Beth Frates wears multiple hats. She is a pioneer in lifestyle medicine and education and practises lifestyle medicine via her health and wellness coaching company, Wellness Synergy, LLC. She is an award-winning teacher at Harvard Medical School and an acclaimed author. One of Beth’s earliest literary successes came with her book, The Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Highly recommended by a wide variety of professionals, it is regarded as a practical guide for anyone looking to embrace a better work-life balance. But it has also served to shine a spotlight on the hugely significant role health care workers can and should have in their interactions with their patients by helping them make appropriate choices to support a healthier lifestyle.
Beth ‘walks the walk’ and never misses an opportunity to talk and educate about the six pillars of lifestyle medicine. They include the management of nutrition, exercise, sleep, stress, substance use and personal connections. She is passionate about her capacity to connect on social media. A prolific contributor to Twitter and Instagram, she harnesses the platforms to share affirmations, discuss evidence-based studies and offer health and self-care tips to an audience far beyond the usual reach of the medical profession. Her Twitter account – @BethFratesMD – has ramped up an impressive 132K followers. Her Instagram posts are an eclectic mix of personal experiences interwoven with a wealth of lifestyle medicine knowledge. Her bio lists interests in yoga and running, her beloved dog, and her career accolades. Above all else she maintains that social interactions are everything – especially after the pandemic.
Beth was recently elected president of the American College of Lifestyle Medicine (ACLM), which comes at a time of growing recognition among health leaders and policymakers that lifestyle medicine can deliver high-value care.
It was the faltering health of Beth’s Father that set her on a quest to learn about the profound influence sustainable lifestyle choices can have on health and quality of life. Lived experiences are often a catalyst for new understanding and change. So, when her Dad suffered a heart attack, largely due to poor diet, lack of exercise and extreme stress, Beth (then aged 18) immersed herself in a journey of learning. Lifestyle medicine, she discovered, helps people change the trajectory of their lives. And physicians, she felt, could benefit from adapting their own habits to prevent burnout, which in turn would help their patients make smarter choices.
She recalls: ‘My Father was financial advising and accounting in New York City in a very competitive market. It’s not easy – you have to constantly be upping your game – and, although he was a healthy, athletic person, by 52 he had fallen off his routine exercise, was not eating healthily and was working from 6.00am until 11.00pm. He would go to church with us on a Sunday but leave us to return to work. Then one day, running for the last train home, he had a heart attack – and it changed everything in our world.’
Thanks to an insightful physician, who gathered the family together to work towards improving her father’s work-life balance, he made a recovery – and her family made massive lifestyle changes. Some of his New York friends were ‘quite savvy’, Beth remembers, and recommended the Pritikin Center, which was one of the earliest programs in lifestyle medicine where they helped him establish a safe and successful rehabilitation by embracing healthy habits.
‘I'm not sure what they called it then, but we would now call it an intensive lifestyle medicine programme. He learned how to exercise safely. My Mom learnt about cooking healthy food, and we had our eyes opened to resiliency and stress management.’
Primed to follow her Dad into the family business, she was studying economics when her lightbulb moment came. It was 1988 and having come across an article by Dr Alan Rozansky about mental stress and cardiac patients and how mental stress could affect heart health as much as physical stress, she grew hungry to learn more. Armed with the paper, she presented herself at Westchester Medical Center in Valhalla, New York, and declared, ‘I'm a college student. My Dad had a heart attack and stroke and I would like to work in this area for the summer.’ Luckily for her she met cardiologist Michael Kay who subsequently became her mentor. He appreciated her bold approach and passion for what was to become a deep love affair with lifestyle medicine. She hasn’t looked back.
It feels a tad distasteful to suggest any upside to the recent pandemic. After all, Beth is a member of the 'physician family' – a community heavily impacted by the global catastrophe. But as a lifestyle medicine pioneer, Beth seemingly used the pandemic as a springboard for change when it shone a much-needed spotlight on physician overload and burnout.
With the media focused on the relentless frontline challenges, there came a heightened awareness of the stressful ‘day-to-day ‘– a subject long overdue for discussion.
Quite simply, the effects of Covid-19 led to discussions not previously had about the mental health risks within the medical profession. It’s an uncomfortable truth Beth seems willing to accept.
Those with a passing concern for the welfare of medics might have foreseen a future less rosy. With the pandemic, physicians had their work cut out; circumstances forced them to adapt quickly. They faced hardships and had to make difficult choices. Tasked with safely and effectively navigating care whilst meeting the demands of changing guidelines and standards, many of these unprecedented challenges led to terrible decision-making scenarios. It took its toll. And, for many, the fallout remains.
Beth is unequivocal about the importance of physician wellness in all this melee. For her, the steps to mitigate against the inevitable dangers to health should begin at a student level. Embracing healthy habits sooner rather than later might even stop those burnout statistics in their tracks – or at least prevent them from rising exponentially. And she believes that if physicians embrace wellness, they are more likely to guide their patients in a similar direction.
She goes as far as to suggest that the successful rehabilitation of patients is influenced by the lifestyle behaviours and attitudes toward wellbeing of their treating health professional. What she often finds with lifestyle medicine is that the physicians who are working to improve their own lifestyles and maintain healthy practices are more likely to feel comfortable counselling patients about these topics. Interestingly, when physicians themselves are feeling over-exhausted and signs of burnout, they often explore healthy living and find lifestyle medicine. Many lifestyle medicine clinicians have shared the fact that this new specialty helped them find new meaning and purpose in their work, helping them work through or escape burnout.
This fact places Beth in a hugely influential position.
She graduated magna cum laude from Harvard College, majoring in psychology and biology. She then attended Stanford Medical School, interned at Massachusetts General Hospital, and completed her residency in the department of physical medicine and rehabilitation at Harvard Medical School, where she served as chief resident.
After residency, Beth focused on stroke and stroke prevention.
And it was in this role that she had something of an epiphany, seeing the possibilities of casting her net wider to guide people to better health with her lifestyle medicine insights.
Joining the dots, she used this background as a starting point to empower a larger spectrum of people, adding behaviour change, coaching and motivational courses to her panoply of skills.
By 2008, Beth had developed the concept of a lifestyle medicine interest group (LMIG).
She has won multiple teaching awards for her work in pre-clinical core courses, including nutrition, musculoskeletal system, central nervous system, endocrine system, and introduction to the professions.
More recently, Beth created a college curriculum on lifestyle medicine for a Harvard Extension School undergraduate and graduate-level course, which many physicians and pre-meds have taken each year.
As director of lifestyle medicine and wellness for the Department of Surgery at Massachusetts General Hospital, she also helped craft an innovative wellness initiative. It is a unique role. With an interest in surgical burnout – notorious for forcing surgeons to rethink their career choice and quit the profession early – her job is to reduce the chances of this happening.
Compassion is Beth’s watchword. She evidently places a high value on self-care and is the embodiment of her health messaging. She exercises regularly – ‘I run a lot – I've always enjoyed that runner's high – and I paddle board, but I like to try new things. I like to be challenged’. She also enjoys yoga, eats healthily and has a dog, Athena, who needs twice daily walking. When we talk over Zoom, her beloved German Shepherd is sat beside her, the perfect close companion and confidante. Her husband and two sons also keep her busy and her desire for a more balanced work-family life set her career pathway.
She considered becoming a surgeon, but she felt that the lifestyle required to practice surgery was not compatible with the family life she envisioned for herself. Even before having her children, she held family time in the highest regard.
‘I enjoy working closely with surgeons and my time with them. I know how demanding their lives can be.’
She loves teaching, coaching and lecturing and has developed a close relationship with the physician community over 30 years. Her focus may be on helping them maintain a healthier perspective, but a strong sense of fun lies at the heart of what she does.
‘Surgeons are driven, competitive people and I can identify with that. But they need to relax, too. It was a surgeon who taught me how to windsurf when I was a medical student at Stanford, so I know they like fun, and I know they like a challenge. I brought my hula hoops to one lecture, and I did some hula hooping and said, “You guys could do this, too. I mean, come on, it's so simple.” One gave it an impressive try, and another did it better than I did! So I added another hoop and double hooped. We had fun, but they also understood that I was serious about lifestyle medicine and that I was there for a reason.’
Her home life inspires her professionally and vice versa. Having overcome a fear of dogs by adopting Reesee, her Goldendoodle who recently passed away, and more latterly Athena the German Shepherd– Beth served as medical editor for the Harvard Special Health Report titled, Get Healthy, Get a Dog [2] that explored the many direct physical and mental health benefits of owning a four-legged friend.
In 2016, she co-wrote The Laughter Prescription [3], a paper that referenced evidence to indicate that laughter is a part of our basic armamentarium that helps prevent diseases and ensure a healthier population. Laugher, she concluded, allows a rush of mood-boosting, pain-alleviating endorphins.
What may have once felt a little left field, these studies serve a serious purpose. Preventative practices reduce the financial burden on the healthcare sectors, makes for healthier physicians who share these best practices with their patients.
Beth has been talking about the transformative effects of healthy habits for more than a decade and is now widely considered an authority on lifestyle medicine.
Her connection with cardiologists goes back a long way from when her father had a heart attack and recently came full circle when she was surprised to receive an email from her original inspiration, the pioneering Dr Alan Rozansky, an advocate of mind and body connections and behavioural cardiology for many years. He wrote to her to tell her he had heard her talk at the Institute of Lifestyle Medicine, had become Board Certified in Lifestyle Medicine, and recently edited an entire journal edition on lifestyle medicine that he was eager to share with the American College of Lifestyle Medicine community. He reached out to Beth as she serves as President of that organization. He had no idea of the fact that his work had had a profound influence on her career. Noting her focus on evidence-based posts, sharing research and even adding a sense of ‘spirituality’ to her feeds, he informed her that he had followed her on Twitter and said, ‘ I love the information you share.’ Beth was delighted – the comments providing a strong sense of validation to her life’s work.
We discuss the power of digital communications, and it is evident that social connections are something she holds dear. Quite possibly, it is the most important in the six lifestyle medicine pillars.
So, just how sustainable are those six pillars in a world beset by constant challenges that includes conflict and crises? There will be times when we lapse, Beth admits, but a sense of purpose, social connections and natural sources of energy help to bolster our resilience. It is not necessarily a quick fix; moreover a long-term commitment.
The relationship between wellness and medicine is not complicated, and Beth is at the forefront of changing attitudes to blend these two areas in everyday lives. That includes those working within the profession who are prone to allowing their focus on self-care to slip. Looking after others can be detrimental to health, which is why Beth argues it is just as important to talk and share stories with colleagues who understand as it is with patients.
When the going gets tough, the co-dependency of physical, economic and social wellbeing is crucial. And if we can implement these habits for such a profound change that it can prevent poor health – without the need for surgical intervention – then what’s not to love, embrace and share forward?
References
- https://www.health.harvard.edu/staying-healthy/get-healthy-get-a-dog
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6125057/
Scientists have developed a ground-breaking AI tool to assist neurosurgeons in deciphering the genetic make-up of brain tumours during surgery.
This state-of-the-art technology offers vital insights into the molecular characteristics of a tumour. It enables surgeons to make real-time decisions about the precise amount of brain tissue to remove and whether it is appropriate to administer targeted anti-tumour medications to the brain.
The research report, led by experts from Harvard Medical School, was published in the Journal Med earlier this month (July 2023).
Accurate molecular diagnosis is critical in brain tumour surgery.
Removing excessive tissue in a less aggressive tumour can adversely affect neurological and cognitive functions. Conversely, insufficient tissue removal in a highly aggressive tumour may leave behind malignant cells that can rapidly grow and spread.
Now this new process can immediately instruct surgeons rather than them waiting days or weeks to learn the molecular type.
The significant milestone could eradicate the issues surrounding the profiling of tumours molecularly that have typically been a challenge in clinical practice.
The AI tool – CHARM (Cryosection Histopathology Assessment and Review Machine) – extracts biomedical signals from frozen pathology slides and provides intraoperative molecular diagnosis in real-time.
Kun-Hsing Yu, senior author and assistant professor of biomedical informatics at the Blavatnik Institute at Harvard Medical School, said: ‘Right now, even state-of-the-art clinical practice cannot profile tumours molecularly during surgery. Our tool overcomes this challenge by extracting thus far untapped biomedical signals from frozen pathology slides.’
Hailed as an advancement of real-time precision oncology, the developers suggest one of the most significant advantages is the potential for immediate treatment.
Certain tumours can benefit from on-the-spot treatment using drug-coated wafers. A Gliadel Wafer is a form of carmustine contained in a wafer. The wafer has a coating that dissolves slowly to release the carmustine directly into the area where the brain tumour was and is often placed directly into the brain at the time of the operation.
The current standard approach for intraoperative diagnosis involves a frozen section. However, freezing tissue can alter the appearance of cells and interfere with the accuracy of clinical evaluation. Additionally, even with microscopes, the human eye may not reliably detect subtle genomic variations on a slide.
CHARM’s AI approach overcomes these limitations to offer an efficient alternative.
Researchers utilised brain tumour samples from 1,524 individuals with glioma, the most aggressive and common form of brain cancer. CHARM demonstrated a remarkable accuracy of 93% when distinguishing tumours with specific molecular mutations and successfully classified three types of gliomas with distinct molecular features that have different prognoses and respond differently to treatments.
CHARM captured visual characteristics of the tissue surrounding malignant cells, allowing it to identify areas with greater cellular density and increased cell death within samples.
These indicators are associated with more aggressive glioma types. The tool also pinpointed clinically significant molecular alterations in low-grade gliomas, a less aggressive glioma subtype with different growth and treatment response propensities.
In addition to identifying molecular markers, the CHARM tool connected the visual characteristics of cells, such as the shape of their nuclei and the presence of oedema with the tumour's molecular profile.
This ability to assess the broader context around the image significantly enhances the accuracy, making it closely resemble how a human pathologist would visually assess a tumour sample.
While the CHARM tool was trained and tested on glioma samples, researchers believe it can be developed to identify other subtypes of brain cancer.
AI models have already been used to profile other types of cancer, such as colon, lung and breast cancers. However, gliomas have presented unique challenges due to their molecular complexity and the substantial variation in the shape and appearance of tumour cells.
It is worth noting that the CHARM tool would need periodic retraining to adapt to new disease classifications as knowledge and understanding of brain cancer continue to evolve.
The AI tool now requires clinical validation and clearance from regulatory bodies.
The potential of this technology to revolutionise brain tumour surgery and improve patient outcomes is highly promising, researchers say.
New research shows that obesity is associated with an increased risk of complications following surgery, including infection, blood clots and kidney complications.
Researchers claim the study highlights the need for broader public health interventions and that obese patients require careful management for these complications.
Using data drawn from the National Surgical Quality Improvement Programme, Robert Meguid and co-researchers studied an initial data set representing more than 5.5 million patients, 44.6% of whom had obesity.
They focused on nine surgical specialties, including general, thoracic and vascular, comparing pre-operative characteristics and post-operative outcomes within body mass index (BMI) classes.
They found that compared to patients of average weight, patients who had overweight or obesity had higher risk-adjusted odds of developing infection, kidney failure and venous thromboembolism, or blood clots in the veins, following surgery.
Patients in the obesity class III category, with a BMI of 40kg/m² or more also had an elevated risk of unplanned hospital readmission.
He said: ‘When we began the research, we did think that increased risk would be the case. Though we did think we might see an increased risk for other post-operative complications beyond infection, kidney failure, and thromboembolism in both overweight and each class of obesity, that wasn't what we saw.’
In his surgical practice, he has observed that extra intra-abdominal fat tissue can lengthen the duration of surgery and make them more complicated. The data he and his colleagues analysed showed that surgery times were six minutes longer for patients with obesity.
Overweight and obesity can be a factor in immediate recovery from surgery.
He added: ‘With lung surgery in particular, ambulating after surgery is a critical part of recovery. It can improve a patient's spirit, decreases the risk of pneumonia, it can improve comfort and decrease the risk of blood clots forming and it can help the bowels wake up. It's so important that patients can be up and walking after surgery, but it can be especially challenging when obesity is a factor.
‘We need to be straightforward in talking about the body, and we need to be honest with our patients. With overweight and obesity being so prevalent in our society, this is not an issue that's going to be solved by one surgeon or one institution. It's a public health issue that we need to be addressing at every level – local, state and national.’
Earlier this month, another study found that a BMI in the range considered overweight is not necessarily associated with a higher risk of death.
The researchers say their work adds to a growing body of evidence to suggest that BMI alone is not an accurate indicator of overall health.
Global media attention is being drawn to the Sheba Medical Centre in Tel Aviv, Israel, a cutting-edge smart hospital that is revolutionising the healthcare industry through its pioneering use of advanced technologies.
With its ground-breaking application of AI technology and robotics, Sheba has earned a reputation as a game-changer in the field.
Israeli Prime Minister Benjamin Netanyahu recently sought treatment at the centre, experiencing first-hand the hospital’s exceptional capabilities when he was treated for dehydration.
As the largest hospital in Israel, Sheba Medical Centre holds a visionary approach to healthcare on a global scale. By combining clinical excellence, medical innovation, and fostering international collaboration, it aims to provide powerful resources to benefit patients worldwide.
The hospital continues to push the boundaries of medical innovation. Recently, a group of physician-entrepreneurs based at Sheba created a ground-breaking AI-driven product capable of instantly diagnosing cardiac issues. This medical advancement was lauded by The Times of Israel, which highlighted its potential to make a life-saving difference.
Known as AISAP (AI-Integrated Scanning for Acute Problems), this real-time scanner utilises AI to provide immediate results and can seamlessly integrate with any POCUS (Point-of-Care Ultrasound) device. The implementation of AISAP has been so transformative that The Times of Israel referred to it as turning POCUS into POCAD (Point-of-Care Assisted Diagnosis). This breakthrough technology is set to redefine the diagnostic landscape and improve patient outcomes significantly.
Meanwhile, The Sun reported from inside the hospital, focusing on a paediatric patient who was being monitored by a ‘state-of-the-art £60,000 robot that doctors use to check on him regularly – ‘even if they are miles away at home’.
Dr Evyatar Hubara and Dr Amir Vardi shared stories of how they care for patients remotely by accessing and assessing data collected via a robot – ‘a powerful tool’ that can act ‘as a first response in a potential emergency’ – and also communicate with patients via the robot if needs be, appearing via a screen to talk to them from his home.
The pioneering hospital was ranked by Newsweek magazine in its prestigious list of the Top 10 Hospitals Worldwide three years running and has been named one of the best smart hospitals and a leader in gastroenterology, neurology and cardiology.
Meanwhile, the Royal College of Surgeons of England (RCS England) is keeping pace with the fast-changing technology has just released Robotic-assisted surgery: A pathway to the future, its new standards and guidance on robotic-assisted surgery (RAS).
Designed to address the challenges and the promises of RAS, the guide provides recommendations on safe adoption and sustainable expansion and includes pointers on how to integrate RAS into surgical services, as well as an outline of the roles and responsibilities of all key stakeholders, including hospitals, surgeons, proctors, robotic companies and regulators.
The publication comes at the same time as the technology company, Intuitive, further cements its support for the RCS England via a new multi-professional network designed to help shape the future development of RAS surgery.
The collaboration will help RCS England’s work to review and develop the evidence base for the use of robotics and ensure RAS training enables improved patient outcomes.
Professor Neil Mortensen, Immediate Past President of the Royal College of Surgeons of England, said: ‘Robotics is here to stay – and we need to leverage this technology and increase take-up where this supports the best quality patient care.
‘Robotic-assisted surgery is not part of the future of surgery; this shift is already occurring. It is the here and now, and when used appropriately, can help surgeons to conduct procedures more precisely and enable patients to recover quicker.’
The College has developed dedicated robotics e-learning and incorporates robotics into its Learning offer. It has accredited multiple surgical training centres providing robotic and minimally invasive surgery training and approved a number of Senior Clinical Fellowships with a robotic training element hosted within UK hospitals. In October 2022, the College accredited Intuitive’s entire global education portfolio.
Surgeons have revealed an innovative bionic hand engineered to enable unparalleled singular finger movement.
This remarkable achievement marks a leap forward within the world of prosthetics, bringing new-found hope to those patients seeking enhanced dexterity and more control.
For the first time, a person with an arm amputation can control every finger of a bionic hand as if it was their own – thanks to novel surgical and engineering advancements merging humans with machines.
The image above shows the patient wearing a prosthetic arm directly attached to the skeleton with an X-ray showing the implanted sensors and the neuromusculoskeletal interface that allows him to control individual fingers of a bionic hand.
By focusing on perfecting these individual finger movements, the team behind the new development aims to restore a sense of natural motion and empower users with greater flexibility in performing everyday tasks, such as pouring a jug of water, picking up a piece of paper, gripping a ball and using a screwdriver.
This is because the bionic hand offers ‘mindful control of thumb, index finger, middle/ring/little finger and wrist’, ‘simultaneous of thumb and index to pinch as well as wrist rotation’, ‘mindful thumb flexion and then simultaneous flexion of individual fingers’ as well as ‘simultaneous control of individual fingers to open and close the hand’.
Surgeons collaborated with engineers to improve the patient experience of prosthetic limbs.
They improved control by rewiring nerves to muscles in a ‘distributed and concurrent manner’, incorporating the embedding of sensors during surgery. Once implanted into the neuromuscular constructs, the sensors are connected to the electronic system of the prosthesis using osseointegration. AI algorithms then decode motor commands, allowing bidirectional communication with the prosthesis and providing direct skeletal attachment.
The research was led by Professor Max Ortiz Catalan, founding director of the Center for Bionics and Pain Research (CBPR) in Sweden, head of neural prosthetics research at the Bionics Institute in Australia, and Professor of Bionics at Chalmers University of Technology in Sweden.
He said: ‘We show that rewiring nerves to different muscle targets in a distributed and concurrent manner is not only possible but also conducive to improved prosthetic control. A key feature of our work is that we can clinically implement more refine surgical procedures and embed sensors in the neuromuscular constructs at the time of the surgery, which we then connect to the electronic system of the prosthesis via an osseointegrated interface. AI algorithms take care of the rest.’
Currently, the drawbacks of prosthetic limbs include limitations in movement, difficulties with control and reliability.
This latest breakthrough means users may master everyday tasks previously not achievable.
The team believes that by reconfiguring the residual limb and integrating sensors and a skeletal implant, they have boosted the capabilities of the bionic hand.
The team reported: ‘We found that the transferred nerves effectively innervated their new targets as shown by a gradual increase in myoelectric signal strength. This allowed for individual flexion and extension of all five fingers of a prosthetic hand by a patient with a trans-humeral amputation.
‘Improved prosthetic function in tasks representative of daily life was also observed. This proof-of-concept study indicates that motor neural commands can be increased by creating electro-neuromuscular constructs using distributed nerve transfers to different muscle targets with implanted electrodes, enabling improved control of a limb prosthesis.’
The study in Science Translational Medicine presents the first documented case of a patient whose body was surgically modified to incorporate implanted sensors that allowed the connection of a hand prosthesis to his neuromusculoskeletal system.
Dr Rickard Brånemark, a research affiliate at MIT, associate professor at Gothenburg University, CEO of Integrum, a leading expert on osseointegration for limb prostheses and who conducted the implantation of the interface, said: ‘It is rewarding to see that our cutting-edge surgical and engineering innovation can provide such a high level of functionality for an individual with an arm amputation. This achievement is based on over 30 years of gradual development of the concept to which I am proud to have contributed.’
To watch the capabilities of the bionic hand, click here
Photo Credit: Zbinden et al., Sci. Trans. Med., 2023./Chalmers University of Technology/Anna-Lena Lundqvist
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With a blockade in place for over a decade, the healthcare system in Gaza has been facing significant challenges. After the 2014 conflict, it was left in a precarious state in terms of infrastructure and healthcare provision.
So in 2015, the charity Medical Aid For Palestinians (MAP) with support from The Ministry of Health of Palestine, approached award-winning cancer surgeon and Rods&Cones ambassador, Professor Shafi Ahmed, to visit Gaza and the West Bank to provide his thoughts and recommendations for building surgical capacity.
In this blog post, Professor Shafi Ahmed explains the efforts taken to address this problem in the region and how advanced remote technology plays a crucial role in maintaining a more sustainable long-term solution. This is his story.
Increasing Surgical Capacity Inside Gaza
“Surgical care in conflict zones and places where, for geopolitical reasons, it is hard to reach remains challenging. It forms an acid test for improving standards in remote training and care for the world as a whole.”
Professor Shafi Ahmed, Global Ambassador, Rods&Cones.
One of the biggest challenges for cancer patients in Gaza is gaining access to the right treatment. With cancer, timely intervention and treatment are everything. Unfortunately, for these patients, the expertise they need often resides outside the Gaza Strip. To access it, they must apply for a visa. For various reasons, approximately two-thirds of visas are rejected by the authorities, denying many cancer patients the surgical care that they desperately need.
For this reason, it was clear from the outset that Gaza needed to increase surgical capacity and expertise. I spent a week visiting the main universities, hospitals, and medical complexes in both Gaza and the West Bank. I also met with government officials. The people I spoke with included leaders and healthcare professionals on the front line. My subsequent report made four recommendations:
Implement more efficient and streamlined training programs led by senior surgeons.
Enhance the surgical skills mix, particularly in the use of laparoscopic surgery.
Modernize training for trainers to help them build better trainee relationships.
Improve holistic cancer care by ensuring a multidisciplinary approach.
With the project agreed upon by trustees of Medical Aid for Palestinians and backed with a substantial budget, the main focus was to build a model of sustainable care. The goal was to leave a legacy within Gaza so that healthcare providers would have the surgical capacity to serve the general population, without patients needing to travel abroad.
Leaving A Lasting Legacy
One of the first things we did was to set up and run a training program for the trainers, helping senior surgeons to become the leaders of tomorrow. Alongside that, we set up two training courses. The first was designed to standardize basic skills at a junior level, so they had the right skills going forward, embedded into their curriculum. The second was to learn laparoscopic skills. This included laparoscopic simulation.
Endorsed by the Royal College Of Surgeons and the participating NGO, I led a program to introduce the courses. We took a stepped approach. We ran the first courses supported by local faculty. The local faculty ran the second course and we supported. By the 3rd course the faculty ran the course entirely themselves with quality assurance provided by the RCS By the third time around, the faculty was running the courses entirely. It was a three-way program, leaving a legacy of expertise within Gaza, and the courses are now running autonomously, three times a year, and the training is sustainable in the long term.
For the first three years, we made regular visits to Gaza. For each visit, the hospitals prepared a list of their most complex cases. We’d spend the day teaching and the evening operating. The local surgical team would perform the operations, and we’d provide guidance and teach surgical techniques.
Building Capacity For Cancer Care
Remote assistance technology enables frontline healthcare workers to bring in the medical expertise they need, without an expert having to leave their current physical space.
In the second phase of the project, we focused on building capacity for colorectal cancer care. The first step was to arrange remote multidisciplinary team meetings (MDTs). This is something practiced as a standard for every cancer patient in the UK. The meetings include a radiologist, a pathologist, surgeons, nurses, and any other relevant healthcare professional to support decision-making around treatments. To deliver the best standard of care, this strategy requires teamwork, group thinking, and collective decisions on the best options for the patient.
Whilst the MDTs in Gaza were well-organized and professional, they sometimes needed help from external experts. We arranged a regular Sunday morning meeting with a team of experts from UK hospitals and the teams in Gaza. We’d go through all of their cases, look at the images, scans, and pathology, as well as understand their restrictions in terms of access to medicines. This helped to ensure the best standard of patient care, considering the available resources.
Together with a small team of specialists, I’ve made a number of week-long visits to various hospitals in Gaza to train and help perform surgery. The team varies each time, bringing different expertise into the hospitals. Alongside five days of training, we spend two or three days in the operating room. We also perform lists for trainees for surgeries such as hernias and gallbladder removal. Each of these visits ends with a symposium on the best standards of care and the latest technological advances for cancer care. Once per year, there is a remote conference on cancer, where the Ministry of Health organizes a cancer symposium.
My most recent visit to Gaza in June 2023 was my tenth operating trip which was a milestone for me and a time to reflect on the project. The team have now supported over a hundred complex surgical operations in 8 years. The first 3 phases of the project – involving 9 surgeons and 3 nurses from the UK and Italy – are now complete. Here’s some of the key data:
211 surgeons successfully completed the training courses.
11 video linked colorectal cancer MDTs.
6 education symposiums.
100+ complex cancer and general surgery operations performed.
$500 000 of Laparoscopic equipment donated.
Using this and other data, we’re now evaluating the impact we’ve had, reflecting on what we’ve done, and what needs to happen next. It has to be said that of all the projects that I have been involved with during my 30-year career as a surgeon, this has been the most important and rewarding one. I’m looking forward to completing Phase 4 by 2025.
Embracing Remote Connectivity
In terms of visualisation, the lighting, and the platform for connecting people and moderating surgical sessions – Rods&Cones is the answer to all the problems that I had before.
Back in 2016, I performed the world’s first virtual reality (VR) surgery. This helped to set the stage and laid the groundwork for the possibilities of remote training. The work we did back then, really helped to support what happened during COVID-19, and the work that’s happening now, both in Gaza and other areas of the world.
Remote connectivity has an important part to play in training. When I think back to my time as Dean of Bart’s Medical School, one of the challenges we came up against was when we had seven or eight students in a surgical theatre. The training wasn’t particularly efficient because many of the students couldn’t take part, and missed out on key knowledge over eight hours in surgery. In some circumstances, this traditional training model almost expects students to learn via osmosis, rather than through active learning. Remote connectivity can help to disrupt that outdated model and provide medical students with higher quality and, ultimately, higher value education.
More than ten years ago, when remote technology became more accessible and more viable, I could see the potential for education. My first live surgery was transmitted to over 14,000 people across the globe in around 180 countries. The next time, that rose to over 50,000 people in 4,000 cities, who connected to watch a live operation. These examples showed the potential of using high-tech but low-cost technology to democratize education. Fast-forward to 2022, Rods&Cones has taken the bull by the horns and created a solution for the problems I was facing when using rudimentary technology in 2014.
Rods&Cones has thought about the inherent challenges. Smart surgical glasses are just one aspect of their solution. They’ve considered the entire surgical environment and the wider ecosystem of training and learning – and how we solve those education problems. It’s clear that they’ve thought about whether the technology makes sense, what the interface looks like, and the experience it provides trainee surgeons.
Rods&Cones In Gaza
In July 2022, I took two Rods&Cones kits to Gaza. The kits went to two different hospitals, where we performed a number of live operations. The remote assistance technology was well received and during my most recent visit in 2023, I learned more about the impact it’s making.
The key to any new technology’s long-term success is stickiness. In this case, that requires regular usage, as well as obvious benefits for frontline healthcare staff, and their connectivity to a wider medical community. It also takes a team to successfully embed remote assistance technology securely and ethically into surgical practice to realize the advantages it brings.
Having a single champion of new technology is great, but with a dedicated team of people, it’s possible to leverage the real benefits for better surgical care, and improve outcomes for patients in a conflict zone, or anywhere else in the world.
Rod&Cones is a remote assistance solution for medical environments. Find out more about the technology that’s helping to democratise surgical care around the world. Book a demo.
A paediatric surgical camp held in Mutate, Zimbabwe, last month saw more than 100 children undergo surgery.
The five-day camp, which was free, took place in Victoria Chitepo Provincial Hospital in Mutare – Zimbabwe's third most populous city.
The project directly follows the launch of Zimbabwe's first ever National Surgical Obstetric and Anaesthesia Strategy (NSOAS).
Like many other parts of the country, Mutare faces various challenges surrounding access to healthcare.
This camp, which focused on hernia surgery, offered huge relief for many families who had been waiting years to receive this care.
Leading the camp was paediatric surgeon Dr Precious Mutambanengwe.
She told Scottish charity Kids Operating Room, which was involved in the development of the strategy: “We have a huge surgical backlog – especially for children with hernias.
“We have over 1,000, and more keep getting added monthly. We are desperate to cut down this waiting list. This is the first one camp focussed on paediatric hernia cases.”
Paediatric surgery in Zimbabwe shares similar challenges with many other African countries.
Among them, a shortage of specialised paediatric surgeons, limited resources, and inadequate infrastructure.
These issues contribute to a high burden of paediatric surgical conditions, a high rate of disease and a high rate of deaths among children who require surgical intervention.
To provide timely, affordable, safe and quality surgical services, the Government of Zimbabwe in September 2022 launched its first five-year plan of the National Surgical, Obstetric and Anaesthesia Strategy (NSOAS).
The strategy aims to promote access to surgical services to district level, a positive move towards strengthening primary health care where 83 per cent of surgical operations in the country happening at national and provincial hospitals.
Additionally, the strategy purposes to address both infrastructure and equipment-related gaps.
Dr Mutambanengwe acknowledged that the NSOAS is set to bring to paediatric surgery in the country – with this surgical camp being just the beginning.
She said: “There has been acknowledgement of the huge need in children for conditions like hernias and tonsillectomies.
“Most facilities lack infrastructure to cater for children and the specialists to carry out the operations.
“NSOAS was key in recruiting donors and partners and is the main reason it was possible to host this camp.”
The five-year strategy has several key components intended to guide the development and implementation of policies and programs related to surgical, obstetric and anaesthesia care.
Zimbabwe was the fifth country in the Southern African Development Community (SADC) Region and ninth in Africa to develop and launch its NSOAS.
However, it was the first country in Southern Africa to specifically single out paediatric surgery interventions in a national health strategy document.
This follows the World Health Assembly 68.15 resolution which recognised the central role of surgery and anaesthesia care in achieving Universal Health Coverage.
The strategy is aligned with Zimbabwe's national health policies and plans, and with global initiatives to improve surgical, obstetric, and anaesthesia care in low- and middle-income countries.
A UK NHS trust has introduced a new surgical technique that means patients who undergo spinal surgery have shorter recovery periods.
Somerset NHS Foundation Trust is the first NHS trust in the south west of the country to purchase an endoscopic spinal surgical system, which will mean many more patients can leave hospital on the same day as their spinal surgery with very little physiotherapy or follow-up care needed.
Mr Ashok Subramanian, consultant spinal surgeons, explained: “There are traditionally a number of risks involved in spinal surgery, particularly with the long incisions made into a patient’s body that often mean they need a long stay in hospital to recover.
“Even after the patient returns home, they tend to experience back pain for a while, with a slow recovery.
“Spinal surgery involves working close to lots of important structures in the body so surgeons need to be very careful during a procedure.
“Over the years technology has advanced and, as with every other speciality, spinal surgery is evolving too.
“For example, for knee problems like a meniscus tear we used to perform open knee surgery back in the 1980s, but this is now done by keyhole surgery with patients often going home on the same day with much less recovery time.
“In fact, it’s now possible for a patient to be back at their work or usual living activity within two weeks, with a reduced risk of infection or arthritis.
“There are, of course, some occasions where this is not possible – mainly for patients with more complex needs.
“Our new endoscopic spinal surgery technique involves inserting a camera into the patient’s spinal canal to remove a piece of bone, ligament, or disc – whatever is causing the problem. All this can be done through a camera under direct and magnified vision.
“One of the key advantages of the technique is that we don’t need to release any of the core spinal muscles, which reduces the chance of back pain for the patient.
“Even a microscope technique would need up to a 2cm incision, but this camera is just 0.6cm thick, so requires a very small incision, reducing any inflammation in the patient’s skin so their recovery can be much quicker with less post-operation pain.
“Another key advantage with this technique is that it can be performed under local anaesthetic so the patient is awake throughout the procedure and can even see it happening on the big screen if they want.
“During the pandemic this was a huge advantage as it meant we didn’t need to give patients a general anaesthetic, which was more complicated for aerosol generated procedures.
“Also, some patients simply aren’t able to have a general anaesthetic due to lung conditions or other medical issues, so this technique can really help them.
“Even if the technique doesn’t work for a patient, there’s no harm done and another option can be explored instead.”
Ashok has been performing spinal procedures using this technique since 2013 through his NHS practice in Scotland.
He has continued to offer this locally in Somerset since his appointment in 2015.
“I was fortunate enough during my time as a registrar to train with the first surgeon to bring the procedure into the UK,” he continued.
“I’ve been really lucky to be an early innovator in this field and I was part of a team that was involved in the presentations to gain NICE guidance and accreditation for the procedure, which meant it could be used as a standard in NHS trusts.
“At present, only about five or six surgeons in the UK perform this procedure and I’m the only surgeon in the south west who uses it, which means we tend to see patients from across the region.
“It’s great for our NHS trust to be at the forefront where we can offer this service to our patients.
“Now that we have purchased the kit to carry out the procedure we hope to be able to increase its availability so it can benefit more patients.
“We are the only NHS trust in the south west to have purchased this equipment so we tend to treat patients across the whole region – in fact our catchment area for spinal surgery is one million people, including the island of Jersey.
“I also teach other surgeons how to perform the procedure, which is something I am very passionate about, and I visit hospitals who are starting to take it on so I can give them advice.”
The resilience and coping abilities of patients who have had liver transplants vary and change over time and are often linked to sociodemographic factors including income, race, and education, a study led by UT Southwestern Medical Center researchers in the US shows.
The findings could lead to tailored interventions to optimise clinical and patient-centred outcomes among liver transplant recipients.
“When we take care of patients who have gone through this life-changing surgery, recovery really evolves over time,” said transplant hepatologist Sarah R. Lieber, M.D., M.S.C.R., Assistant Professor of Internal Medicine and a member of the Division of Digestive and Liver Diseases.
“We don’t fully understand or capture that with current metrics that focus on mainly clinical outcomes such as survival. The aim of this project was to get a more in-depth view of novel patient-reported concepts at different stages of survivorship.”
Dr Lieber led the study published in Liver Transplantation, working with UTSW mentor Amit G. Singal, M.D., M.S., Professor of Internal Medicine, a member of the Division of Digestive and Liver Diseases and the Harold C. Simmons Comprehensive Cancer Center, Medical Director of the Liver Tumor Program, and Chief of Hepatology.
Transplantation offers the chance for a cure for thousands of patients in the US every year with diseases or trauma that affect the liver.
Although more than 70 per cent who receive this surgery survive at least five years, Dr Lieber said, their recovery can be filled with physical, emotional, and psychological challenges.
Liver transplant survivors must adapt to a new life that includes strict medication adherence, frequent clinical monitoring and unanticipated complications.
To better understand what factors influence survivorship, Dr Lieber and colleagues emailed surveys to hundreds of patients who received liver transplants between January 1990 and November 2019 and were followed at the University of North Carolina Liver Transplant Center.
The surveys collected sociodemographic information such as age, sex, race, ethnicity, education level, and income; pre-transplant characteristics such as reason for transplantation, waitlist time, and psychiatric history; and post-transplant characteristics including length of hospital stay, employment status, and whether patients had a caregiver.
They also included survey questions validated for other chronic conditions to assess the patients’ abilities to positively cope as well as their level of post-traumatic growth, resiliency and symptoms of anxiety and depression.
The researchers received 191 completed surveys from patients with a broad span of survival periods ranging from less than a year post-transplant to more than 10 years.
A majority of respondents were male (about 64 per cent) and Caucasian (about 84 per cent) and ranged from 28 to 83 years old.
The surveys showed that although 85 per cent in the early survival period (one year or less) had high post-traumatic growth, only about 15 per cent of late survivors (between five and 10 years) had the same characteristic.
High resilience was reported in only about 33 per cent of survivors and was associated with relatively high income.
Lower resilience was seen among patients with longer hospital stays and later survival stages.
Patients who reported a lower ability to cope after transplant were more likely to be 65 or older, non-Caucasian, have less education, or needed a transplant for nonviral liver disease.
Dr Lieber said about 25 per cent of liver transplant survivors had clinically significant anxiety and depression, more frequent among early survivors and women with pre-transplant mental health disorders.
These characteristics could help predict clinical outcomes, she said.
For example, anxiety and depression, the ability to cope, and resilience have been shown to predict how well a patient can self-manage care and interact effectively with the health system for other chronic diseases, and are important predictors for quality of life and functioning, such as the ability to return to work and engage in daily activities.
Dr Lieber and her colleagues plan to continue to study other facets of survivorship in liver transplant patients, such as how these variables change over time, which could help researchers develop tailored interventions to improve clinical outcomes and quality of life.
“High-quality care of patients after liver transplant includes treating the whole person,” Dr Lieber said.
“Survivorship research informs how we develop and implement interventions to help our transplant community.”
Alvaro Noriega Ramirez, a Clinical Research Assistant in the Division of Digestive and Liver Diseases, also contributed to this study.
This research was funded by the UT Southwestern Fund to Retain Clinical Scientists (UT-FOCUS), the American Heart Association (923721), the Doris Duke Charitable Foundation COVID-19 Fund to Retain Clinical Scientists, and the American College of Gastroenterology Junior Faculty Development Award.
Dr Singal is a Dedman Family Scholar in Clinical Care and holds the Willis C. Maddrey, M.D. Distinguished Chair in Liver Disease.
Swiss scientists at EPFL have developed electrode arrays that can be funnelled through a small hole in the skull and deployed over a relatively large surface over the brain’s cortex.
The technology may be particularly useful for providing minimally invasive solutions for epileptic patients.
Scientist Stéphanie Lacour’s specialty is the development of flexible electrodes that adapt to a moving body, providing more reliable connections with the nervous system. Her work is inherently interdisciplinary.
So, when a neurosurgeon asked Lacour and her team to come up with minimally invasive electrodes for inserting through a human skull, they came up with an elegant solution that takes full advantage of their expertise in compliant electrodes, and inspired by soft robotics actuation. The results are published in Science Robotics.
The challenge? To insert a large cortical electrode array through a small hole in the skull, deploying the device in a space that measures about 1 mm between the skull and the surface of the brain – without damaging the brain.
“Minimally invasive neurotechnologies are essential approaches to offer efficient, patient-tailored therapies,” said Stéphanie Lacour, professor at EPFL Neuro X Institute.
“We needed to design a miniaturised electrode array capable of folding, passing through a small hole in the skull and then deploying in a flat surface resting over the cortex. We then combined concepts from soft bioelectronics and soft robotics.”
From the shape of its spiraled arms, to the deployment of each arm on top of highly sensitive brain tissue, each aspect of this novel, deployable electrode is ingenious engineering.
The first prototype consists of an electrode array that fits through a hole 2cm in diameter, but when deployed, extends across a surface that’s 4cm in diameter.
It has six spiraled-shaped arms, to maximise the surface area of the electrode array, and thus the number of electrodes in contact with the cortex.
Straight arms result in uneven electrode distribution and less surface area in contact with the brain.
Somewhat like a spiralled butterfly intricately squeezed inside its cocoon before metamorphosis, the electrode array, complete with its spiralled-arms, is neatly folded up inside a cylindrical tube, ie the loader, ready for deployment through the small hole in the skull.
Thanks to an everting actuation mechanism inspired from soft robotics, each spiralled arm is gently deployed one at a time over sensitive brain tissue.
“The beauty of the eversion mechanism is that we can deploy an arbitrary size of electrode with a constant and minimal compression on the brain,” said Sukho Song, lead author of the study.
“The soft robotics community has been very much interested in this eversion mechanism because it has been bio-inspired. This eversion mechanism can emulate the growth of tree roots, and there are no limitations in terms of how much tree roots can grow.”
The electrode array actually looks like a rubber glove, with flexible electrodes patterned on one side of each spiral-shaped finger.
The glove is inverted, or turned inside-out, and folded inside of the cylindrical loader.
For deployment, liquid is inserted into each inverted finger, one at a time, turning the inverted finger right side out as it unfolds over the brain.
Song also explored the idea of rolling up the arm of the electrode as a strategy for deployment.
But the longer the arm, the thicker it becomes when rolled up. If the rolled-up electrode becomes too thick, then it would inevitably take up too much room between the skull and the brain, placing dangerous amounts of pressure on the brain tissue.
The electrode pattern is produced by evaporation of flexible gold onto very compliant elastomer materials.
So far, the deployable electrode array has been successfully tested in a mini-pig.
The soft neurotechnology will now be scaled by Neurosoft Bioelectronics, an EPFL spin-off from the Laboratory for Soft Bioelectronic Interfaces, that will lead its clinical translation.
The spin-off was recently granted 2.5 million CHF Swiss Accelerator by Innosuisse.