even sleep. There are also issues when patients have hairy or moist skin, not to mention diseased skin that can become irritated or prevent the leads from adhering effectively.’

Grech goes on to explain that the leads can sometimes cause significant damage to the skin, particularly in premature babies, whose delicate skin could actually slough off when the adhesive leads are removed.

‘There is also a higher likelihood of infections spreading from one patient to another, regardless of how well these leads are disinfected. Hospital-transmitted infections are actually incredibly common, and they can lead to higher mortality rates, particularly in places like the ICU where patients are already vulnerable,’ Grech says.

The Word Health Organisation has prioritised research to find alternatives to contact-based devices such as monitoring leads. It wants to reduce  antimicrobial resistance, which is a global and health development threat.

Finding new solutions

The spike in global interest and the recent focus on social distancing led project lead investigator Dr Owen Falzon to set up the multidisciplinary team and attack the issue with technical and clinical solutions.

‘The inter-faculty collaboration between UM and Mater Dei Hospital allowed us access to a full suite of equipment and resources, as well as the possibility to run tests in controlled conditions and clinical settings, to give us a much deeper understanding of the systems needed,’ Falzon explains.

Falzon, together with the Director of the UM’s Centre for Biomedical Cybernetics, Prof. Ing. Kenneth Camilleri, worked to synergise medical and scientific research, a step which has so far been uncommon in Malta. The team of researchers decided to dive into the concept of photoplethysmography (PPG), which operates on the idea that changes in someone’s heart rate can be detected through skin colour changes.

‘The basic idea is that every time the heart beats, it pumps freshly oxygenated blood — which is redder in colour — to the surface of the skin,’ explains Grech. ‘This gives the patient a pinker hue. The process is invisible to the naked eye, but a basic camera can pick up the subtle change.’

Grech goes on to explain that using a camera, known as remote PPG, would be non-invasive and would ultimately enhance patient wellbeing.’The absence of leads would mean that patients can move around in their beds without fear of getting disconnected or tangled. The risk of contamination and skin damage would be lowered, and the remote data collection would also allow for more effective physiotherapy sessions as patients need not be concerned about getting disconnected from monitors during these important sessions.’

What happens to the footage?

In the interest of this project, the team has already gathered around 44 hours of footage in total; first from healthy volunteers (approximately 31.5 hours) and then from ICU patients (approximately 12 hours). But how does that translate into medical data that health professionals can interpret?

Data analyst Dr Abdelkader Helwan explains that the data and videos are being fed into a convolutional neural network — a form of Artificial Intelligence (AI) that can learn how to carry out complicated tasks based on the data it is fed. Helwan will then work on creating an algorithm that allows the machine to recognise anomalies and irregularities in patient heart rates, in the same way an ECG monitor would.

Helwan explains that AI is becoming increasingly important in the health sector, with models successfully detecting and classifying diseases like skin cancer and beating experts at determining the malignancy of tumours.

‘Our work in this particular project is very robust as we are using various video scenarios, including a variety of poses, illuminations, and distances from the camera,’ he adds. ‘Filming patients in a hospital environment will allow our AI to better overcome common issues identified in this method of data collection.’

Some of the most common challenges to remote PPG have been highlighted in medical and research journals. From the placement of the equipment to data privacy issues, this research project is trying to overcome several challenges.

‘The camera itself can be a little cumbersome, so we need to think of where we can place the equipment to effectively monitor patients without disrupting the staff if we are to use this method in a real world setting,’ Grech explains.

‘Clinical tests have also thrown up issues like light changes causing a disruption to the data collected. If there are lights flashing from various monitors or pumps around the patient, the data may become muddled,’ explains Helwan. ‘Movements of hospital staff around the patient can also cause disruption to the data collection.’

Echoing Helwan, Grech explains that this research project collected data in dim light, bright light, and even darkness to train the AI to interpret data in as varied conditions as possible. The idea was to simulate real use.

Next steps

‘Beyond the practical aspects,’ says Grech, ‘our clinical tests have shown that we need to have a wider data set to compare to. The data collected from healthy patients often does not match up to the conditions of patients in wards like the ICU.’

‘The algorithm won’t be able to recognise patients whose heart rates are perhaps outside the normal zones, so we are currently applying for ethical approval to collect data from healthy patients doing exercise. This will allow the algorithm to develop an understanding of more elevated heart rates, for instance,’ she adds.

Data privacy is another key issue. Given that this data relates to patients with severe health issues, the team had to seek approval from Mater Dei Hospital and UM Ethical Committees to ensure that the data is secure, with only the clinical and research team having access.

A further hurdle the team came up against is the expensive nature of the equipment in question, with some of the machines costing thousands of euros. To this end, the team successfully applied for funding from the Malta Council for Science and Technology for the NIVS Project.

‘As mentioned earlier, we have already identified the need to analyse more elevated heart rates and feed it into the system, but the aim is to use all this data to assess the accuracy of the system and finally test it in a real-world setting,’ Grech adds.

The hope is for the research to ultimately become widely used in hospitals. The team have opted for a broader data set than has been attempted so far in any international study. Most studies around the subject have employed exclusionary criteria and focused on specific issues like patients undergoing haemodialysis treatment or preterm infants, but the local research team has chosen to have a broader variety of patients to properly test this form of data collection.

Intensive Care Consultant Dr Stephen Sciberras and the Head of UM’s Anatomy Department Prof. Jean Calleja Agius explains that the ambitiously wide data collection will allow the team to build an estimation model that should work seamlessly in a busy hospital setting.

‘The ICU offers the best opportunity to collect as much data as possible in a clinical situation, as it incorporates a wide variety of conditions,’ Sciberras explains. ‘Patients here can be awake or asleep, some could be breathing normally while others use ventilators, and so on… This ultimately means that the system will be better calibrated for everyday use, rather than only a specific type of patient.’

With infectious energy and optimism, the team has largely completed their data collection and are now well into the data analysis stage. Should these results be favourable, the project would likely change the image of hospitals as we know them and push them into a more contact-free future, a feeling that is entirely on-brand in our post-Covid world.

EURATOM – Europe’s Fusion Future

In the first weeks of November, the world came together for the 26th United Nations Climate Change Conference, an event researchers across the globe are calling ‘the world’s best last chance to get runaway climate change under control’. During this two-week conference, one of the aims was to put forward proposals to ‘secure global net zero by mid-century and keep 1.5 degrees within reach’, which will involve phasing out coal use around the world and putting more resources into sustainable energy methods. One such method that is being touted as a groundbreaking solution is nuclear fusion. THINK magazine sat down with Prof. Ing. Pierluigi Mollicone and Prof. Ing. Martin Muscat, associate professors at the Department of Mechanical Engineering at the University of Malta, to learn more about what nuclear fusion is all about.

Fossil fuels and Renewable Energy

What do we mean when we talk about fossil fuels and renewable energy? Fossil fuels are fuels formed from geological processes acting on dead and decaying organic matter from many millions of years ago. These fuels occur in the form of coal, oil, and natural gas and are extracted all over the world from the Earth’s crust. Fossil fuels have proven very popular since their pivotal role in the industrial revolution and have led to the creation of the world we live in today. They are relatively inexpensive to extract and easy to contain and transport across the globe. However, as we have seen over time, they have a devastating effect on our environment, releasing large amounts of carbon dioxide, the major culprit of the greenhouse effect and the warming of our planet. Burning these fuels has also led to air quality depletion that has impacted our health. 

Caption: Fossil fuel consumption in 2019. Several countries still rely heavily on fossil fuel. Graph courtesy of OurWorldinData.

Fossil fuels are a finite resource, unlike renewable energy sources, which are sustainable and can be replenished. Common renewable energy sources include solar, wind, hydro, tidal, geothermal, and biomass. As you can imagine, the major positive of renewable energy sources is the lack of pollutants; however, these sources are sometimes intermittent and can be quite dependent on environmental conditions. According to the Global Energy Review in 2021 by the International Energy Agency, ‘the share of renewables in electricity generation is projected to increase to almost 30% in 2021, their highest share since the beginning of the Industrial Revolution and up from less than 27% in 2019.’ But where does nuclear energy fit in with all of this?

Nuclear Energy – Fusion and Fission

Nuclear energy generation involves altering the way atoms are structured; however, there are two types of energy generation, fusion and fission. Both create large amounts of energy, but there are some major differences between the two. As Mollicone explains, ‘either you split the atom, which is called fission, or you join the atom, which is fusion.’ Fission reactions release large amounts of energy via the action of splitting atoms into smaller atoms, using a large, unstable isotope, such as uranium, as fuel. Particles are fired at the fuel, which splits it down into two smaller isotopes, releasing a large amount of energy and more particles that lead to further splitting, creating a chain reaction.

Prof. Ing. Martin Muscat (left) and Prof. Ing. Pierluigi Mollicone (right), associate professors at the Department of Mechanical Engineering at the University of Malta

Fusion, on the other hand, involves combining two atoms to generate energy. It’s the same mechanism that is currently happening in our Sun, explains Mollicone, producing the light and warmth we feel all the way here on Earth. In the Sun, due to the extreme temperatures and gravitational forces, hydrogen atoms travel at rapid speeds and collide with each other. In normal circumstances, these atoms would repel each other, but in these extreme conditions, they fuse together, producing a helium atom. The fuels used for fusion reactions in man-made plants are currently two isotopes of hydrogen: deuterium, and tritium. Due to both fission and fusion reactions requiring fuels that are finite, they cannot be regarded as renewable energy sources.

Image: (Fusion vs Fission- EUROfusion [euro-fusion.org]) Caption: Left (a fusion reaction) Right (a fission reaction) 

Understanding how these reactions can produce energy falls at the feet of Einstein’s famous equation describing mass-energy equivalence, which is most easily recognised in its written form, E=mc2. The difference in mass between the original atoms and the products, the ‘m’ in the equation, is multiplied by the speed of light (the ‘c’) squared, resulting in a large amount of energy being released. Hence the viability of using this for power.

Benefits of Fusion

Nuclear fusion has a multitude of benefits, which is why the world is pooling its resources to create a viable fusion-energy facility on Earth. Fusing atoms together in a controlled way releases nearly four million times more energy than a chemical reaction such as the burning of coal, oil, or gas, and four times as much as nuclear fission reactions at equal mass. Fusion has the potential to provide the kind of baseload energy needed to provide electricity to our cities and our industries. Other positives include the fact that nuclear fusion (when using hydrogen) does not produce CO2. 

The fear of nuclear fallout has left many people wary of nuclear power. However, while both fusion and fission harness the power of the atom, their risks are quite different.

As Mollicone describes, ‘there are two main problems with fission reactions; you get a lot of radioactive waste, which lasts for many years.’ The waste that is produced has to be stored for around 1000 to 10,000 years, while ‘the radioactivity of high-level waste decays to that of the originally mined ore’ (World Nuclear Association, 2021). Mollicone continues, explaining the second problem, which is that fission reactions ‘are not stable’. Muscat adds, ‘what happens is, if the cooling system breaks down and you cannot cool your nuclear reaction, then the reaction goes out of control, then you’ll get a huge explosion.’ Reactions like this have led to disasters such as those in Chernobyl and Fukushima, which have had devastating and lasting effects on the communities and environment. 

Whereas with fusion reactions, there is very little long-lived radioactive waste. The half-life of the small amount of radioactive waste from fusion is about 12.5 years, and as Muscat describes, a fusion reactor can be stopped by ‘just stopping the injection of fuel, much like how without fuel, a diesel engine will stop functioning.’ This means that these dangerous explosions don’t occur.

Fusion in Europe

Mollicone thinks ‘the answer will not be to rely on a single source’, but ‘that the answer is a mix of energy solutions to have a sustainable future energy supply.’ Many countries around the world are hoping that fusion will prove to be a valuable addition to existing renewable sources. Europe is making strides towards achieving a viable reactor with projects like ITER and DEMO enabled by the EUROfusion consortium. The latter is a project that Mollicone and Muscat are working on in collaboration with the Malta Council for Science and Technology via the ENDURE programme, helping to design components for a fusion reactor that aims to produce more energy than it requires to run. 

Check out THINK’s follow-up article about the EUROfusion Project, where we will be hearing more from Mollicone and Muscat about their work and how to design a working fusion reactor!