Category Archives: Surgery

Silver shines as antibacterial for medical implants

There have been growing concerns in the global health care system about the eradication of pathogens in hospitals and other patient-care environments. Overuse of antibiotics and antimicrobial agents has contributed to the emergence of antibiotic-resistant superbugs – such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) – which are difficult to kill. Lower immunity of sick patients coupled with the escalating problem of antibiotic-resistant pathogens has driven increased rates of infection in hospital and surgical environments.

It’s become crucially important to find ways to control infection in these settings. My research has focused on ways we can do so using alternative antibacterial materials such as the heavy metal silver. I’ve been working on a technique that electrically activates silver to create an antimicrobial surface. We can use this technology to create touch-contact and work surfaces – for instance, door knobs, push plates, countertops – that would help control the transmission of infections, primarily in health care environments. And now we’re experimenting with using silver in medical implants.

Silver takes the gold in fighting bacteria

Silver has long been known for its antibacterial properties. A variety of medical products including ointments, bandages, surgical tools and catheters employ silver-based technologies to prevent or fight infection.

But just an inert lump of silver isn’t going to do much. To be effective, it must first ionize. Research has shown that it’s silver in its ionic (Ag+) and not elemental form that is antibacterial. An atom of silver has a neutral charge; we need to ionize it – take away a negatively charged electron – to transform it into its positively charged ionic form. Silver-based antibacterial surfaces must release silver ions directly into the pathogenic environment to be effective.

Silver ions have antibacterial properties for a few reasons. They can interfere with with cell DNA and affect their ability to procreate. They can inhibit enzymes involved with respiration, essentially suffocating the bacteria cells. And they can react with sensitive thiol groups on bacterial proteins to destroy normal biological activity of the protein. The multi-modal activity also makes it difficult for bacteria to develop resistance in the same way they do to specific antibiotic medications.

Taking silver to inner space

Particularly with our aging population, the number of joint replacement surgeries is growing in the US. And with more surgeries, the associated risks of infection go up too. Now my work with my student George Tan is focused on taking the bacteria-fighting power of silver ions inside the body.

Schematic diagram of silver ions dispersing from the implant and fighting pathogens.
Rohan Shirwaiker, CC BY-NC-ND

We are engineering ways to apply a low-intensity electrical charge to a silver-titanium orthopedic implant. Our technique releases silver ions that kill or neutralize bacteria on and around the implant. The power source, which could be a strong watch battery, can potentially be integrated into the implant design. The body’s own fluids act as a conducting medium between the titanium and silver, enabling the low-level electrical current necessary to create and release the silver ions into the environment which might contain pathogens.

Clear zones around the implant’s silver electrodes show that it’s stopping pathogens from growing nearby.
Rohan Shirwaiker, CC BY-NC-ND

This technology has the potential to dramatically reduce infections which negatively affect patient health, quality of life and health care costs. Our in vitro lab testing has shown a 99% decrease in bacteria growth on and around implants after 24 hours and an infection-free environment after 48 hours.

One of the engineering challenges is to precisely control the level of silver that is released so that no healthy cells are compromised; silver can be toxic. In future, we may explore the possibility of a smartphone app to control the power source and the release of silver ions remotely. Perhaps we could also devise a way to track the biophysical activity around the implant area. Broad application of the system could result in a significant advancement in the fight against infection, with the potential to be incorporated into any type of surgical implant.

Infection continues to be a major complication associated with implantable devices. Although rates vary, an average annual infection rate of approximately 5% (at least 100,000 cases/year) associated with orthopedic procedures involving fracture fixation devices and joint prostheses costs the US healthcare system over $1.5 billion annually. Treatment may require surgical procedures including implant removal, debridement of infected tissue, implant replacement and 6–12 weeks of antimicrobial therapy. Innovations in silver microbial technology could eventually have a wide-ranging impact on patient outcomes as well as on the health of the medical economy.

This article was originally published on The Conversation.
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Yes, sexism is rife in surgery – and it’s time to do something about it

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You would expect women to flourish in medicine. Since 1996, women have outnumbered men in Australian medical schools. More than half of general practice trainees, two out of three paediatric trainees, and close to three in four obstetricians in training are women.

Look at surgical training and this pattern stops: fewer than one in three surgical trainees are women, and the numbers fall further as doctors reach advanced training. Just 9% of surgeons in Australia are women.

Late last week, vascular surgeon Dr Gabrielle McMullin unleashed a storm by suggesting that sexual harassment was common in surgical training. She said gaining redress was so compromised that if a female doctor was propositioned, providing a sexual favour may be the only way to sustain her career.

Data from medical schools in the United States, the United Kingdom and Australia all confirm that sexual harassment occurs in medical school. A 2005 US study of medical students found 92.8% of female students had experienced, observed or heard about at least one incident of gender discrimination and sexual harassment during medical school. This harassment continues into specialist training.

Systemic bullying and harassment ranges from crass sexualised jokes, inappropriate touching and crass commentary on female doctors’ bodies, to frank requests for sexual favours. Some of these may occur in public, but much is unwitnessed.

Women doctors report that they may be able to manage harassment by patients and by their peers, but harassment from supervisors is much more difficult to deal with. Many women doctors are reluctant to come forward and develop feelings of guilt and resignation.

Sexual harassment occurs within a larger culture of discrimination against women in post-graduate medical training. A recent US study of female surgeons found 87% experienced gender-based discrimination in medical school, 88% in residency and 91% in practice.

Anecdotal reports suggest some women trainees are asked at interview about their intentions to have children, or advised that only certain careers are suitable for women with children. When employed, some female trainees report being given job contracts that are structured so they can never meet the criteria for maternity leave. Others say their rosters make it impossible to carry on with a career while maintaining caring responsibilities.

The toxicity of surgical training arises because it’s highly hierarchical, male-dominated, and – like most hospital-based training in the specialties – involves an intense apprenticeship training mode. Career advancement depends on personal recommendation from supervisors, and careers can be stymied by withholding this.

Junior doctors face increasing pressure for specialist training places. Although positions for many specialties are gradually increasing, this is out of kilter with the large increase in medical graduates, following the establishment of new medical schools over the last ten years.

In a high-pressure surgical environment, where older male consultants dominate, and there is great competition for training positions and jobs, women can often find themselves in very poor bargaining positions, vulnerable to sexual harassment.

Although female surgeons may face the worst of sexual harassment, this culture is endemic to medicine more generally and is so common that many doctors do not even notice it. A recurrent theme expressed by victims is the difficulty being believed, and once believed, not seeing any consequences for the perpetrator.

Sexual harassment is fundamentally about power. Saying sexual harassment is about “sex” is like hitting someone over the head with a shovel and calling it gardening. Identifying sexual harassment as it occurs can prove challenging for the doctors and medical students involved, especially if senior peers, including women, laugh it off or engage in collaborative bullying.

Nor is it limited to women. Bullying on the basis of sexual preference, race and age have all been reported in the medical workplace.

To solve the problem, we first need acknowledgement that career repression via sexual harassment, bullying and humiliation occurs, and that victims are not supported when they report.

We also must recognise that full-time apprenticeship mode of training, particularly when there are limited training positions, places junior doctors in a structurally vulnerable position.

We need more and broader modes of training. Part-time training remains unusual in most training programs except general practice. There are currently six part-time surgical trainees, accounting for 0.5% of all training positions in surgery, despite evidence that these trainees are as successful as full-time trainees.

The Royal Australasian College of Surgeons’ announcement yesterday that it will establish an expert advisory committee into bullying and harassment is very welcome. Other specialist colleges should also review harassment in their own programs.

Written policies on harassment in the workplace have existed for many years in health workplaces, but they have not changed the culture. It is time for a concerted approach from both colleges and hospitals to recognise and embrace the kinds of changes that will make medical training inclusive and safe for all medical graduates.

This article was originally published on The Conversation.
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When a University Hospital Backs a Surgical Robot, Controversy Ensues

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Flipping through the New York Times magazine, former hospital executive Paul Levy was taken aback by a full-page ad for the da Vinci robot.

It wasn’t that Levy hadn’t seen advertising before for the robot, which is used for minimally invasive surgeries. It was that the ad prominently featured a dozen members of the surgery team at the University of Illinois Hospital and Health Sciences System. “We believe in da Vinci surgery because our patients benefit,” read the ad’s headline.

“While I have become accustomed to the many da Vinci ads, I was struck by the idea that a major university health system had apparently made a business judgment that it was worthwhile to advertise outside of its territory, in a national ad in the New York Times,” Levy, former chief executive of the prestigious Beth Israel Deaconess Medical Center in Boston, told me by email.

As Levy scanned the ad further, he noticed that at the bottom the ad bore a copyright for Intuitive Surgical Inc., the maker of the da Vinci system. It included this line: “Some surgeons who appear in this ad have received compensation from the company for providing educational services to other surgeons and patients.”

Ads for prescription drugs and medical devices are common, and some feature physician testimonials about why they believe the product works. Physicians also deliver promotional talks for drug and device makers, something we’ve covered extensively in our Dollars for Docs series.

But a whole hospital department? Levy wondered: Was this kosher?

“I was stunned that a public university would allow its name and reputation to be used in that way,” he wrote. “The next day, I did a little research on the university’s own website and confirmed that my initial reaction was correct: The ad violated the University’s code of conduct and administrative procedures, and likely state law.”

Da Vinci robotic systems aren’t cheap. The Wall Street Journal reported last year that they can cost up to $2.2 million each, and questions have been raised about their value. A study found that deaths and injuries caused by the robots are going underreported to the U.S. Food and Drug Administration. And the American Congress of Obstetricians and Gynecologists said in a statement last year: “There is no good data proving that robotic hysterectomy is even as good as2014let alone better2014than existing, and far less costly, minimally invasive alternatives.”

Levy, who runs a blog called Not Running a Hospital, began writing a series of posts about the ad. The first, called Time to Fire Somebody, ran on Jan. 22. “The University has allowed its reputation to be used in a nationally distributed advertisement produced and owned by a private party, in benefit to that party’s commercial objectives. This is not consistent with 2018exercising custodial responsibility for University property and resources,'” it said.

Levy subsequently wrote a post noting that some of those who appeared in white coats in the ad weren’t doctors; one wasn’t even a medical professional, instead serving as the administrative director of the University of Illinois at Chicago Robotic Surgery Training Center, according to her LinkedIn profile.

Levy found that the university’s campus administrative manual appears to prohibit such advertising: “In general, the University cannot permit its image to be used in any commercial announcement, in a commercial or artistic production, including the World Wide Web or in any other context where endorsement of a product, organization, person, or cause is explicitly or implicitly conveyed,” the manual says.

Subsequent posts focused on the hospital’s board of trustees, Intuitive’s disappointing earnings, and the compensation received by the dean of the University of Illinois College of Medicine at Chicago for serving on the board of directors of drug maker Novartis. Levy forwarded the posts to the president and trustees of the university and suggested that they investigate.

Then, one day this month, Levy received an email from Thomas Hardy, the University’s executive director of university relations. It said the ad was paid for by Intuitive, the da Vinci maker, and that neither the university nor those pictured were compensated for appearing in the ad. Nonetheless, Hardy’s note continued,

“We asked Intuitive to suspend the ad, and the company agreed, immediately upon learning of concerns expressed about it. Our request was based on a business decision; we were concerned that the ad was not benefiting UI Health. Out of an abundance of caution, we decided to review circumstances surrounding the publication of the advertisement. We will use this opportunity to conduct a methodical assessment of policies, guidelines, procedures and practices, and where corrective changes are required we will take the appropriate action.”

The president of the University of Illinois system asked his vice president for research to investigate the matter and report back to him by March 15 if policies had been violated.

By writing about the issue, Levy appears to have made an impact on how the university navigates commercial relationships.

But the university and Intuitive are not patting Levy on the back.

In response to questions from me, Hardy reiterated what he had told Levy and also pointed me to a Boston Globe opinion column that faulted Levy for lapses in judgment in a personal relationship with a female employee while he led Beth Israel Deaconess. Levy was fined $50,000 by the hospital’s board of directors.

When I asked Hardy how this was relevant, he wrote in an email, “I believe if you’re attributing claims and accusations to the blogster, your readers deserve to know his reported background so they can make an informed decision about his credibility2026Wanted to make sure you have the pertinent information.”

Levy said he had admitted his errors publicly and apologized.

Intuitive spokeswoman Angela Wonson said in a statement that she believes the ad was appropriate and that the testimonials from university staff were unpaid.

“Medical schools and their affiliated hospitals are our customers and play an important role in training surgeons. In the past year, there has been much misinformation about robotic-assisted surgery, spread largely by plantiffs’ lawyers as well as segments of the health-care community threatened by our groundbreaking technology. Intuitive’s advertising campaign is intended to educate both the medical and patient communities by using factual information from independent, peer-reviewed studies that prove the safety of our system. The University of Illinois, which uses our technology, and the people featured in the advertisement agreed to appear without compensation. Those who use our technology see first-hand the outcomes resulting from its use. Their unpaid testimonials of da Vinci surgery are credible and sincere.”

Levy first questioned the value of the da Vinci in a blog post in 2007, but a year later, he wrote about how his hospital bought one anyway. “Why? Well, in simple terms, because virtually all the academic medical centers and many community hospitals in the Boston area have bought one. Patients who are otherwise loyal to our hospital and our doctors are transferring their surgical treatments to other places,” he wrote.

Other medical device companies also use doctors in their ads and videos. Hologic Inc., which makes a 3D mammogram machine took out an ad in a trade journal last year featuring the staff of Methodist Hospitals in Merrillville, Ind. And Accuray, which makes the CyberKnife, a competitor for the da Vinci system, includes physician testimonials in videos on its site. One video features a physician from Beth Israel Deaconess. The videos do not disclose if the doctors have been paid.

“Accuray does not typically reimburse physicians to participate in the video testimonials on the website and they are not considered company spokespeople,” the company said in a statement. “Some of the physicians and/or their institutions may have received payment for other activities, such as speaking at an educational or medical conference, or for conducting research.”

Beth Israel spokesman Jerry Berger said its doctor, Irving Kaplan, “was approved under the policy we had in place when the video was shot in 2011. He was not compensated for the appearance.”

Levy said he has a financial relationship with EarlySense, which makes equipment to monitor heart rate, respiration and patient movement. He sits on the company’s advisory board. It is not a competitor to Intuitive.

Correction: An earlier version of this story incorrectly spelled the name of Merrillville, Indiana as Merryville, Indiana.

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Squeeze Your Way To A Pain-Free Surgery

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Some medical procedures and surgical operations allow, in some cases even require, that a patient remain awake. A new study compares how effective different distraction interventions are in reducing levels of anxiety and pain when patients undergo such procedures. Using stress balls, talking to a nurse, and watching a DVD eased the surgical patients’ anxiety while… Continue reading →