Month: September 2023

Mastering a Third Robotic Arm is Surprisingly Quick

Interfaces for DoF augmentation (figure by Tobias Pistohl). From Eden at al., Nature Communications. 2022

Busy doctors and nurses may have often found themselves wishing they had an extra arm to help with a patient or help with a difficult suture. Researchers around the world are developing supernumerary robotic arms to help workers achieve certain tasks unaided, or with less strain – but how long would it take to master learning an additional limb? The answer is: not long at all. One hour’s worth of training is enough for people to carry out a task with their ‘third arm’ as effectively as with a partner, according to the results of a new study published in IEEE Open Journal of Engineering in Medicine and Biology.

A new study by researchers at Queen Mary University of London, Imperial College London and The University of Melbourne has found that people can learn to use supernumerary robotic arms as effectively as working with a partner in just one hour of training.

The study investigated the potential of supernumerary robotic arms to help people perform tasks that require more than two hands. The idea of human augmentation with additional artificial limbs has long been a staple of science fiction.

Demonstrating performing a suture with an assistant robotic arm.

“Many tasks in daily life, such as opening a door while carrying a big package, require more than two hands,” said Dr Ekaterina Ivanova, lead author of the study from Queen Mary University of London. “Supernumerary robotic arms have been proposed as a way to allow people to do these tasks more easily, but until now, it was not clear how easy they would be to use.”

The study involved 24 participants who were asked to perform a variety of tasks with a supernumerary robotic arm. The participants were either given one hour of training in how to use the arm, or they were asked to work with a partner.

The results showed that the participants who had received training on the supernumerary arm performed the tasks just as well as the participants who were working with a partner. This suggests that supernumerary robotic arms can be a viable alternative to working with a partner, and that they can be learned to use effectively in a relatively short amount of time.

“Our findings are promising for the development of supernumerary robotic arms,” said Dr Ivanova. “They suggest that these arms could be used to help people with a variety of tasks, such as surgery, industrial work, or rehabilitation.”

Source: Queen Mary University of London

Chronic Back Pain may be Easier to Treat if it’s ‘in the Brain’

Photo by Sasun Bughdaryan on Unsplash

One therapy for chronic back pain is to teach patients how to ‘reprocess’ it in the brain. Now, this therapy may become even more effective thanks a study published in JAMA Network Open. The study examined the critical connection between the brain and pain for treating chronic pain. Specifically, they looked at the importance of pain attributions, which are people’s beliefs about the underlying causes of their pain, to reduce chronic back pain severity. Understanding the source of the pain may help some to avoid surgery which may be ineffective or even worsen the pain.

“Millions of people are experiencing chronic pain and many haven’t found ways to help with the pain, making it clear that something is missing in the way we’re diagnosing and treating people,” said the study’s first author Yoni Ashar, PhD, assistant professor of internal medicine at the University of Colorado Anschutz Medical Campus.

Pain is often in the brain

Ashar and his team tested whether the reattribution of pain to mind or brain processes was associated with pain relief in pain reprocessing therapy (PRT), which teaches people to perceive pain signals sent to the brain as less threatening. Their goal was to better understand how people recovered from chronic back pain. The study revealed after PRT, patients reported reduced back pain intensity.

“Our study shows that discussing pain attributions with patients and helping them understand that pain is often ‘in the brain’ can help reduce it,” Ashar said.

To study the effects of pain attributions, they enrolled over 150 adults experiencing moderately severe chronic back pain in a randomised trial to receive PRT. They found that two-thirds of people treated with PRT reported being pain-free or nearly so after treatment, compared to only 20% of placebo controls.

“This study is critically important because patients’ pain attributions are often inaccurate. We found that very few people believed their brains had anything to do with their pain. This can be unhelpful and hurtful when it comes to planning for recovery since pain attributions guide major treatment decisions, such as whether to get surgery or psychological treatment,” said Ashar.

Before PRT treatment, only 10% of participants’ attributions of PRT treatment were mind- or brain-related. However, after PRT, this increased to 51%. The study revealed that the more participants shifted to viewing their pain as due to mind or brain processes, the greater the reduction in chronic back pain intensity they reported.

The role of discussing brain drivers of chronic pain 

“These results show that shifting perspectives about the brain’s role in chronic pain can allow patients to experience better results and outcomes,” Ashar adds.

Ashar says that one reason for this may be that when patients understand their pain as due to brain processes, they learn that there is nothing wrong with their body and that the pain is a ‘false alarm’ being generated by the brain that they don’t need to be afraid of.

The researchers hope this study will encourage providers to talk to their patients about the reasons behind their pain and discuss causes outside of biomedical ones.

“Often, discussions with patients focus on biomedical causes of pain. The role of the brain is rarely discussed,” said Ashar. “With this research, we want to provide patients as much relief as possible by exploring different treatments, including ones that address the brain drivers of chronic pain.”

Source: University of Colorado Anschutz Medical Campus

High Rates of Hyperglycaemia with Alpelisib Treatment for Breast Cancer

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New research has uncovered high rates of hyperglycaemia among breast cancer patients being treated with the oral medication alpelisib. The researchers say that patients receiving this medication should have their blood sugar levels monitored and managed well before treatment with alpelisib. The results are published by Wiley online in CANCER, a peer-reviewed journal of the American Cancer Society.

Alpelisib targets the phosphoinositide 3-kinase (PI3K) protein that is involved in cell growth and when mutated can fuel cancer. In 2019, the US Food and Drug Administration approved the use of this drug in combination with fulvestrant, an oestrogen receptor blocker, for certain cases of metastatic breast cancer that have mutations in the gene that codes for a PI3K subunit.

Unfortunately, targeting PI3K can lead to hyperglycaemia as a side effect which, if severe, can result in dehydration or kidney damage and can require hospitalisation. Sherry Shen, MD, of Memorial Sloan Kettering Cancer Center, and her colleagues set out to describe the incidence, risk factors, and treatment patterns of alpelisib-associated hyperglycaemia in patients with metastatic breast cancer treated in a clinical trial or as standard care at their institution.

Among 147 patients treated with alpelisib as standard care, the rate of hyperglycaemia was 80.3%, and the rate of serious hyperglycaemia was 40.2%. Among 100 patients who were treated during a clinical trial, rates were lower (34.0% any grade and 13.0% serious hyperglycaemia). The median time to onset of hyperglycaemia after initiating alpelisib was 16 days. An initially elevated haemoglobin A1c, an indicator of high blood sugar such as in prediabetes or diabetes, was a risk factor for later developing hyperglycaemia.

Among patients who developed hyperglycemia, 66.4% received treatment, most commonly with the diabetes drug metformin.

“If a patient is identified to have a PI3KCA mutation and thus eligible for treatment with alpelisib, we should be checking haemoglobin A1c level and partnering with the patient’s primary care physician and/or endocrinologist to optimise their blood sugar levels,” said Dr Shen. “This needs to be done months before initiating alpelisib, because once alpelisib is started, hyperglycaemia usually develops within the first two weeks of treatment. Being pre-emptive about improving glycaemic status and treating prediabetes/diabetes will hopefully lower the patient’s risk of developing hyperglycaemia and thus, lower their risk of needing to discontinue a drug that could be effective for their cancer.”

Senior author Neil M. Iyengar, MD noted that optimising a patient’s blood sugar levels often involves changes to dietary and exercise patterns, and potentially introducing certain medications. “Improving metabolic risk factors through lifestyle interventions may also improve dose delivery of alpelisib, and ongoing clinical trials by our group and other groups are testing whether metabolic interventions such as the ketogenic diet or newer medications used to treat diabetes could also improve the treatment efficacy of cancer therapies that target the PI3K pathway,” he said.

Source: Wiley

Early Cleft Palate Surgery Yields Better Speech Results

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According to a new international study published in the New England Journal of Medicine, cleft palate surgery at the age of six months provides better conditions for speech and language development compared to surgery at 12 months.

Isolated cleft palate is a congenital condition where the palate is not closed and there is an opening between the mouth and the nose. The condition occurs in 1 to 25 per 10 000 births worldwide.

“There has previously been limited evidence for the optimal age for cleft palate surgery in children to achieve the best results”, says Anette Lohmander, professor emeritus at at Karolinska Institutet and principal investigator for the Stockholm centre in the study.

The study, by researchers from Karolinska Institutet and Karolinska University Hospital, among others, involved 558 children from 23 different centres around Europe and South America. Of these, 235 children were randomly assigned to a group to undergo surgery at six months of age and 226 children were randomly assigned to undergo surgery at twelve months of age.

Speech-language therapists/pathologists performed standardised audio-video recordings at one, three and five years of age. The researchers then evaluated the children’s babbling, velopharyngeal function, and speech.

At age five, the researchers found insufficient velopharyngeal function in 21 children (8.9%) who had surgery at six months of age compared with 34 children (15%) who had surgery at age 12 months.

Complications resulting from surgery were rare in both groups. Four serious adverse events were reported but were resolved on follow-up.

The conclusion of the study was that velopharyngeal function for speech at five years was better in the children who had undergone surgery at six months of age than in those who had undergone surgery at 12 months of age. Risks associated with earlier repair may include maxillary arch constriction and the need for secondary surgery for velopharyngeal insufficiency.

“An additional advantage of the early surgery age was a higher incidence of canonical syllables. It is a milestone in children’s language development and is established in typically developed children by the age of ten months at the latest,” says Anette Lohmander, who continues. “The children included in the study had no developmental delay or other deviant conditions. The conclusion is that when it is possible to operate on the cleft palate early, it seems to provide the best conditions for speech and language development.”

Source: Karolinska Institutet

Study Explains a Link between COVID and Increased Cardiovascular Risk

Source: Wikimedia CC0

A study published in the journal Nature Cardiovascular Research shows that SARS-CoV-2 can directly infect the arteries of the heart and cause the fatty plaque inside arteries to become highly inflamed, increasing the risk of heart attack and stroke. The findings may help explain why certain people who get COVID have a greater chance of developing cardiovascular disease, or if they already have it, develop more heart-related complications.

In the National Institutes of Health (NIH)-funded study, researchers focused on older people with atherosclerotic plaque, who died from COVID. However, because the researchers found the virus infects and replicates in the arteries no matter the levels of plaque, the findings could have broader implications for anybody who gets COVID.

“Since the early days of the pandemic, we have known that people who had COVID have an increased risk for cardiovascular disease or stroke up to one year after infection,” said Michelle Olive, PhD, acting associate director of the Basic and Early Translational Research Program at the National Heart, Lung, and Blood Institute (NHLBI), part of NIH. “We believe we have uncovered one of the reasons why.”

Though previous studies have shown that SARS-CoV-2 can directly infect tissues such as the brain and lungs, less was known about its effect on the coronary arteries. Researchers knew that after the virus reaches the cells, the body’s immune system sends in macrophages to help clear the virus. In the arteries, macrophages also help remove cholesterol, and when they become overloaded with cholesterol, they morph into a specialised type of cell called foam cells.

The researchers thought that if SARS-CoV-2 could directly infect arterial cells, the macrophages that normally are turned loose might increase inflammation in the existing plaque, explained Chiara Giannarelli, MD, PhD, associate professor in the departments of medicine and pathology at New York University’s Grossman School of Medicine and senior author on the study. To test their theory, Giannarelli and her team took tissue from the coronary arteries and plaque of people who had died from COVID and confirmed the virus was in those tissues. Then they took arterial and plaque cells – including macrophages and foam cells – from healthy patients and infected them with SARS-CoV-2 in a lab dish. They found that the virus had also infected those cells and tissues.

Additionally, the researchers found that when they compared the infection rates of SARS-CoV-2, they showed that the virus infects macrophages at a higher rate than other arterial cells. Cholesterol-laden foam cells were the most susceptible to infection and unable to readily clear the virus. This suggested that foam cells might act as a reservoir of SARS-CoV-2 in the atherosclerotic plaque. Having more build-up of plaque, and thus a greater number of foam cells, could increase the severity or persistence of COVID.

The researchers then looked at the predicted inflammation in the plaque after infecting it with the virus. They observed the release of inflammatory cytokines, also known to promote the formation of even more plaque. The cytokines were released by infected macrophages and foam cells. The researchers said this may help explain why people who have underlying plaque buildup and then get COVID may have cardiovascular complications long after getting the infection.  

“This study is incredibly important as it adds to the larger body of work to better understand COVID,” said Olive. “This is just one more study that demonstrates how the virus both infects and causes inflammation in many cells and tissues throughout the body. Ultimately, this is information that will inform future research on both acute and Long COVID.”

Though the findings conclusively show that SARS-CoV-2 can infect and replicate in the macrophages of plaques and arterial cells, they are only relevant to the original strains of SARS-CoV-2 that circulated in New York City between May 2020 and May 2021. The study was conducted in a small cohort of older individuals, all of whom had atherosclerosis and other medical conditions; therefore, the results cannot be generalised to younger, healthy individuals.

Source: National Institutes of Health

Is There a Risk of Manic Episodes in Children Taking Antidepressants?

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Mania is a possible but rare side effect of treatment with antidepressant medication in adults, but there is little known about its occurrence in children and adolescents. A newly published paper in JAMA Psychiatry investigated this, finding no evidence of mania/hypomania induced by antidepressants by 12 weeks after treatment initiation. However, caution is necessary in treatment for children with more severe depression or where a parent has bipolar disorder.

“In children and adolescents with unipolar depression, we did not find evidence of antidepressant-induced mania/hypomania by 12 weeks after treatment initiation”, says first author Suvi Virtanen, postdoctoral researcher at Karolinska Insitutet. “This corresponds to the timeframe for antidepressants to exert their psychotropic effect and when treatment-induced mania is expected to emerge. Hospitalisations, parental bipolar disorder, and the use of antipsychotics and antiepileptics were the most important predictors of mania/hypomania.”

Antidepressants are increasingly prescribed to paediatric patients with unipolar depression (as opposed to bipolar depression which is seldom diagnosed in childhood), but little is known about the risk of treatment-emergent mania (ie, the transition from depression into mania shortly after the initiation of antidepressant treatment). Previous research suggests paediatric patients may be particularly vulnerable to this adverse outcome. The results provide complementary information to randomised clinical trials (RCTs) from a large cohort of patients treated in a real-world setting.

The researchers conducted a register-based study on children and adolescents, aged 4–17, diagnosed with unipolar depression between 2006 and 2019. They applied the emulation of target trial framework to guide the study design and analysis, reducing the bias of observational studies and mimicking a RCT.

Antidepressant treatment was unrelated to the risk of mania/hypomania, suggesting other characteristics are more relevant when evaluating which patients may have an increased risk of switching from unipolar depression into mania. “Our model using administrative information from several national registers had a moderate predictive ability, suggesting it is possible to identify patients at high risk for mania/hypomania with a prognostic clinical prediction model. The model has potential to be improved in later work”, says senior author Zheng Chang, Principal Researcher at the Department of Medical Epidemiology and Biostatistics.

Source: Karolinska Institute

First-in-human Treatment with Tumour Vaccine Shows Positive Results against Gliomas

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Tumour vaccines alert a cancer patient’s immune system to proteins that are carrying cancer-typical alterations, and may prove useful in gliomas, which are resistant to most forms of treatment including immune checkpoint inhibitors. Reporting in Nature Medicine, physicians and cancer researchers have now performed a first-in human treatment of eight adult patients with advanced midline gliomas with a peptide vaccine. The vaccine, which mimicked a histone protein mutation typical of this type of cancer, proved to be safe and induced the desired immune responses against the brain tumour, with one patient experiencing remission for more than 31 months.

Cancer vaccinations depend on distinct protein structures on cancer cells by which immune cells can differentiate them from healthy one. Mutations in the tumour genome often lead to protein structures that are altered in a way typical of cancer.

Diffuse midline gliomas are among the most aggressive brain tumours. They usually occur in children and young adults near the brain stem and are therefore difficult to access surgically. Chemotherapy or radiotherapy also have limited effectiveness. In this type of cancer, mutations characteristically occur in the gene encoding histone H3 (H3K27M), a packaging protein of DNA. The mutation gives rise to a novel protein structure (a neoepitope) that can be recognised as foreign by the patient’s immune system.

“Such mutations, which occur in identical form in many patients, are rare in cancer. They literally lend themselves to the development of tumor vaccines because they occur in all cancer cells, since the mutated histone is causative for the development of midline gliomas. This means that vaccination against the mutated protein gets to the root of the problem,” explains Michael Platten, Director of the Department of Neurology at the University Medical Center Mannheim and Head of Department at the German Cancer Research Center (DKFZ).

The researchers led by Katharina Sahm and Michael Platten synthetically reconstructed the section of the histone H3 protein with the characteristic mutation. Using this peptide, they were able to curb the growth of H3K27M-mutated tumours in a mouse model. Encouraged by the results, the team decided to test the mutation-specific vaccine produced at the University of Tübingen in patients in a phase I-trial*, which is still ongoing.

In parallel, the physicians, together with colleagues from Munich, Berlin, Bonn and Münster, treated eight adult patients with the peptide vaccine in time-limited individual curative trials. These patients, who could not be enrolled in the trial protocol, suffered from diffuse midline gliomas with H3K27M mutation that progressed after standard therapy. Some of the affected individuals received therapy with immune checkpoint inhibitors in addition to tumor vaccination.

No serious side effects were observed in any of the vaccinated patients. Five of the eight treated patients developed specific immune responses against the mutant protein, which were dominated by CD4 T-helper cells. In one of the patients who had shown a strong immune response, the tumour regressed completely and she remained tumour-free for 31 months.

The vaccine peptide, which is comparatively long at 27 amino acids, worked in patients with different HLA variants. HLA proteins are responsible for the presentation of the mutant peptide on the cell surface and differ from person to person depending on their genetic background. Supported by the HI-TRON Mainz — Helmholtz Institute of the DKFZ, the researchers also observed that immune responses decreased over time, so repeated administration of the vaccine could support a sustained effect.

“We cannot make any further statements about the efficacy of the vaccination based on these treatments. In any case, the current study has given us valuable information that will help us to further optimise the development of brain tumour vaccines in the future,” explains the study’s senior author Katharina Sahm, senior physician at the Neurological University Hospital Mannheim and DKFZ researcher. A phase I-trial is currently underway to test the vaccine against the H3K27M mutation in patients with newly diagnosed midline gliomas. Evaluation is expected to begin around 2025.

Source: German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ)

Children’s ‘Growing Pains’ may be Tied to Migraines

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New research published in the journal Headache reveals that, in children and adolescents, pain in the lower limbs – what are often called “growing pains” by clinicians and are commonly attributed to rapid growth – may indicate the presence or risk of migraines.

The study included 100 children and adolescents born to mothers with migraines seen at a headache clinic, with half of the youth experiencing growing pains.

“In families of children with growing pains, there is an increased prevalence of other pain syndromes, especially migraine among parents,” the authors wrote. “On the other hand, children with migraine have a higher prevalence of growing pains, suggesting a common pathogenesis; therefore, we hypothesised that growing pains in children are a precursor or comorbidity with migraine.”

After five years of follow-up, 78 patients completed the study, of which 42 were from the group that experienced growing pains and 36 were from the control group. Headaches occurred in 76% of participants who had growing pains and in 22% of controls. Growing pains persisted in 14% of participants who had growing pains at the start of the study and appeared in 39% of participants who were previously asymptomatic.

“Pain in the lower limbs of children and adolescents… may reflect a precursor or comorbidity with migraine,” the authors concluded.

Source: Wiley

Yoga Therapy Improves Quality of Life and Cardiovascular Function

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Yoga therapy and lifestyle modifications have been shown to improve heart failure (HF) patients’ quality of life and enhance their cardiovascular function. A new study, presented at the American College of Cardiology Asia 2023 conference, examines the long-term outcomes of yoga therapy to determine the benefit of adding yoga therapy as a complementary treatment in the management of HF. After 12 months, participants with HF receiving yoga therapy continued to show improvement in left ventricular systolic function as well as quality of life.

The study included 75 heart failure patients (aged 30–70 years old) at a tertiary care centre in South India, who underwent coronary intervention, revascularisation or device therapy within in the previous six to 12 months. All of the patients included in the study were less than or equal to New York Heart Association (NYHA) Class III and had been on optimised medical therapy for at least 6 months to 12 months, and had a left ventricular ejection fraction (LVEF) of < 45%.

The interventional group included 35 participants (31 men and 4 women) and 40 (30 men and 10 women) were in the non-interventional (control) group. The interventional group received yoga therapy and guideline-directed medical therapy, while the control group only continued with standard guideline-directed medical therapy. Echocardiographic parameters were compared at various follow-ups to see the impact of yoga therapy on heart failure patients.

“Yoga is a combination of mind-body techniques, which is a set of physical exercises [asana] with breathing techniques [pranayama], relaxation and meditation that can be effectively used to stimulate physical and mental well-being,” said lead author Ajit Singh, PhD, research scientist for the Indian Council for Medical Research at Kasturba Medical College & Hospital, Manipal Academy of Heart Education in Manipal, India. “Our patients observed improvement in systolic blood pressure and heart rate compared to patients who were on medication without yoga.”

Participants in the yoga group were taken to the Department of Yoga at the hospital and an experienced yoga therapist taught selected yoga therapy like pranayama, meditation and relaxation techniques. Each session lasted around 60 minutes and participants were supervised for one week at the training centre before being asked to continue self-administered yoga at home. Those in the yoga group were advised to perform yoga at least five days a week for 12 months. At the training centre all the participants were taught together to perform the same steps, but individual support was available.

Researchers measured quality of life improvements using the World Health Organization Quality of Life questionnaire, which uses 26 questions to evaluate quality of life in four aspects: physical, psychological, social and environmental health. The participants completed the questionnaire at enrolment, as well as at 24 weeks and 48 weeks of follow-up. According to the researchers, the study showed participants in the yoga group had improvement in endurance, strength, balance, symptom stability and quality of life. They also observed that while patients improved physically and psychologically, there was no improvement in social and environmental health.

Echocardiographic parameters did not show any significant differences between the two groups at baseline. At both the six- and 12-month follow-up, improved biventricular systolic function was seen in the interventional (yoga) group compared to the control group. The interventional group also showed substantial improvement in functional outcomes as assessed by NHYA classification.

“This study proves that the addition of yoga therapy to standard medical management of heart failure leads to an improvement in left ventricular systolic function and quality of life in heart failure patients,” Singh said. “Hence, yoga therapy may improve physical well-being and left ventricular function among heart failure patients on guideline-directed optimal medical therapy.”

Source: American College of Cardiology

Netcare Group Signs Landmark Clean Energy Agreement

Netcare well on track with environmental strategy targets

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In a tangible step towards further reducing its carbon footprint, the Netcare Group has successfully agreed commercial terms for a Renewable Energy (RE) Supply Agreement with independent clean energy solutions provider NOA Group Trading (NOA).

Netcare chief executive officer Dr Richard Friedland noted that the development is a significant milestone in realising the Group’s environmental sustainability strategy, which has made considerable strides since its implementation in 2013.

“Improvement of our energy efficiency initiatives remains a key focus area of this strategy. Netcare has also committed to procuring 100% of its purchased electrical energy from renewable energy sources by 2030, supporting the Race to Zero global campaign with targets that exceed the requirements of the Science Based Target initiative (SBTi) aimed at limiting global warming.

“This transaction represents Phase 1 of achieving this aim and includes six of our facilities where RE will be wheeled through the electricity grid from a combination of wind and solar farms, covering up to 100% of energy consumption at these facilities. This represents approximately 11% of the Group’s total energy consumption which is currently being supplied by Eskom’s predominantly coal fired power stations.

“In combination with other initiatives already implemented under Netcare’s sustainability programme, this transaction will increase the proportion of Netcare’s total energy consumption that is derived from RE sources to around 26%,” he says.

Dr Friedland noted that Netcare’s management teams are actively working towards finding viable solutions to supply RE to the remaining municipal-connected sites in the Group while continuing to build on existing renewable energy initiatives. The Group’s environmental sustainability programme also continues to demonstrate an impressive return on investment to date, illustrating the commercial opportunities in environmentally conscious engineering.

According to Karel Cornelissen, chief executive officer of NOA Group, renewable energy will be wheeled through the national grid to the six designated Netcare facilities via the existing Eskom distribution transmission network and delivery of renewable energy to these facilities is expected to commence by the first quarter of 2026. “The agreement represents a significant step towards a clean-energy future by one of South Africa’s healthcare industry leaders, and we are pleased to partner with Netcare on this crucial advancement,” he says. 

Netcare joined the Race to Zero global campaign in 2021 and was the first healthcare institution in Africa to do so. The campaign strives to rally leadership and support from businesses, cities, regions and investors for a healthy, resilient, zero carbon recovery that prevents future threats, creates jobs, and unlocks inclusive, sustainable growth.

“The devastation of climate change to the environment and among communities is already resulting in enormous hardship and tragedy not only in South Africa but around the world. We cannot sit idly by while this happens. Urgent action must be taken by implementing innovative solutions,” says Dr Friedland.  

“During the past decade, Netcare has actively been engaged in several planned energy, waste and water management initiatives. This meaningful transaction is yet another step towards implementing appropriate green solutions while contributing towards a healthier environment for the people of South Africa in the decades to come and beyond,” he concludes.