Anaesthetic subspecialties and sustainable healthcare: a narrative review.

The principles of environmentally sustainable healthcare as applied to anaesthesia and peri-operative care are well documented. Associated recommendations focus on generic principles that can be applied to all areas of practice. These include reducing the use of inhalational anaesthetic agents and carbon dioxide equivalent emissions of modern peri-operative care. However, four areas of practice have specific patient, surgical and anaesthetic factors that present barriers to the implementation of some of these principles, namely: neuroanaesthesia; obstetric; paediatric; and cardiac anaesthesia. This narrative review describes these factors and synthesises the available evidence to highlight areas of sustainable practice clinicians can address today, as well as posing several unanswered questions for the future. In neuroanaesthesia, improvements can be made by undertaking awake surgery, moving towards more reusables and embracing telemedicine in quaternary services. Obstetric anaesthesia continues to present questions regarding how services can move away from nitrous oxide use or limit its release to the environment. The focus for paediatric anaesthesia is addressing the barriers to total intravenous and regional anaesthesia. For cardiac anaesthesia, a significant emphasis is determining how to focus the substantial resources required on those who will benefit from cardiac interventions, rather than universal implementation. Whilst the landscape of evidence-based sustainable practice is evolving, there remains an urgent need for further original evidence in healthcare sustainability targeting these four clinical areas.

Variables associated with survival in patients with invasive bladder cancer with and without surgery.

We recorded the survival of 141 patients assessed for radical cystectomy, which included cardiopulmonary exercise testing. The median Kaplan-Meier survival estimates were: 1540 days for the whole cohort; 2200 days after cystectomy scheduled (n = 108); and 843 days without surgery. The mortality hazard remained double that expected for a matched general population, but survival was better in patients scheduled for surgery than those who were not: the mortality hazard ratio (95%CI) after cystectomy was 0.43 (0.26-0.73) the mortality hazard without surgery, p = 0.001. The mortality hazard ratios for the three-variable Bayesian Model Averaging survival model for all 141 patients were: referral for surgery (0.5); haemoglobin concentration (0.98); and efficiency of carbon dioxide output (1.05). Efficiency of carbon dioxide output was the single variable in the postoperative model (n = 108), mortality hazard 1.08 (per unit increase). The ratio of observed to expected peak oxygen consumption associated best with mortality in 33 patients not referred for surgery, hazard ratio 0.001. Our results can inform consultations with patients with invasive bladder cancer and suggest that interventions to increase fitness and haemoglobin may improve survival in patients who do and who do not undergo radical cystectomy.

Brain stem death testing after thiopental use:A survey of UK neuro critical care practice.

A postal survey was conducted to determine how thiopental is used in UK neurosurgery critical care units. Thirty units were contacted and 26 replied. Thiopental is used in 23 units. The majority (60%) of these units govern the use of thiopental with protocols or guidelines and 74% use cerebral monitoring to guide dosage. When patients have had thiopental, 20 units delay brain stem testing, two will not perform tests and one unit incorporates cerebral angiography into their protocol. Twelve units use serum thiopental assays in their brain stem testing procedures, but there is wide variation in the interpretation of the results. We found inconsistency and confusion surrounding brain stem testing in this patient group, raising the possibility of misdiagnosis of brain stem death.

The effect of acetaldehyde on human brain transketolase activity.

Chronic alcoholism and thiamine deficiency are well documented factors in the aetiology of Wernicke-Korsakoff Syndrome. More recently, acetaldehyde (ACH) has been implicated as a possible aetiological factor. In the present investigation the direct effect of ACH was studied on the activity of transketolase, a thiaminedependent enzyme, as well as two non-thiamine-dependent enzymes (aspartate aminotransferase and lactate dehydrogenase), isolated from five control human brains. The concentration of ACH required to inhibit 50% activity of holo- and apo-transketolase was 80 mM and 60 mM, respectively, whereas that for aspartate aminotransferase and lactate dehydrogenase was 14 mM and 10 mM, respectively. None of the enzymes were completely inhibited by the range of ACH concentrations used in the study. It was concluded that the thiamineindependent enzymes were markedly affected by the concentrations of ACH which did not affect the thiaminedependent enzyme, transketolase. In vitro studies with homogenates pre-treated with ACH in the presence of various concentrations of glutathione showed that the latter had a protective effect against loss of transketolase activity.

Thiamine pyrophosphate effect and normalized erythrocyte transketolase activity ratio in Wernicke-Korsakoff patients and acute alcoholics undergoing detoxification.

Thiamine deficiency may be assessed clinically by an abnormally low specific erythrocyte transketolase activity and/or by abnormally large activation by thiamine diphosphate in vitro (or 'TPP effect'). In the present investigation, we report erythrocyte transketolase activation by TPP in acute alcoholics and Wernicke-Korsakoff patients undergoing detoxification. A new age-dependent parameter was used to improve the reliability of transketolase activity as an indicator of marginal thiamine deficiency. Thus normalized transketolase activity ratio (NTKZ), primary activation ratio (PAR) and further activation ratio (FAR) were measured in 29 acute alcoholics and 12 Wernicke-Korsakoff patients upon admission, and also on 47 control subjects. It was possible to follow up 14 of the 29 acute alcoholics after 7 days of treatment. Twenty-one per cent of the acute alcoholics and 33% of the Wernicke-Korsakoff patients, on admission to the detoxification Unit, had NTKZ values beyond the defined critical conditions for thiamine deficiency, whereas 7% of the former and 25% of the latter had PAR values beyond these critical conditions. Furthermore, all three parameters were significantly different in the Wernicke-Korsakoff patients compared to the other groups. The pattern of improvement of the different parameters on follow-up varied considerably and is difficult to explain, as only the NTKZ was statistically significant. Hence, only eight out of 14 acute alcoholics showed improvement in NTKZ, seven showed improvement of PAR and six showed improvement of FAR after treatment. Five patients showed improvement of both NTKZ and PAR and none of the patients showed improvement of all three parameters. We conclude that our findings confirm previous reports and that this modified transketolase activation test improves its reliability as an indicator of marginal thiamine deficiency.

The influence of brain acetaldehyde on oxidative status, dopamine metabolism and visual discrimination task.

The toxic effect of acetaldehyde on brain oxidative capacity and dopamine metabolism has been investigated in rat brains after a single intraperitoneal injection of acetaldehyde (5 mmol/kg) and the results compared with those from chronically ethanol fed rats. Acetaldehyde was present in rat brain 120 hr after a single dose of acetaldehyde, confirming that it is able to cross the blood-brain barrier. Brain catalase increased significantly after acetaldehyde or chronic ethanol administration although there were no other significant changes in the total brain activity of superoxide dismutase, glutathione peroxidase or glutathione reductase. Dopamine turnover was increased in both experimental groups. The acute dose of acetaldehyde reduced the ability of the rats to relearn a computer visual discrimination task.

The genesis of alcoholic brain tissue injury.

1. Acetaldehyde has been implicated in the pathogenesis of alcohol-related liver damage by two mechanisms. Adduct formation with many tissue constituents, especially proteins, makes them immunologically foreign or reduces enzyme activity and formation of cytotoxic free radicals from acetaldehyde metabolism. Adduct formation damage to microtubule associated proteins and to hepatocyte membranes impedes protein movement into, out of and around the cell. 2. Evidence that these mechanisms also have a role in alcoholic brain damage includes raised blood acetaldehyde in alcoholics, especially in those chemically dependent, or in other abnormal states; effects of extra-hepatic free radical toxicity, including induction of superoxide dismutase activity and damaged, abnormal variants of the thiamin-dependent enzyme transketolase and extrahepatic acetaldehyde-adduct formation with haemoglobin. That acetaldehyde-mediated impairment of microtubule systems also damages the brain is suggested by its importance for the maintenance by protein transport of often greatly extended brain cell processes. 3. Oxygen-derived free radicals can damage brain tissue, the effects including cerebral oedema, neuronal loss and damage to the blood-brain barrier, all changes also reported in the brains from alcoholic patients. Alcohol-related pathology in the brain differing from that in the liver, shows sharper regional variations in vulnerability and adverse effects due to nutritional deficiencies, especially of B-group vitamins. Even though some such deficits are capable of causing encephalopathy in the non-alcoholic, the strong association between them and chronic alcoholism points to possible aggravation by metabolic interactions at various levels between acetaldehyde and thiamin or other B-vitamins. Selective regional vulnerability may reflect differences in ease of acetaldehyde access or to important metabolic differences. Alteration of animal behaviour by acetaldehyde points to a need to correlate clinical evidence of acetaldehyde central nervous cytotoxicity with the incidence of different types of cognitive defect.

The age dependence of the activity and activation of human red blood cell transketolase.

Erythrocyte transketolase has been measured in normal controls and non-alcoholic patients not at risk from nutritional deficiency and without signs of brain damage. The enzyme activity declines steadily with age over a range from 18 to 90 years with a statistically significant fall of 25% over this period. Since this decline is apparent whether or not thiamin diphosphate is added in vitro to activate the apoenzyme, the activation ratios are independent of the age effect. The decline is seen in both sexes in patients and normal subjects. It is concluded that the reliability of the specific transketolase activity as an indicator of marginal thiamin deficiency will be improved if the results are expressed as a percentage of the mean normal value corrected for age with values less than 60% of the age adjusted mean taken to indicate possible deficiency.

Interaction between pyridine nucleotide coenzymes and heme proteins as a possible source of error in assay of activities of coenzyme-linked enzyme.

The ultraviolet absorbance spectra of pyridine nucleotide coenzymes change in the presence of heme-containing proteins. The positions of each of the two main absorbance peaks of NADH are shifted progressively towards shorter wavelengths in the presence of increasing concentrations of hemoglobin, and the third peak, at 220 nm, disappears altogether. Similar changes are seen in the spectra of NAD+ and NADPH, and similar effects on these spectra are produced by myoglobin and cytochrome c, but not by comparable concentrations of albumin. The spectral shifts are generally accompanied by a decreased peak height. This finding may help explain problems reported by previous workers in the measurement of the activity of enzymes such as transketolase or lactate dehydrogenase in erythrocyte hemolysates. Errors may be considerable if allowance is not made for this effect, especially if the concentration of heme protein in the spectrophotometer cuvette much exceeds 1 g/L. The interaction appears to indicate some form of bonding, occurring generally between pyridine nucleotide coenzymes and the heme group in proteins. We relate the findings to measurement of activities of pyridine nucleotide-linked enzymes in erythrocyte lysates and in plasma containing myoglobin after muscle breakdown.

The transport of leucine and aminocyclopentanecarboxylate across the intact, energy-depleted rat blood-brain barrier.

The transport across the blood-brain barrier of the large neutral amino acid leucine and the nonmetabolised aminocyclopentanecarboxylate (ACPC), of similar molecular size, was studied in the perfused, energy-depleted rat brain. It was found that when both leucine and ACPC were perfused for periods of up to 10 min their accumulation in the brain increased in a linear fashion. The ratio of perfusate radioactivity per milliliter and tissue radioactivity per gram (Rt/Rp) rose to above unity for both leucine and ACPC, indicating continued uptake against a concentration gradient of the radiolabel within the CNS. When the effect of increasing the concentration of the amino acid upon its influx into the brain was studied, it was found that under these conditions the kinetics of transport for both leucine and ACPC were of a similar order of magnitude to those reported previously in vivo. The values for the Michaelis constant for transport (Km), maximum rate of transport (Vmax), and the constant for the apparently linear, nonsaturable component (Kd) for leucine into the cerebrum were 84.5 +/- 29.0 microM, 45.5 +/- 1.5 nmole/min/g, and 2.62 +/- 0.15 microliters/min/g, respectively, and for ACPC 381 +/- 64 microM, 54.0 +/- 1.5 nmole/min/g and 0.35 +/- 0.10 microliter/min/g, respectively. Comparing this data with previously reported values it is suggested that the transport of leucine into the central nervous system from a perfusate or bolus where no other competing amino acids are present, is flow dependent. Furthermore, ACPC enters the brain almost entirely by a carrier-mediated process, with little or no nonsaturable influx despite a similar oil/water partition coefficient as leucine.

Approaches to the alcohol problem in the workplace.

The main problem areas posed by either alcohol or alcoholism in the workplace are identified as alcohol-related accidents, reduced work performance and loss of working time. In addition to the heavy costs of these problems for industry, it is suggested that a further and generally ignored burden comes from the premature death in middle life of alcoholics who will include a disproportionately large number of top management and more skilled employees. A comparison with the history of alcohol-related road traffic accidents suggests that there is scope for large savings from an effective campaign to reduce the incidence of alcohol-related problems in the workplace. An outline is given of the managerial steps involved in setting up and running a company alcohol programme and North American and early U.K. experience is assessed to indicate the approaches most likely to lead to effective prevention. An analysis is attempted of the conditions needed for effectiveness and the reasons for the reported high success rate of many existing programmes. Background information is provided of the resources available to assist such a project, including specialist organizations, publications, videos and facilities for staff training.

Superoxide dismutase in the erythrocytes of acute alcoholics during detoxification.

The activity of erythrocyte superoxide dismutase in acute alcoholic patients on admission does not form a single population but clusters in two groups either above or below the normal range. The values in both groups revert towards the normal after a week of treatment. The divergent activities of this free radical scavenging enzyme between the two groups could not be explained by differences in age, haematology or liver function tests but are likely to be acute responses, possibly to diverse drinking patterns in the period immediately preceding admission.

Alcohol and brain damage.

1. The safe limits of alcohol intake are difficult to define because of individual variations in susceptibility to damage. The present recommendations are based largely on epidemiological studies of liver damage. 2. Recent investigations indicate that alcoholic brain damage is much more common than previously suspected. More information is required about its natural history and the characteristics of individuals most likely to suffer damage. 3. Thiamin (vitamin B1) deficiency has long been associated with brain damage and may result from a number of additive causes in the alcoholic patient. New information indicating damage to the protein moeity of some of the thiamin-using enzymes has been reviewed, as have possible mechanisms of brain cell necrosis.

Dietary amino acid analogues and transport of lysine or valine across the blood-brain barrier in rats.

Studies were undertaken to determine if dietary disproportions of amino acids would alter flux into brain of the amino acid present in the diet in a growth-limiting concentration. Rats were adapted to a lysine-limiting diet before receiving a meal of this control diet, alone or with added lysine or homoarginine (a competitor for lysine transport) or both, before intravenous infusion of [14C]lysine. The brain-to-plasma radioactivity ratio was lower in rats fed extra lysine or homoarginine than in rats fed the control diet, whereas lysine flux and brain lysine concentration were high in rats fed extra lysine alone. Flux and concentration were lower in rats fed homoarginine + lysine than in rats fed extra lysine alone. Other rats were fed a valine-limiting diet containing added valine, norleucine (a competitor for valine transport) or both, before [14C]valine was infused. Valine flux and brain valine concentrations were higher in rats fed extra valine than in control rats, whereas flux was lower in the group fed norleucine alone. Valine flux was higher in rats fed norleucine + valine than in the rats fed norleucine alone. Our studies show that dietary disproportions of amino acids can alter the flux of specific amino acids across the blood-brain barrier.

Rat brain apotransketolase: activation and inactivation.

Kinetic analysis of the combination of rat brain apotransketolase with thiamine diphosphate suggested that the enzyme exists in more than one form. One part of the apoenzyme reacted rapidly with thiamine diphosphate to reconstitute the holoenzyme, but another part appeared to combine only relatively slowly. In addition, an apparently irreversible further change took place, the apoenzyme being converted progressively to a form which apparently could not be activated by thiamine diphosphate. The relative proportions of the three forms i.e., that reacting rapidly, slowly, or not at all with thiamine diphosphate, were a function of the duration and conditions of storage, with the proportion of the apoenzyme form which reacted rapidly with thiamine diphosphate decreasing progressively. The findings reported here provide a possible explanation for problems various workers have encountered in attempting to evaluate Michaelis constants for the reaction of thiamine diphosphate with apotransketolase.