Dozens in northeast England report symptoms of potentially deadly botulism after getting Botox

Health officials in the UK are investigating reports of dozens of people suffering from a potentially life-threatening condition following Botox procedures in northeastern England, as well as allegations of the illegal sale of Botox-like products.
The local trust of the UK's National Health Service (NHS) in the county of Durham put out an alert on June 13 about several people seeking medical attention after having adverse reactions to cosmetic procedures involving Botox.
Since the incident first came to light last week, 28 individuals have reported symptoms of botulism after receiving cosmetic procedures, the UK Health and Security Agency (UKHSA) told CNN in a statement Friday.
Botulism is a life-threatening condition caused by toxins made by Clostridium botulinum bacteria that attack the nervous system and cause paralysis.
'These toxins (but not the bacteria) are the active ingredient in Botox and similar products,' Dr. Joanne Darke, a consultant in health protection at the UKHSA, said in the statement, adding that it is 'important to go to a licensed practitioner.'
Iatrogenic botulism is a type of botulism that occurs when too much of the cosmetic form, Botox, is injected into a muscle. Botox is a leading cosmetic treatment for wrinkles, as well as for medical conditions such as migraines and excessive sweating.
The UKHSA said the reactions reported have included symptoms of severe drooping of the upper eyelids, double vision, difficulty swallowing, slurred speech and lethargy.
Other symptoms of botulism can include facial muscle weakness.
Botulism requires immediate medical attention and is fatal in 5-10% of cases, according to the NHS website.
While most people make a full recovery with treatment, which typically involves getting injections with antitoxins, without quick care, paralysis can spread to muscles used to control breathing.
While investigations into the cause of the cases are ongoing, the UKHSA said that 'evidence so far does not suggest that the product used has been contaminated. Symptoms are being reported a few days up to four weeks after injection.'
'The practitioners associated with most of the reported cases are no longer carrying out these procedures,' said Dr. Simon Howard, a consultant in health protection at the UKHSA, in the statement.
'However, that does not mean that we may not see more cases as symptoms can take up to four weeks to develop although we are now seeing the number of cases coming forward decreasing which is encouraging news,' he continued.
Howard advised people to ensure they take precautions when seeking aesthetic procedures and advised anyone with symptoms to seek medical attention.
The UK's Medicines and Healthcare products Regulatory Agency (MHRA) told CNN Friday that it is investigating 'allegations surrounding the illegal sale and supply of Botox-type products in the North-East, and want to reassure the public that we take such claims very seriously.'
The agency encouraged people in the UK who believe they have had side effects from medicine or received falsified stock to report it to its Yellow Card program.
'Our Criminal Enforcement Unit works hard to identify those involved in the illegal trade in medicines and takes robust enforcement action where necessary. This can include criminal prosecution,' Dr. Alison Cave, chief safety officer at MHRA, said in the statement.
'Botulinum toxin (Botox) is a prescription-only medicine and should only be available in the UK under the supervision of a doctor or other qualified healthcare professional,' she continued.
In the United States, a growing cluster of botulism cases linked to cosmetic injections was reported in Massachusetts earlier this month. The state's Department of Health said it was investigating 10 cases of suspected iatrogenic botulism all associated with Botox procedures performed at one spa, Rodrigo Beauty.

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Medscape

an hour ago

• Medscape

Jun 20 2025 This Week in Cardiology

Please note that the text below is not a full transcript and has not been copyedited. For more insight and commentary on these stories, subscribe to the This Week in Cardiology podcast , download the Medscape app or subscribe on Apple Podcasts, Spotify, or your preferred podcast provider. This podcast is intended for healthcare professionals only. In This Week's Podcast For the week ending June 20, 2025, John Mandrola, MD, comments on the following topics: a big, deep dive into CTA and fractional flow reserve CT, and a sobering report on the new EVOQUE valve. Mark Petrie from the UK writes to correct my description of the CRAAFT-HF trial. I mistakenly said it was a surgical vs catheter ablation trial, but Dr Petrie said that they were actually randomizing to atrial fibrillation (AF) ablation plus heart failure with reduced ejection fraction (HFrEF) medical therapy vs HFrEF medical therapy alone in patients with left ventricular dysfunction. Saturday is the first day of summer. Where has the time gone? There is a spot at the halfway point of our 5 AM ride, about 20 miles out in the country that the sun rises over a farm on a hill. It's a hot spot on the ride but once a year I try to convince the crew to stop for a photo. Imaging and Behavior Change Five Reasons I Don't Believe an Imaging Test Improves Outcomes My friends in Edinburgh, who have been leaders in the use of coronary computed tomographic angiography (CCTA), report on a nested substudy within the SCOT-HEART 2 trial. Let's start with SCOT-HEART 1, which randomized symptomatic patients (stable CP) to receive CTA plus standard care vs standard care alone — which often included functional stress testing. CCTA-led care led to a significantly lower rate of death from cardiovascular (CV) death and nonfatal myocardial infarction (2.3 vs 3.9%). This seemed like a big win for CCTA, but the controversy centered on the fact that the small delta in statin use in the two groups (more in the CTA) was nowhere near enough to drive the large reduction in myocardial infarction (MI). For instance, I cited Andrew Foy, who calculated that to believe statin therapy drove SCOT-HEART, you'd have to believe statins have a number needed to treat (NNT) of 3, not its normal 50-100. Nonetheless, the use of CCTA is different in cost-constrained systems like Scotland. In Scotland, it is used to reduce coronary angiography and PCI. Knowledge of coronary artery disease (CAD) is used to guide medical therapy, and there is no incentive to do more angiography. In the United States, CCTA is used as a cash machine, because the nanosecond an American patient and American doctor see CAD, the patient gets a hotline to the cath lab and PCI. The problem, of course, with anatomical testing is that you can have twinge of chest pain from a cramp and if you have incidental CAD, boom, you now have lifelong dependence on antiplatelet. Now to the SCOT-HEART 2 trial, which is a randomized controlled trial (RCT) using CTA. The study question is this: Is screening with CTA more clinically effective than CV risk scoring with an equation? The plan is to enroll at least 6000 people (not patients, people ) in Scotland who are at risk of heart disease to CTA-guided management vs equation-guided management. They will use an equation called ASSIGN, which is like the pooled cohort equation (it only uses outcome data from Scotland) and includes the social deprivation score. Those in the equation (or standard care) arm get lifestyle advice and lipid-lowering therapy (LLT) for 10-year risk > 10%. Those in the CTA arm get lifestyle advice for normal CTA, lifestyle advice, plus LLT and aspiring for non-obstructive disease, and for those with obstructive disease, they get lifestyle advice, LLT, aspirin, ACE inhibitor plus review by a cardiologist. At 5 years, the primary outcome is coronary death or MI. There are lots of secondary outcomes. JAMA Cardiology has published a nested cohort study within SCOT-HEART 2 looking at a primary outcome of the proportion of participants who achieved the National Institute for Health and Care Excellence (NICE) recommendations for diet, BMI, smoking and exercise. Diet, smoking and exercise were self-reported, and weight, BMI, and step count were measured. The study population included 400 people enrolled over 4 years, which does not seem like a lot. At 6 months, those in the CTA screening were more likely to meet the primary composite endpoint of compliance with the NICE recommendations for diet, BMI, smoking and exercise — it was 17% vs 6%. These seem low but that's because people had to reach all four of the components. The relative risk increase was an odds ratio of 3.4 times more likely to achieve these four goals in the CTA group. Other secondary findings were that fewer participants in the CTA group were recommended for LLT (51% vs 75%). That's because the risk score placed more above 10% but with normal CTA, LLT was not given. Even though fewer LLTs were recommended with CTA, acceptance of LLT was higher in the CTA group, 77% vs 46%. In the end, statistically similar numbers of patients took LLT in both groups (44% vs 35%). Antiplatelet use was much higher in the CTA group, 40% vs 0.5%. The authors broke down secondary outcomes based on whether CTA showed disease, and this associated with slightly lower weight, BMI, waist circumference, blood pressure, total and LDL cholesterol concentrations, and greater improvements in daily step count. Another interesting twist was that 100 individuals in the CTA arm were given a verbal report of their CTA and the 100 were shown their images. No differences were seen in the two subgroups for the primary and secondary outcomes. The authors were pretty calm in their conclusions. They note these interesting observations, that CTA resulted in more accurate risk stratification where some patients with high equation risk had no disease and some patients with low equation risk had disease. CTA did increase acceptance of lipid-lowering therapy as well as increase the proportion of patients reaching lifestyle goals. The obvious take-home message here is that this data supports the seeing-is-believing idea. The editorialists wrote enthusiastically that: 'the results of this nested randomized clinical trial within the SCOT-HEART 2 study are striking. A preventive strategy incorporating CCTA appeared to be not only more precise but also more motivating to participants and clinicians. CCTA reclassified 1 in 3 individuals based on 10-year risk score, targeting therapy to those who were assumed to derive greatest benefit.' I laud the Edinburgh team for doing SCOT-HEART 2. But the differences in verbal acceptance of lifestyle, or LLT use, or aspirin use, or tiny blood pressure (BP) changes are not what we care about. The only outcome is MI or coronary death. When you submit a person with no disease to medical imaging, it ought not be for motivation. It should only be for their health benefit. The changes in lifestyle or drug use or more precise risk stratification are made up surrogate endpoints that have meaning only if there is a difference in outcomes. I strongly oppose the use of imaging to scare patients into taking statins or not eating chips. In Scotland, the downstream effects of CTA may be different than in the US. Here, it is highly likely that seeing disease will affect future interventions. Let's say there is mild disease noted on a screening CTA. Maybe the US patient is given statins and aspirin. Well, what do you think happens in the months or years to come the next time that patient has a twinge of CP? It's right to the ER and then the cath lab for stents or bypass. We need to celebrate the fact that SCOT-HEART 2 will be done, but until then, we need to resist the urge to image our patients based on minor differences in surrogate endpoints, some of which are self-reported. Heart disease treatment and prevention is simple: it's lifestyle (including diet and exercise), possibly lipid-lowering therapy. Imaging is not required and should not be done until there is evidence it improves outcomes. Symptoms Don't Always Indicate the Severity of Coronary Artery Disease JACC-CV Interventions has published a research letter looking at the association between cardiac symptoms and coronary plaque. I will call this a back-to-the-future study with modern imaging confirming a lesson that Dr Bernard Lown described a half-century ago Only now we get to toss around terms like fractional flow reserve, total plaque atheroma, and — sit down for this one — artificial intelligence–enabled quantitative coronary plaque analysis (AI-QCPA) tools. I will speak about the letter, which is modest, but the main thing that happened is that it caused me to look into the FFR-CT data. And OMG. The researchers used data from the ADVANCE registry, which was a 5000-patient registry from multiple centers done to assess how often FFR-CT changes management vs regular CT. The sample included about 4300 patients who referred for coronary CT and had a coronary lesion. Symptoms were characterized by a) squeezing chest or neck pain, b) pain precipitated by exertion, c) relieved by nitrates or rest. Typical angina had all three; atypical angina had 2 of 3, noncardiac had one, and there was also a group with dyspnea only. There were five groups of patients: 25% no symptoms 10% dyspnea only 6% noncardiac 37% atypical chest pain 22% typical angina Now pause. The authors had total plaque volume and FFR-CT on each of these patients. Then they just did correlations. And they found, with these correlations: Only typical angina had a positive correlation with plaque atheroma. Typical angina also correlated strongly with negative values of FFR-CT. The authors also noted, surprisingly, that atypical chest pain, noncardiac chest pain, and dyspnea each correlated with higher FFR-CT, greater than 0.8 suggestive of normal flow. The authors and imaging proponents seem excited about this. In a Medscape news article, one of the authors says: 'Even having no symptoms was not a reliable indicator of cardiovascular health in these patients. Just because a patient doesn't report any symptoms doesn't mean there is no atherosclerosis.' Also quoted in the news article, Matthew Budoff, MD, a cardiologist at UCLA said: 'cardiologists rely heavily on symptoms to determine how severe cardiovascular disease is, but the new research is beginning to dispel that idea.' Budoff also added that: 'the new findings support the idea CT angiography should be a bigger part of the diagnostic process, so clinicians can look not only at whether a patient has stenosis but also go beyond to see if they have any atherosclerosis or plaque that might be a target for medical therapy.' This letter seems so funny to me. One of the first lessons we were taught at Indiana University in the 1990s was that when a patient presented with typical angina and even a positive stress test, that catheterization would show left main or severe triple vessel disease about 10%, it would be normal in 10%, and somewhere in between in 80%. In other words, symptoms are a very unreliable marker of CAD. Now we have a study that uses have artificial intelligence (AI), CT, FFR, and multivariable regression to confirm something that's as old as the hills. I don't agree with Dr Budoff that cardiologists rely heavily on symptoms. At least not in many places in the US. The main requirement for a stress test in the US is insurance coverage and the main requirement for a cath is a wrist. We don't rely on symptoms. We rely on imaging and angiography. I have this saying that I don't say too much anymore but think often: If every stress imaging machine broke for a month, heart disease outcomes would not change. I wonder whether this also applies to CTA imaging and surely to FFR-CT. A colleague tells me that FFR-CT adds $1500 to basic CTA. I find that shocking. Now I want to go to the advance registry paper in 2018. The main value in this research letter was a kick in the butt to go back to the original evidence for this FFR-CT business, the publication of the ADVANCE registry in the European Heart Journal in 2018. First author Fairbairn. This will be a trigger warning because this is one of those things you can't unsee or unhear. ADVANCE registry included about 5000 patients with symptoms concerning for CAD and atherosclerosis on CCTA. The authors recorded the basic info, symptoms, CCTA and FFR-CT findings were recorded along with treatment plans. They also had 90-day outcomes. For each enrolled patient, a clinical management review committee used data from coronary CTA to determine the management plan using the following criteria: (a) optimal medical therapy, (b) percutaneous coronary intervention (PCI), (c) coronary artery bypass graft surgery (CABG), or (d) more information required. The primary endpoint of the registry is the reclassification rate between the management plan based on coronary CTA alone vs CTA plus FFR-CT. Two teams came up with the original plan based only on CTA. A site team and a blinded core team from Duke. The primary endpoint was the reclassification of the treatment plan from the CT-FFR results. The primary results were that it changed management in about two-thirds of the cases. It was hard for me to see a pattern in the reclassification. The authors tell us later that the majority of subjects were safely deferred to medical management alone, and only a minority required 'further testing.' A second finding was that rate of no significant disease at angiography was significantly lower in patients who had a positive FFR < 0.8 (about 15%) vs > 0.8 (44%). Odds ratio for no significant disease was 0.19 for a positive FFR (that is < 0.8) A third finding was that 19 MACE events happened in the 90 days after the study, 10 of them were death, and all happened in the FFR < 0.8 category — 19 vs 0. The authors concluded that FFR-CT was great. It guided management, helped predict no disease, and even had a strong association with MACE events. They noted this: 'FFR-CT led to a recommendation of invasive coronary angiography (ICA) in only 40% of subjects in a cohort with an anatomic obstructive disease rate of 72%, and subjects referred for ICA downstream were significantly more likely to have obstructive disease at ICA if they had a positive FFR-CT.' And this: 'Importantly, a negative FFR-CT was associated with an excellent short-term prognosis, as none of the 1600 subjects with negative FFR-CT experienced death, MI, or unplanned hospitalization for ACS and urgent revascularization.' A colleague in imaging advises me that this was one of the major studies cited to establish FFR-CT. My gosh, this is terrible. What a mess. First of all, the study was sponsored by HeartFlow. It was a late-breaker at ESC in 2018. I must have had jet lag because I missed it. Much of my criticism follows a Twitter thread from my friend Venk Murthy at University of Michigan. A primary endpoint in change in management in a voluntary registry sponsored by the company is about as weak an endpoint as you can get. Why isn't this a measurement of clinical psychology? What if you chose, say, in a non-industry-funded study, a doctor team skeptical of FFR-CT. I bet few would be swayed by the CT-FFR results. Another problem was that most of the FFR-CT values were abnormal in the left anterior descending artery (LAD) and were between 0.7-0.85. We know this from the IQR values. But now I will cite a study from Christopher Cook in Darrell Francis' group published in JAMA Cardiology 2017. What this London group found is that when doing a systematic review of all studies measuring the diagnostic accuracy of FFR-CT, they found that values just under the cutoff of 0.8 (that is, between 0.7 and 0.8) had the lowest accuracy — only 46% accurate. Pause there. That's like a coin flip. Cook et al report that if you want accuracy from FFR-CT, say 82% overall accuracy threshold, you needed values lower than 0.63 or above 0.83. And if you wanted more stringent 95% and 98% diagnostic accuracy thresholds from FFR-CT, you needed values lower than 0.53 or above 0.93, and lower than 0.47 or above 0.99, respectively. A third issue is that most of the patients (77%) were nontypical angina — either atypical or non-cardiac pain. But we know from the Manesh Patel seminal NEJM paper from 2010 that when patients with atypical symptoms go to cath, the chance of obstructive disease is low — regardless of the results of stress testing. In fact, a positive stress test only changed the likelihood of having CAD from 35% to 41%; hence, my stance that if every stress imaging machine broke, CV outcomes would hardly change. The point in citing this seminal paper is that most patients in the ADVANCE registry study — the 77% with atypical symptoms — should not have had a change in management. A fourth issue is that the MACE events are 100% noise — 19 vs 0. And 10 deaths in the first 90 days. I can't even believe they mentioned MACE events. The CI for the odds ratio goes from 1.2 to 326. The P-value, however, was calculated to be significant at .039, which is crazy. So, in sum, this is one of the weakest, late-breaking, practicing-changing trials I have seen. It's a psychology experiment and we have no idea a) which treatment strategy was best, and b) what meaning is there in changing a treatment strategy without knowing which one is correct. If we wanted to know about FFR-CT, it's simple: you randomize people to care with the HeartFlow FFR-CT vs those without. Then you measure outcomes — MI, CV deaths, even urgent revascularization. But this was not done. Instead, FDA approves the HeartFlow, proponents and key opinion leaders speak highly of it, these studies are not highly criticized, and CT scans get $1500 added to them. HeartFlow was approved de novo in 2014 but received a 2019 clearance for 'virtual modeling.' When I asked my AI friend Claude to explain the difference between the two designations — 2014 and 2019 — one of the 'significant' points was a business model expansion wherein the original FFR-CT was a one-time diagnostic test, but the 'planner (the virtual modeling) creates additional revenue opportunities for each patient who needs intervention.' And then this: the 2019 decision Expands HeartFlow's market from diagnosis into treatment planning. My AI program Claude must not know I am a critical appraiser because it then wrote: Physicians can now use HeartFlow for the entire patient journey: diagnosis → treatment planning → post-intervention assessment. This creates much stronger physician adoption and stickiness. And it makes the cost–benefit analysis more favorable since one CT scan can support multiple clinical decisions. The 2019 Planner approval was huge for HeartFlow because it transformed them from a diagnostic company into a comprehensive coronary care platform. Instead of just answering "Does this patient need a catheterization?", they can now answer: "Exactly how should we treat this patient's disease?" This is why HeartFlow's valuation and market penetration accelerated significantly after 2019. They weren't just competing with stress tests anymore; they were competing with the entire invasive workup process. I had no idea this stuff was happening. What a tragic waste of money. This may be one of the lowest value medical interventions I have seen. And you think I am wrong to be hopeful about FDA new leadership. Regulators should have required an RCT. Since they did not require and RCT, physicians should. Companies are not nefarious. They simply jump over the bar we hold for them. In this case the bar was ridiculously low. Speaking about lax FDA regulation, JACC has published a sobering research letter on the transcatheter tricuspid valve replacement called the EVOQUE valve. This one is also really scary. On this I hardly need commentary; I can just tell you the data. First author was Lior Lupu. FDA approved the valve in February 2024. This was based on the pivotal TRISCEND II trial, which was driven quality-of-life measures, not hard outcomes, and was not blinded. Thus, placebo effects were surely present. The group of authors from Washington, DC used the MAUDE database at FDA, which stands for Manufacturer and User Facility Device Experience. It contains information about device malfunctions, injuries, and deaths associated with medical devices that have been reported by manufacturers, healthcare facilities, and users. The main weakness of MAUDE is that there is no denominator and it's voluntary. In the year since approval, the research team found 150 reports on EVOQUE that describe 158 events. 1. Bradycardia or high degree atrioventricular (AV) block was most common (n = 70 or 44%) and there were 2 deaths. 66 of the 70 required pacemakers. Most were detected at the implant however a third were seen later between days 3 and 90. 2. Device malposition, migration, or embolization occurred in 33 patients (20.9%), causing 6 deaths. Most events were diagnosed within 3 months: 76% intraprocedurally, 14% within 2 days, and 7% between 3 days and 3 months. Management included transcatheter valve-in-valve implantation in 10 cases (eg, SAPIEN-in-Evoque), with 2 requiring a second valve for optimization. Two patients underwent transcatheter treatment for paravalvular leak, while 16 required surgery. 3. EVOQUE leaflet thickening or thrombus was identified in 20 patients (12.7%), with clinical or hemodynamic consequences reported in 16 of the 20. Cases were detected within the first month (56.3%), between months 2 and 6 (25.1%), and after 1 year (18.8%). Management included thrombolysis (n = 4), transcatheter valve-in-valve implantation (n = 2; 1 also had device migration), and surgery (1 patient with severe postprocedural thrombosis with hemodynamic instability). 4. Cardiac tamponade was reported in 8 patients (5.1%), with 5 patients undergoing surgery and 4 deaths. 5. Venous injury or bleeding occurred in 8 patients (5.1%), with 2 deaths. 6. Five cases of ventricular tachycardia, fibrillation, or cardiac arrest were reported: 2 intraprocedurally and 3 postprocedurally (days 0, 4, and 7). 7. Mechanical failure of the delivery catheter was reported in 4 patients (2.5%), all due to nose cone separation. The authors write that while bradycardia, tamponade, valve injury, and valve thrombosis had been reported in the trial, valve malposition, migration, or embolization — the second most frequently reported adverse event in this research letter — were not reported in the trial. So, they were new discoveries. Also, additionally, 3 cases of ventricular arrhythmia or cardiac arrest were reported within the first postprocedural week without a definite etiology. Nose cone separation wherein the nose can go missing into the PA also occurred. Like I said, I hardly need comment because the list of complications is so sobering. Of course, MAUDE has no denominator, but on the other hand it is also voluntary, so this is likely underreporting. I would note that only 237 patients received a valve in the TRISCEND II pivotal trial. There were substantial complications noted. To me, this was quite lax regulation. First, there should have been a trial with a sham procedure. Quality-of-life metrics are meaningless when one group gets a procedure and the other group gets bland white tablets. Second, there should have been more patients in the trial. And third, the approval should have been contingent on a required database, such as that with TAVR. This report is really scary given the number of deaths. In fact, mortality from tricuspid valve surgery is the main reason transcatheter techniques were designed. In the transcript, I highlighted in orange font the number of deaths. I counted 14 deaths and 5 cases of ventricular tachycardia/cardiac arrest. Proponents may cite the learning curve, but I doubt it because I read that the company did a slow rollout where centers who were part of the trial were first. And you wonder why I am a medical conservative and slow adopter.

Vogue

2 hours ago

• Vogue

I Drank Beet Juice Every Day for a Month—It Had This Unexpected Effect

Disclaimer: I am a caffeine fiend. I drink so much coffee that my local barista regularly chides me, reminding me 'it's not good for your heart' to start the day with a triple-shot flat white before 6 a.m. But when I became pregnant—and had to limit my daily caffeine intake to around 200 mg a day (or two single-shot coffees)—it was a struggle to say the least. Pre-pregnancy, I also indulged in nootropics, Diet Coke, and caffeine-infused anything to help me get through the day. But now? It was all a no. And I was flat out tired. That's when I stumbled upon a juice called the 'Fatigue Fighter' made of beets, apples, oranges, celery, and ginger. I was willing to give basically anything a try, and quickly downed an entire container. Delicious. But it wasn't until my energy soared that I became a believer. Read on for all the reasons that maybe you should give it a try, too. What are the benefits of drinking beet juice? I've waxed lyrical about my personal experience with beet juice, but what are the actual health benefits? Evelina Sabonaityte, MD and clinical nutritionist, claims that beet juice is 'a nutrient-packed elixir.' Here are some of the benefits of beet juice, according to Evelina and Dr Katy Kasraie, one of the general practitioners at The London General Practice.

Yahoo

4 hours ago

• Yahoo

Kate Middleton Shares New Message After Dropping Out of Royal Ascot Appearance

Kate Middleton has written a poignant message to children's hospices, saying it was an "immense privilege" to see their work The Princess of Wales, 43, praised them for lifting the spirits of children and families "through life, death and beyond" Her June 20 message, as Children's Hospice Week draws to an end, came six months after she took on the role of patron to a hospice in South WalesKate Middleton is showing her support for kids' hospices in a poignant week. In a new message issued on Friday, June 20, the Princess of Wales praised how hospices 'lift the spirits' and support seriously ill children and their families through 'life, death and beyond.' She said it was an 'immense privilege' seeing the work up close of two hospices, with East Anglia's Children's Hospices and Tŷ Hafan Children's Hospice, during her visits as their patron. It came in a week when Princess Kate, 43, dropped out of an expected visit to the Royal Ascot race meeting on Wednesday. Kate is still managing her return to public-facing duties amid her recovery from cancer treatment. In her message on June 20, Kate wrote, 'No parent expects to hear that their child has a serious health condition that could shorten their life. Sadly, this is the reality faced by thousands of families across the country, leaving them heartbroken, fearful of the future and often desperately isolated." 'Being able to access the support of one of the U.K.'s 54 children's hospices means they don't have to face that future alone," she added. 'As Patron of East Anglia's Children's Hospices and Tŷ Hafan Children's Hospice in South Wales, I have the immense privilege of seeing for myself the extraordinary work of our children's hospices," she said. "Lifting spirits through laughter, fun and play, as well as listening, holding, caring and sharing, they support children and families through life, death and beyond." "This Children's Hospice Week, I hope you will join me in celebrating the life-changing work they do and thanking them for the vital care they provide to children and families experiencing the most challenging times," Kate concluded. Support for children's hospices has been an ever-present part of Princess Kate's public work since she started in public life soon after marrying Prince William in 2011. She has also visited hospices around the world during her overseas tours. During Children's Hospice Week, which ends on June 22, the charity Together for Short Lives brings together the vital services to celebrate the incredible work they do for seriously ill children and their families. Kate made her first visit to Tŷ Hafan in January, spending more time than she was scheduled, crouching down, talking to youngsters and their families and joining in with the games. Tŷ Hafan — which means "Haven House" in Welsh — is located in Sully, South Wales, and was built with the support of Prince William's late mother, Princess Diana. Tracy Jones, the director of family well-being services who showed Kate around, said on the day of the visit in January, 'She immediately gravitated to the children and families — she spent quality time talking to every child and their parents.' 'It's been the most inspiring visit,' Jones added. 'She crouched down and was straightaway on the level of the children. If they were in a wheelchair, she crouched at that level. If they were on the floor, she would be at the level,' she continues. 'We were seriously impressed with how she could stay in a crouch, as it's not that comfortable!" "She instinctively seemed to know where to touch a child that was going to provide the connection, but not cause any distress or startle a child. She was looking at the children, even if she was talking to the parent. It's what we do, as we're used to working with children who are nonverbal," she added. Nick Carroll, CEO of Together for Short Lives, praised Kate's "ongoing support for Children's Hospice Week over many years [that] has helped to raise much-needed awareness of the life-changing work children's hospices do, every day of the year." "Their extraordinary lifeline care for children with life-limiting and life-threatening illnesses enables families to make the most of their lives together, whether that's for years, months or only hours," he said. 'Together with all the children's hospices, we thank the Princess of Wales for her invaluable contribution.' Irfon Rees, Chief Executive of Tŷ Hafan Children's Hospice, said in a statement on June 20, 'Her Royal Highness is clearly profoundly committed to the needs of children and young people, and in January, during her first visit to our hospice as our patron, her kindness and empathy were evident." 'Having HRH's support during Children's Hospice Week means that not only can we take time to celebrate the difference that children's hospices, including Tŷ Hafan, have made to the lives of so many families, but that we can also remind people of the importance of supporting their local children's hospice so that no family has to live their child's short life alone.' Can't get enough of PEOPLE's Royals coverage? to get the latest updates on Kate Middleton, Meghan Markle and more! Kevin Clements, Chief Executive of EACH, based in the area close to the Wales family's country home, Anmer Hall, in Norfolk, added, 'We're so incredibly grateful for The Princess' invaluable contribution as our dedicated Royal Patron. Her ongoing support and vast profile have projected our charity onto the global stage, and this latest message is a perfect way to mark Children's Hospice Week." 'It's a great opportunity to shine a light on the work of children's hospices generally, as well as giving us an opportunity to raise awareness and remind everyone of the need for public support, given we rely on donations for the majority of our income.' Read the original article on People