Professionalisation and specialisation in the practice of anaesthesia in the UK.

The year 2024 marks 70 years since graduation of the first candidates in revised examinations for Fellowship of the Faculty of Anaesthetists of the Royal College of Surgeons (FFARCS). Here we review the progress of specialisation and professionalisation of anaesthesia in the UK.

John Graunt F.R.S. (1620-74): The founding father of human demography, epidemiology and vital statistics.

John Graunt, a largely self-educated London draper, can plausibly be regarded as the founding father of demography, epidemiology and vital statistics. In his only publication, based on a pioneering analysis of the London Bills of Mortality, he replaced guesswork with reasoned estimates of population sizes and the first accurate information on male:female ratios. He quantified the extent of immigration from countryside to city and his demonstration of the 'dying out' of a cohort paved the way for life table analysis. His comparison of London data with rural data provided the first recognition of the 'urban penalty'. His use of the first known tabular aggregates of health data clarified distinctions between acute diseases, which were often epidemic, and chronic illnesses which were often endemic. He quantified the high infant mortality and attempted the calculation of a case fatality rate during an epidemic of fever. He was the first to document the phenomenon of 'excess deaths' during epidemics. He provided a template for numerical analysis of demographic and health data and initiated the concepts of statistical association, statistical inference and population sampling. By making a novel concept intelligible to a broad audience he influenced the thinking of doctors, demographers and mathematicians.

Sir William Osler (1849-1919) and God's House in Ewelme.

When William Osler was appointed Regius Professor of Medicine in Oxford he also became, ex officio, Master of the Almshouse at Ewelme in Oxfordshire. The link with the Almshouse, its inmates and the villagers of Ewelme gave great pleasure to both Osler and his wife, who spent much time there. This paper explores reasons why Osler found the position so attractive and rewarding.

The narrow-sense and common single nucleotide polymorphism heritability of early repolarization.

BACKGROUND: Early repolarization (ER) is a risk marker for sudden cardiac death. Higher risk is associated with horizontal/descending ST-segment ER in the inferior or inferolateral ECG leads. Studies in family cohorts have demonstrated substantial heritability for the ER pattern, but genome-wide association studies (GWAS) have failed to identify statistically significant and replicable genetic signals. METHODS AND RESULTS: We assessed the narrow-sense and common single nucleotide polymorphism (SNP) heritability of ER and ER subtypes using ECG data from 5829 individuals (TwinsUK, BRIGHT and GRAPHIC cohorts). ER prevalence was 8.3%. In 455 monozygous vs 808 dizygous twin pairs, concordances and twin correlations for ER subtypes (except horizontal/descending ST-segment ER) were higher and familial resemblance (except notched ER) was significant. Narrow-sense heritability estimates derived from 1263 female twin pairs using the structural equation program Mx ranged from 0.00-0.47 and common SNP heritability estimates derived from 4009 unrelated individuals of both sexes using Genome-wide Restricted Maximum Likelihood (GREML) ranged from 0.00-0.36, but none were statistically significant. CONCLUSION: From our data, ER shows limited genetic predisposition. There appears to be significant environmental influence and these modest narrow-sense and common SNP heritability estimates may explain why previous GWAS have been unsuccessful.

L-tryptophan radical cation electron spin resonance studies: connecting solution-derived hyperfine coupling constants with protein spectral interpretations.

Fast-flow electron spin resonance (ESR) spectroscopy has been used to detect a free radical formed from the reaction of l-tryptophan with Ce (4+) in an acidic aqueous environment. Computer simulations of the ESR spectra from l-tryptophan and several isotopically modified forms strongly support the conclusion that the l-tryptophan radical cation has been detected by ESR for the first time. The hyperfine coupling constants (HFCs) determined from the well-resolved isotropic ESR spectra support experimental and computational efforts to understand l-tryptophan's role in protein catalysis of oxidation-reduction processes. l-Tryptophan HFCs facilitated the simulation of fast-flow ESR spectra of free radicals from two related compounds, tryptamine and 3-methylindole. Analysis of these three compounds' beta-methylene hydrogen HFC data along with equivalent l-tyrosine data has led to a new computational method that can distinguish between these two amino acid free radicals in proteins without dependence on isotope labeling, electron-nuclear double resonance, or high-field ESR. This approach also produces geometric parameters (dihedral angles for the beta-methylene hydrogens) that should facilitate protein site assignment of observed l-tryptophan radicals as has been done for l-tyrosine radicals.

Ischemic preconditioning prevents free radical production and mitochondrial depolarization in small-for-size rat liver grafts.

BACKGROUND: Ischemic preconditioning (IP) renders tissues more tolerant to subsequent longer episodes of ischemia. This study tested whether IP attenuates injury of small-for-size liver grafts by preventing free radical production and mitochondrial dysfunction. METHODS: IP was induced by clamping the portal vein and hepatic artery for 9 min. Livers were harvested 5 min after releasing the clamp. Mitochondrial polarization and cell death were assessed by intravital confocal/multiphoton microscopy of rhodamine 123 (Rh123) and propidium iodide. Free radicals were trapped with alpha-(4-pyridyl 1-oxide)-N-tert-butylnitrone and measured using electron spin resonance. RESULTS: After quarter-size liver transplantation, alanine aminotransferase, serum bilirubin, necrosis, and apoptosis all increased. IP blocked these increases by more than 58%. 5-Bromo-2'-deoxyuridine labeling and increases of graft weight were only approximately 3% and 0.2% in quarter-size grafts without IP, respectively, but increased to 32% and 60% in ischemic-preconditioned grafts, indicating better liver regeneration. Eighteen hours after implantation, viable cells with depolarized mitochondria in quarter-size grafts were 15 per high power field, and dead cells were less than 1 per high power field, indicating that depolarization preceded necrosis. A free radical adduct signal was detected in bile from quarter-size grafts. IP decreased this free radical formation and prevented mitochondrial depolarization. IP did not increase heat shock proteins 10, 27, 32, 60, 70, 72, 75 and Cu/Zn-superoxide dismutase (SOD) but increased heat shock protein-90, a chaperone that facilitates protein import into mitochondria, and mitochondrial Mn-SOD. CONCLUSION: Taken together, IP decreases injury and improves regeneration of small-for-size liver grafts, possibly by increasing mitochondrial Mn-SOD, thus protecting against free radical production and mitochondrial dysfunction.

By royal appointment - The Chase Family of Apothecaries.

Medical dynasties are not uncommon, but medical dynasties which serve royalty are rare. This paper describes the work and responsibilities of three successive generations of the Chase family who served as apothecaries to a total of seven British monarchs. Two of them were also Masters of the Worshipful Society of Apothecaries of London, as also was a later member of the family.

Sustained formation of alpha-(4-pyridyl-1-oxide)-N-tert-butylnitrone radical adducts in mouse liver by peroxisome proliferators is dependent upon peroxisome proliferator-activated receptor-alpha, but not NADPH oxidase.

Reactive oxygen species are thought to be crucial for peroxisome proliferator-induced liver carcinogenesis. Free radicals have been shown to mediate the production of mitogenic cytokines by Kupffer cells and cause DNA damage in rodent liver. Previous in vivo experiments demonstrated that acute administration of the peroxisome proliferator di(2-ethylhexyl) phthalate (DEHP) led to an increase in production of alpha-(4-pyridyl-1-oxide)-N-tert-butylnitrone (POBN) radical adducts in liver, an event that was dependent on Kupffer cell NADPH oxidase, but not peroxisome proliferator-activated receptor (PPAR)alpha. Here, we hypothesized that continuous treatment with peroxisome proliferators will cause a sustained formation in POBN radical adducts in liver. Mice were fed diets containing either 4-chloro-6-(2,3-xylidino)-2-pyrimidinylthioacetic acid (WY-14,643, 0.05% w/w) or DEHP (0.6% w/w) for up to 3 weeks. Liver-derived radical production was assessed in bile samples by measuring POBN radical adducts using electron spin resonance. Our data indicate that WY-14,643 causes a sustained increase in POBN radical adducts in mouse liver and that this effect is greater than that of DEHP. To understand the molecular source of these radical species, NADPH oxidase-deficient (p47phox-null) and PPARalpha-null mice were examined after treatment with WY-14,643. No increase in radicals was observed in PPARalpha-null mice that were treated with WY-14,643 for 3 weeks, while the response in p47phox-nulls was similar to that of wild-type mice. These results show that PPARalpha, not NADPH oxidase, is critical for a sustained increase in POBN radical production caused by peroxisome proliferators in rodent liver. Therefore, peroxisome proliferator-induced POBN radical production in Kupffer cells may be limited to an acute response to these compounds in mouse liver.

Increased Number of Beam Angles Is Associated With Higher Cardiac Dose in Adjuvant Fixed Gantry Intensity Modulated Radiation Therapy of Left-Sided Breast Cancer.

PURPOSE: To analyze the relationship between angle number and mean heart dose (MHD) in adjuvant fixed gantry intensity modulated radiation therapy (FG-IMRT) treatment of left-sided breast cancer as is currently practiced in the community. METHODS AND MATERIALS: We performed a retrospective, multi-institutional review of women with left-sided breast cancer receiving adjuvant FG-IMRT between 2012 and 2014, encompassing 85 centers in 15 states. Bivariate and multivariate regression analyses were done to identify factors associated with MHD. Long-term cardiac risk was estimated according to a previously published model. RESULTS: Of the 538 women included, 284 had >2 gantry angle treatment plans (multi-angle), and 254 had 2 gantry angle (standard) plans. Median MHD was higher in patients with multi-angle plans compared with standard (median 475 vs 203 cGy). Number of gantry angles was significantly associated with MHD, with multi-angle plans independently increasing MHD by 229 cGy. Absolute risk of acute coronary events 20 years after treatment was estimated as 7 excess events per 1000 women for standard plans, compared with 12 excess events for multi-angle plans. CONCLUSIONS: Fixed gantry IMRT breast treatment plans with >2 gantry angles were associated with increased MHD, which translated to an increased cardiac risk. Clinicians should account for this potential drawback in treatment technique when assessing overall plan quality.

Electron spin resonance and spin trapping technique provide direct evidence that edaravone prevents acute ischemia-reperfusion injury of the liver by limiting free radical-mediated tissue damage.

A novel free radical scavenger, 3-methyl-1-phenyl-2-pyrazolin-5-one (edaravone), is used for the treatment of acute ischemic stroke and is protective in several animal models of organ injury. We tested whether edaravone is protective against acute liver warm ischemia/reperfusion injury in the rat by acting as a radical scavenger. When edaravone was administered prior to ischemia and at the time of initiation of the reperfusion, liver injury was markedly reduced. Production of oxidants in the liver in this model was assessed in vivo by spin-trapping/electron spin resonance (ESR) spectroscopy. Ischemia/reperfusion caused an increase in free radical adducts rapidly, an effect markedly blocked by edaravone. Furthermore, edaravone treatment blunted ischemia/reperfusion-induced elevation in pro-inflammatory cytokines, infiltration of leukocytes and lipid peroxidation in the liver. These results demonstrate that edaravone is an effective blocker of free radicals in vivo in the liver after ischemia/reperfusion, leading to prevention of organ injury by limiting the deleterious effects of free radicals.

Reduction of ciclosporin and tacrolimus nephrotoxicity by plant polyphenols.

The immunosuppressants ciclosporin (cyclosporin A, CsA) and tacrolimus can cause severe nephrotoxicity. Since CsA increases free radical formation, this study investigated whether an extract from Camellia sinensis, which contains several polyphenolic free radical scavengers, could prevent nephrotoxicity caused by CsA and tacrolimus. Rats were fed powdered diet containing polyphenolic extract (0-0.1%) starting 3 days before CsA or tacrolimus. Free radicals were trapped with alpha-(4-pyridyl-1-oxide)-N-tert-butylnitrone (POBN) and measured using an electron spin resonance spectrometer. Both CsA and tacrolimus decreased glomerular filtration rates (GFR) and caused tubular atrophy, vacuolization and calcification and arteriolar hyalinosis, effects that were blunted by treatment with dietary polyphenols. Moreover, CsA and tacrolimus increased POBN/radical adducts in urine nearly 3.5 fold. Hydroxyl radicals attack dimethyl sulfoxide (DMSO) to produce a methyl radical fragment. Administration of CsA or tacrolimus with (12)C-DMSO produced a 6-line spectrum, while CsA or tacrolimus given with (13)C-DMSO produced a 12-line ESR spectrum, confirming formation of hydroxyl radicals. 4-Hydroxynonenal (4-HNE), a product of lipid peroxidation, accumulated in proximal and distal tubules after CsA or tacrolimus treatment. ESR changes and 4-HNE formation were largely blocked by polyphenols. Taken together, these results demonstrate that both CsA and tacrolimus stimulate free radical production in the kidney, most likely in tubular cells, and that polyphenols minimize nephrotoxicity by scavenging free radicals.

Mistress Joyce Jeffreys and her physician, Dr Bridstock Harford (1607-1695).

The notebooks of Joyce Jeffreys, a wealthy Hereford businesswoman in the mid-17th century, provide information about the medicines she purchased and the fees she paid to her medical advisors. Her physician, Dr Bridstock Harford, was a successful doctor but a troublesome neighbour, who was often the subject of litigation. As an ardent parliamentarian, he held public offices during the Commonwealth. Later his opinions mellowed and he ended his days as a loyal subject of the king and a benefactor to his city.

Lady Brilliana Harley (1598-1643): Her medicines and her doctors.

Lady Brilliana Harley was the redoubtable chatelaine of Brampton Bryan Castle in Herefordshire during the mid-seventeenth century. Her many letters reveal much about the medications which she dispensed to her family and about the family's medical attendants. Whenever possible the Harleys preferred to consult university-educated physicians rather than the local apothecary or surgeon. These physicians are all known from other sources but Brilliana's letters add to what is known of their provincial practices. In particular, they reveal their willingness to undertake blood-letting, often thought to be the province of the more lowly surgeon, and they emphasise the great distances travelled by these practitioners and the difficulties faced by two of them during the Civil War.

Polyphenols from Camellia sinenesis prevent primary graft failure after transplantation of ethanol-induced fatty livers from rats.

Fatty liver caused by ethanol decreases survival after liver transplantation in rats. This study investigated if antioxidant polyphenols from Camellia sinenesis (green tea) prevent failure of fatty grafts from ethanol-treated rats. Donor rats were given ethanol intragastrically (6 g/kg). After 20 h, livers were explanted and stored in University of Wisconsin solution for 24 h. Prior to implantation, the explanted grafts were rinsed with lactated Ringer's solution containing 0 to 60 microg/ml polyphenols. Alanine aminotransferase (ALT) release after liver transplantation was 4.5-fold higher in recipients receiving ethanol-induced fatty grafts than in those receiving normal grafts. Liver grafts from ethanol-treated donors also developed severe focal necrosis. Graft survival was 11% in the ethanol group versus 88% for normal grafts. Polyphenol treatment at 60 microg/ml blunted ALT release by 66%, decreased necrotic areas by 84%, and increased survival to 75%. Ethanol increased alpha-(4-pyridyl-1-oxide)-N-tert.-butylnitrone free radical adducts in bile by 2.5-fold, as measured by electron spin resonance spectroscopy, and caused accumulation of 4-hydroxynonenal in liver sections, effects blunted by polyphenols. Epicatechin gallate, a major polyphenol from C. sinenesis, also decreased enzyme release, minimized pathological changes, and decreased free radical adduct formation. In conclusion, polyphenols scavenged free radicals in ethanol-induced fatty livers and decreased injury after liver transplantation.

The CYP inhibitor 1-aminobenzotriazole does not prevent oxidative stress associated with alcohol-induced liver injury in rats and mice.

Cytochrome P450 (CYP) 2E1 is induced by ethanol and is postulated to be a source of reactive oxygen species during alcoholic liver disease. However, there was no difference in liver pathology and radical formation between wild-type and CYP2E1 knockout mice fed ethanol. Other CYP isoforms may contribute these effects if CYP2E1 is inhibited or absent. The purpose of this study was, therefore, to determine if blocking most of the P450 isoforms with 1-aminobenzotriazole (ABT; 100 mg/kg i.g.), has any effect on liver damage and oxidative stress due to alcohol in rats and mice. Male C57BL/6 mice and Wistar rats were fed either high-fat control or ethanol-containing enteral diet for 4 weeks. ABT had a significant inhibitory effect on many P450 isoforms independent of concomitant alcohol administration. However, ABT did not protect against liver damage due to alcohol in either species. Indices of oxidative stress and inflammation were also similar in livers from vehicle-treated and ABT-treated animals fed ethanol. In summary, suppression of P450 activity with ABT had no apparent effect on oxidative stress caused by alcohol in both rats and mice. These data support the hypothesis that oxidative stress and liver damage can occur independently of CYP activities in both rats and mice during early alcohol-induced liver injury.