Oxford Medicine January 2010

Oxford medicine THE NEWSLETTER OF THE OXFORD MEDICAL ALUMNI OXFORD MEDICINE . DECEMBER 2009

Dispelling myths about Alzheimer’s disease Twenty-one years of OPTIMA Alzheimer’s disease (AD) has been called the silent epidemic: there are about 500 new cases every day in the UK and the world-wide prevalence has been estimated to be 36 million in 2010, which will rise to about 115 million in 2050. Research is the only answer to this huge challenge.

Research into AD in Oxford began in the early 1980’s with pioneering studies by Margaret Esiri, Gordon Wilcock and Tom Powell in the Departments of Neuropathology and Human Anatomy. These studies applied quantitative analysis to histopathological markers in the brains of patients who had been fully assessed in life, so allowing correlations to be drawn between cognitive deficits and pathology. At the same time, animal experiments in the Department of Pharmacology showed that the acetylcholinesterase of cerebrospinal fluid (CSF) was not derived from blood plasma but was secreted from neurons in the brain. It was logical to see if the recently discovered loss of cholinergic neurons in the brain of AD patients was reflected in a decreased level of acetylcholinesterase in CSF – and it was. Thus began collaboration between Margaret Esiri and myself which led to the setting up of the Oxford Project to Investigate Memory and Ageing (OPTIMA) in 1988. My co-founders were Margaret Esiri, Elizabeth King and Kim Jobst. What we originally set out to do was see if the molecular forms of acetylcholinesterase in lumbar CSF could be used as a diagnostic test for AD. To do this, we needed a longitudinal, clinico-pathological study where CSF was taken in life and patients and controls were followed through to autopsy and histopathological diagnosis; that is essentially what OPTIMA is. A special feature of OPTIMA is that it is run by the nurses; for 20 years the senior nurse and operations manager was Elizabeth King. Elizabeth taught us that if we want co-operation from our participants we have to give them something back in the form of support, care and education. This enlightened approach is one of the main reasons why OPTIMA has an autopsy rate close to 90% and why in 21 years only some 45 participants out of more than 1,100 have withdrawn.

When OPTIMA began, views about AD were dominated by two dogmas: first, that it is an inevitable part of normal ageing; second, that it is mainly determined by our genes. OPTIMA has played an important part in dispelling these myths and we now believe that AD is a slowly developing multifactorial disease with a host of non-genetic risk factors interacting with some susceptibility genes. (The familial varieties with autosomal dominant genes are very rare and only occur in patients with earlyonset of symptoms.) The challenge now is to identify those non-genetic risk factors that can be modified and to carry out clinical trials to see if modifying them does indeed slow down the progression of the disease.

OPTIMA’s first challenge was to find ways of diagnosing AD in life and of following the progression of the disease. We began life in a small office in the Clinical Neurology corridor in the Radcliffe Infirmary, not far from the Radiology department.

Two radiologists were very important in our early work: Andy Molineux and Basil Shepstone.

Margaret Esiri had shown that the part of the brain with the densest accumulation of neurofibrillary tangles in AD was the medial temporal lobe, but this is hardly visible on the standard axial CT scan.

Andy Molineux changed the angle of the scanner so that the long axis of the temporal lobe was revealed. By 1992, we had enough cases to autopsy to show that CT scans in life of patients dying with AD showed a highly significant thinning of the medial temporal lobe compared with age-matched controls such that it was a valuable aid to diagnosis; the result was a paper in The Lancet that stimulated world-wide adoption of imaging the medial temporal lobe in dementia. The temporal lobe oriented CT scan also allowed us to follow disease progression: we measured the thickness of the medial temporal lobe each year in AD patients and in volunteer controls. I well remember when we decoded the results in 1994: it was around midnight, but I called Kim Jobst and told him that in AD patients the medial temporal lobe shrank at almost ten times the rate in controls. We realised that, contrary to dogma, AD could not simply be an acceleration of normal ageing but must follow some catastrophic event in the brain. In other

The Oxford Project to Investigate Memory and Ageing (OPTIMA)

Contents Letter from the President .3 In the news; Achievements and Awards . . . . . . . . . . . . . .4 Oxford Centre for Monitoring and Diagnosis (MADOX) . . . . . . . . . . . . . . .7 Kambia Govt. Hospital, Sierra Leone . . . . . . . . . . . . . .9 The Arab-Israeli conflict . .10 Dodd Review

. . . . . . . . . . .11

Elections to Executive Committee . . . . . . . . . . . .12 2010 North American Reunion . . . . . . . . . . . . . . .12 Obituaries Events

. . . . . . . . . . . . . .13

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FIGURE. MRI subtraction scans at 5 y intervals of two normal elderly subjects. a) Subject (aged 79 y): plasma vitamin B12 535 pmol/L at base-line; whole brain atrophy rate 0.28% per y. b) Subject (aged 76 y): plasma vitamin B12 at base-line 192 pmol/L; whole brain atrophy rate 1.7% per y. The blue pixels (arrow), mainly around the ventricles, show where the tissue has shrunk (atrophy) more than 1mm between scans.

See Vogiatzoglou et al., Neurology 2008, 71:826-832.

words, it was a true disease and so we could look for the causes without having to unravel the causes of normal ageing. The Lancet accepted our paper, but did not like the use of ‘catastrophic event’ in the title. We now had a tool to follow the progression of the disease independent of any clinical assessment.

Basil Shepstone is an expert in nuclear medicine and in 1989 he told us that he could easily diagnose AD using SPECT to study regional cerebral blood flow. We were sceptical, so he offered to cover the cost of the first 50 subjects scanned. He was right: reduced blood flow in the posterior parieto-temporal cortex was indeed a characteristic of patients who had histopathologically-confirmed AD. Because we had also scanned the same patients with temporal lobe CT, we were able to show that a combination of thin medial temporal lobes and the neocortical SPECT perfusion deficit gave a highly accurate diagnosis independent of any clinical assessment. More recently, Kevin Bradley used the SPECT scans taken at different times during disease progression to create templates that related the scan image to the pattern of distribution of neurofibrillary tangles after death. This important discovery, published in Brain, was awarded the new investigator Neuroimaging Prize by the American Alzheimer Association in 2004, the first such award outside America. Another discovery arose from the use of multi-modal neuroimaging: we realised that the perfusion deficits in the neocortex were related to the degree of atrophy of the medial temporal lobe and we proposed the hypothesis that the neocortical changes were a consequence of disconnection of these areas from the medial temporal lobe.

In a seminar at the Clinical Trial Service Unit in 1995 I described our finding of rapid atrophy of the medial temporal lobe in AD and suggested that it may be the consequence of a vascular event in the brain.

Afterwards, Robert Clarke came up to me and asked if we had thought of looking at plasma homocysteine levels in our subjects, because homocysteine was a recently established risk factor for vascular disease. We soon established collaboration with the leading laboratory in this field, directed by Helga Refsum in Bergen, and within 6 months we had the answer: plasma homocysteine levels are raised in patients who have confirmed AD. Homocysteine levels are mainly determined by folate and vitamin B12 status and so it was not surprising to find that the levels of these two vitamins were lower in AD. But none of the patients was classically vitamin deficient: the levels were in the low-normal range. This may be OPTIMA’s most important discovery, but it took a long time to convince the world (charted in the Channel 4 film, ‘Assault on the Mind’). Eventually, the paper was published in Archives of Neurology in 1998 and was selected by the American Medical Association as one of the two most important papers of the year. It is the fourth most cited paper in the journal and has to date been

cited more than 700 times. The paper is important because homocysteine is one of the first readily modifiable risk factors for AD. Levels of plasma homocysteine can be lowered by supplements containing folic acid and vitamin B12 and so trials can be done to see if these vitamins can slow down the progression of the disease or, better, prevent the disease from developing. With our former Clinical Director, Robin Jacoby, OPTIMA has just completed a pilot randomised trial of the second type (VITACOG) in which 220 volunteers over 70 with memory problems were recruited in Oxford. The end-point in the trial was the rate of shrinkage of the brain assessed by serial MRI scans over two years. If this trial is successful, it will justify much larger trials to see if the vitamins will slow conversion from cognitive impairment to AD. I have given a highly selective and personal account of OPTIMA, but would like to end by mentioning just a few of OPTIMA’s other important achievements.

• Creation of a biobank of > 30,000 samples of blood, DNA, CSF, urine and brains from well-characterised participants • Demonstration of epistasis, the interaction between two susceptibility genes, in the risk of AD • Aberrant entry of neurons into the cell cycle in AD may precede neurodegeneration • Low-normal vitamin B12 levels are associated with faster rate of atrophy of the brain in normal elderly (see Figure) • Impaired performance on two cognitive tests can predict when normal elderly will become cognitively impaired over a period of up to 20 years The achievements of OPTIMA depend crucially on the ability to follow participants for a long period, until they die. Few other projects in the world have managed to do this in so many people with such detailed assessments in life. Over a period of 21 years OPTIMA has created an international reputation and has helped to dispel the myths about AD. We are now confident that this disease can be tackled and that it will eventually be possible to prevent many from developing one of mankind’s cruellest diseases.

In 2008 I was very pleased to hand over Directorship of OPTIMA to Professor Gordon Wilcock, who is ably supported by Sharon Christie (Senior Nurse and Operations Manager) and Ellen McCulloch (Clinical Trials Manager). Over the years, OPTIMA has been very fortunate to receive financial support from a wide variety of sources, industrial, MRC, charitable and personal donations. Our main supporters have been Bristol-Myers Squib, Merck & Co. Inc, MRC, and the Charles Wolfson Charitable Trust. OPTIMA is a founding member of the Alzheimer’s Research Trust network of UK centres. Further information can be found at: http://www.medsci.ox.ac.uk/optima

A. David Smith, Professor Emeritus of Pharmacology, Founding Director of OPTIMA

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Letter from the President

2010 will be a year of anniversaries and, even though this issue of Oxford Medicine was printed in 2009, it will not be distributed until the New Year which allows me to write about them. The first anniversary that we shall celebrate is that of medical teaching within the University which began 700 years ago. Please do not challenge me on the precise year as that is largely lost in the mist of time but it flourished sufficiently that the University was granted a Regius Chair of Medicine by King Henry V111 in 1546. Furthermore, the Schola Medicinae had a distinguished reputation and at times rivalled the great medical schools of Bologna and Padua with physicians such as William Harvey, Thomas Willis and Richard Lower still very much everyday names. It is one of those fascinating quirks of history that the practice of clinical medicine was regarded as being a trade by the University and therefore not worthy of a scholastic institution. The debate concerning the introduction of a clinical school was long and bitter but that story is well known and is going to be told again by Dr Eric Sidebottom at our annual meeting on March 27th. It is interesting to speculate whether the antagonists would have continued in their views if they had been able to foresee the establishment of the Weatherall Institute of Molecular Medicine, the Cancer Research Centre, the Wellcome Trust Centre for Human Genetics, the recently formed Department of Experimental Medicine and the many other laboratories that have contributed to our success in the science of medicine and in translational research. Thus, we chose to celebrate some of the achievements of the Medical School in the annual symposium on March 27th. Details can be found elsewhere in this issues and I look forward to welcoming you back to Oxford to enjoy that occasion.

The second anniversary is that of the Oxford Medical Alumni itself – we are 10 years old having been formed in 2000. OMA grew out of a sense that the Medical School was not in touch with its graduates and, learning from Universities in North America, Oxford University itself began to think of the need to ‘keep in touch’. The Alumni Relations Office has been very ably led by Lady Nancy Kenny and I am delighted that OMA is now working very closely with her to everyone’s mutual benefit. However, to return to the establishment of OMA, it was the product of deliberations between the Division of Medical Sciences, the Friends of 13 Norham Gardens, Green College ( now Green Templeton College ), and members of what had been the Oxford Medical Graduate’s Club. By courtesy of Professor John Ledingham, we have just acquired the history of that Club published in 1984 and it makes fascinating reading. The Club was established in 1884 by Dr A.B. Shepherd (Brasenose) who was Dean of St Mary’s Hospital. He gathered 9 Oxford medical graduates in his house who agreed to form the club. At the inaugural dinner on 22nd May 1984, twelve rules were drawn up. Rule 2 stated that the purpose of the Club should be entirely social and not scientific and that members could invite guests provided that they were graduates of either Oxford

or Cambridge, although it was widened to graduates of any university in 1887. Dinners were held annually, always in London, and it is interesting to read that members themselves provided entertainment following the dinner which consisted of music, singing and recitation. The first Oxford dinner was in 1899 which was held in Christ Church with Professor Burden-Sanderson in the chair. In 1922, a postal ballot was taken concerning the admission of women which was rejected by 71 to 52 votes and, despite frequent debates; it was not until 1956 that female medical graduates were allowed to become members. In addition to this history, we also have the record of those dining, and their guests, from 1939 onwards until 1996. During our 10 years as OMA we have continued to flourish, membership has grown (but still only about 20% are subscribers – hint, hint!) and are no longer just a social club. I think that it is the success of our annual symposia that has re-invigorated the organisation and hopefully we can build on this.

We now have a clearly defined constitution which allows for good governance and allows for a turnover of the Officers and other members of the executive committee so that new ideas can be introduced and any Alumnus that wishes to be involved can get themselves elected. That is now very pertinent as we will need to elect new members in March 2010 (please read the details later in this issue). Our Honorary Secretary and Treasurer, Amanda Salisbury and Richard Maxwell respectively, have completed two terms of office and I am extremely grateful to them for all their input during the 6 years that they have served.

Finally, I would like to mention that all of you who have email addresses will receive details of a scheme that we hope to set up which allows any of our current students to be in contact with individual members to obtain advice on careers, opportunities for working overseas, or just to obtain information about life as a qualified doctor.

Mentorship is now almost standard in American medical schools and it has been something that our students have been requesting. A questionnaire that has just been completed by the current clinical students shows enthusiastic support (although only 15% of them replied – maybe only those who are interested). We are advised by the legal office of the University not to use the term ‘mentor’ but I hope Alumni will be open to being contacted by students.

As ever, my thanks go to Jayne Todd, our Administrator, who continues to work tirelessly on our behalf. When she was forced to have time off in the summer, just as the copy for the July issue of Oxford Medicine was gestating, I now have firsthand knowledge of just how much is involved. I am also grateful for the Executive Committee which meets every 6-8 weeks to plan events and make them happen. They join me in sending our best wishes to all Alumni for a prosperous and productive New Year.

Professor Derek Jewell

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People in the News Professor Fiona Powrie has been elected to the Sidney Truelove Chair of Gastroenterology at Oxford. As part of this role, she will establish a new Academic Gastroenterology Unit to apply findings from on the interaction between intestinal bacteria and the immune system, and how this usually beneficial relationship breaks down in inflammatory bowel disease.

Professor Powrie of the Sir William Dunn School of Pathology is the first winner of the new Ita Askonas Prize, a €10,000 European award for leading female immunologists, in recognition of the insights her research has provided into inflammatory bowel disease. The prize has been established by the European Federation of Immunological Societies and the European Journal of Immunology to recognize outstanding female immunology researchers at an early stage of their career. Professor Powrie received the award at the European Congress of Immunology in Berlin. Over the last 15 years, Professor Powrie and her laboratory have provided many new insights into immune regulation in the intestine and how this may break down in IBD. In particular, her findings on intestinal T cell responses has influenced the field and identified several new targets for treatment of the condition.

Peter Rothwell, Professor of Clinical Neurology has been awarded the BMJ 2009 Outstanding Achievement in Evidence Based Health Care. Professor Rothwell has pioneered developments in stroke prevention throughout his career. This award recognises his work on demonstrating the need for acute preventative treatment and now such treatment reduces the early risk of major strokes by 80%. The Evidence based results from his team in Oxford has led to a national and international change in clinical practice, backed now by official guidelines from NICE. Professor Cyrus Cooper, holder of the Norman Collisson Chair of Musculoskeletal Science and Director of the Botnar Research Centre, has been presented with the inaugural Duchess of Cornwall Award for his outstanding contribution to the field of osteoporosis.

Professor Cooper leads an internationally competitive programme of research into the epidemiology of musculoskeletal disorders, most notably osteoporosis. His key research contributions have included: discovery of the developmental influences which contribute to the risk of osteoporosis and hip fracture in late adulthood; demonstration that maternal vitamin D insufficiency is associated with sub-optimal bone mineral accrual in childhood; characterisation of the definition and incidence rates of vertebral fractures; and the lead-

ership of large pragmatic randomised controlled trials of calcium and vitamin D supplementation in the elderly as immediate preventative strategies against hip fracture.

Sir Roger Bannister Neurology Prize. After a very generous benefaction, from Sir Roger Bannister, to reward and acknowledge the most outstanding medical students on the Year 5 Neurology attachment, the annual Sir Roger Bannister Neurology Prize has been established. Eleven students achieved the criteria for candidature for the prize. The examiners were the Director of Teaching and the Internal and External Examiners in Neurology. The prize was awarded to Adam Handel, Wadham College.

Professor Angela Vincent has been awarded the ABN Medal, awarded annually in recognition of outstanding contributions by a British neurologist to the science or practise of neurology. This reflects the very high regard in which she is held by clinical neurologists for her outstanding clinical research and for the enthusiasm and interest with which she deals with the translational aspects of neuroimmunology, in which she excels. She follows in the footsteps of John Newsom Davis, ABN medallist in 1999, and is the first non-practising clinician to be awarded the medal and only the third woman – a real recognition of all her achievements. In addition the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) membership unanimously approved the Board of Director’s recommendation that Angela Vincent become an Honorary Member of the Association. Angela will be presented with a plaque at the 56th Annual Meeting to be held in San Diego, California, 7-10 October 2009. Angela has also been elected an Emeritus Fellow of Somerville College.

Dr Simon Fisher — The first ever Eric Kandel Young Neuroscientists Prize was presented to Simon Fisher, from the Wellcome Trust Centre for Human Genetics, at a gala ceremony in Zurich yesterday. The jury award-

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ed Dr Fisher the prize for his investigations into building the first bridges between genes, brains and human spoken language. At present his primary focus is on an important gene known as FOXP2. Those carrying damaged versions of FOXP2 have problems with their speech and language development. By applying stateof-the-art genetic and functional genomic techniques, using FOXP2 as a unique molecular window into the key neural pathways underlying speech and language, has enabled the discovery of a gene critical to language acquisition.

Professor Rajeesh Thakker — Research on inherited disorders of bone metabolism – a group of diseases including some cancers, kidney stones and rickets – has led to Professor Rajesh V Thakker becoming the first non-American to receive the Founder’s Award from the American Society of Bone and Mineral Research. The 2009 Louis V Avioli Founder’s Award was presented to Professor Thakker at the society’s annual meeting in Denver, Colorado.

Professor Thakker is the May Professor of Medicine at the University of Oxford and a Fellow of Somerville College. His research in the Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM) is aimed at determining the causes of inherited bone and mineral metabolism conditions and developing treatments for these diseases, which include cancers of the hormone and endocrine system, over- or under-activity of the parathyroid gland, and rickets.

Professor Colin Blakemore has been invited to give this year’s Ferrier Lecture in recognition of his outstanding research on vision, the early development of the brain and the plasticity of the cerebral cortex.

This triennial lecture commemorates the pioneering work of Sir David Ferrier on brain function.

In the Department of Cardiovascular Medicine a number of staff have had personal achievements including: Professor Keith Channon appointed Director of the Biomedical Research Centre in Oxford.

Professor Stefan Neubauer appointed Chairman of the British Society of Cardiovascular Magnetic Resonance 2008-2010, and presented with the Thomas Lewis Lecture, British Cardiovascular Society 2008 Professor Nic Smith awarded an EPSRC Senior Leadership Fellowship

Professor Shoumo Bhattacharya awarded a BHF Professorship

Dr Joseph Selvanay agam (part of Professor Stefan Neubauer's research group) won the Society for Cardiovascular Magnetic Resonance Clinical Young Investigator Award 2008.

News from graduates 1974 Prof essor Pete r Rubin (1974) was appointed Chair of the GMC in April 2009.

Professor Rubin splits his time between his new appointment at the GMC and fulfilling his academic and clinical roles in Nottingham where he is Professor of Therapeutics at Nottingham University and an Honorary Consultant Physician at Nottingham University Hospitals NHS Trust.

1975 Professor Neil Jones (1975), has been, since 1993, Professor of Orthopaedic Surgery and Professor of Plastic and Reconstructive Surgery at the University of California Los Angeles School of Medicine and Chief of Hand Surgery and Microsurgery at the Ronald Reagan-UCLA Medical Centre. He has been nominated for both hand surgery and microsurgery in ‘Best Doctors in America’ every year since 1992. He was recently elected president of the American Society for Reconstructive Microsurgery for 2008-2009 – the premier organisation of surgeons worldwide who specialize in the reattachment of amputated limbs; microsurgical reconstruction after cancer and the latest developments of hand and face transplantation.

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1984 Dr Niraj Varma (1984) was given leave to supplicate for DM in 2009 on a thesis of “Subcellular mechanisms of ischaemic diastolic dysfunction". Niraj Varma is a staff physician in the Center for Electrical Therapies in the Sydell and Arnold Miller Family Heart & Vascular Institute at the Cleveland Clinic. Specializing in the treatment of heart arrhythmias, his interests include ablation for atrial fibrillation and ventricular tachycardia, defibrillator implantation and biventricular pacing. Dr. Varma worked in Edinburgh and at Papworth, Addenbrooke’s and Barts before taking a research fellowship in basic science cardiology at Boston University and Harvard Medical School for which he was awarded a PhD from Oxford. He completed his post-doctoral training as a fellow in clinical cardiac electrophysiology at Beth Israel Hospital, Harvard Medical School in Boston.

1986 Dr Robin Choudhury (1986) received the Michael Davies Early Career Award, 2008 from the British Cardiovascular Society, and has been appointed Clinical Director of the Oxford Acute Vascular Imaging Centre.

1988 Dr David AJ Lloyd (1998) has been granted leave to supplicate for the Degree of Doctor of Medicine on a thesis of “Tissue engineering and the current management of intestinal failure.” Dr Lloyd is a consultant in the Lennard-Jones Intestinal Failure Unit, St Mark's Hospital and Academic Institute.

From the archives ….

Radcliffe Infirmary Rugby Football Club 1950.

1998 Dr James Mountford (Lincoln 1992-1998) is married to Jennifer Rusby and in January 2010 became Director of Clinical Quality at UCL Partners, one of the Academic Health Sciences Centres in London, with UCLH, Great Ormond St, Moorfield's and the Royal Free as founding partners along with UCL. Before that he worked in McKinsey's healthcare practice and from 2005-7 was a Health Foundation Harkness Fellow based at Massachusetts General Hospital.

Dr Jennifer Rusby (St John’s 1992-1998) is married to James Mountford and has recently been appointed as a Consultant Oncoplastic Breast Surgeon at the Royal Marsden Hospital in Surrey. She did her surgical training in Wessex before undertaking a research fellowship at Massachusetts General Hospital, a National Oncoplastic Fellowship in Birmingham and a final fellowship at the Royal Marsden in Chelsea.

Staff at the Oxford Centre for Functional MRI of the Brain (FMRIB) have been increasing their families and our congratulations go to the following: Mark Woolrich – a girl, Sharon Dirckx – a boy and Kyle Pattinson – a girl!

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Oxford Centre for Monitoring and Diagnosis (MADOX) National institute for Health Research- School for Primary Care Research “Increasing the evidence base for primary care practice The Oxford Centre for Monitoring and Diagnosis in Primary Care (MaDOx) programme has now been running for six months and much has been achieved. The number of research projects continues to expand and the group has also recently submitted NIHR HTA grant proposals for the use of blue tooth technology for the detection and monitoring of hypertension using home monitoring, further evaluation of vital signs measurement using data fusion, and point of care tests for influenza.

The Centre is now fully staffed and we enjoy a steady stream of international Academic Visitors, increasing the department’s research collaborations across the globe. So, even as we unfortunately say goodbye to Osamu Takahashi from Japan, we welcome Dr Silvana Bettiol, a recent new arrival from Tasmania, who will be doing some work with Dr Thompson and Dr Harnden on Pertussis. We also welcomed the arrival of Professor John Balla from Melbourne, Australia in April for what will be his fourth visit to the department in recent years.

HORIZON SCANNING FOR NEW AND EMERGING TECHNOLOGIES The horizon scanning programme identifies new diagnostic technologies that are relevant to primary care. This includes technologies currently used in secondary care, rather than primary care, as well as novel diagnostic devices, diagnostic methods and clinical prediction rules. The priorities of this programme are Cardiovascular Disease, Cancer, Infection and Child Health. We are applying a Delphi method to develop consensus criteria from a panel of experts for prioritising the assessment of the new and emerging diagnostic technologies.

This consists of a series of questionnaires listing diagnostic prioritisation criteria, which are ranked according to their importance by experts working in various areas of diagnosis (e.g. government, academic, industry). We use several information sources for horizon scanning which include monthly literature searches, the McMaster Online Rating of Evidence (MORE) System, the Horizon Scanning Centre (Birmingham) and industry publications and contacts. Several new diagnostic technologies have been identified and we are currently preparing short reports on these technologies. The reports outline the details of the technology, the patient group and use, the importance and previous research. We identify which further research questions need to be answered. These reports will be disseminated to NHS bodies, including the Health Technology Assessment programme and the National Institute for Health and Clinical Excellence.

We will also produce health economic assessments and systematic reviews on priority diagnostic technologies.

MORE ACCURATE MEASUREMENT OF BLOOD PRES SURE In our initial pilot we contacted 82 general practices within Oxfordshire Primary Care Trust region, and assessed 438 BP devices in practices using the P.M.S. (Instruments) Ltd Pressure Tester.

Our initial results suggest for measurements accuracies of 0-3 mmHg there was no difference between an aneroid and a mercury sphygmomanometer. However, digital devices were half as likely as mercury device to read within 0-3 mmHg, 41% vs. 73%: RR 0.56 (0.44 to

0.77). About 1/5th of all machines performed in the range 3-10 mmHg of accuracy. Both aneroid (12% vs. 4%: RR 2.89, 1.01-8.26) and digital devices (13% VS. 4%: RR 3.01, 1.12-8.08) were more likely than mercury devices to read >10mmHg inaccurate. These results were presented at SWSAPC and currently Dr Christine A’Court and Sarah Sanders have had a gratifying response from many Oxon practices with the follow up study who are keen to know how their manometers perform. They have so far checked almost 250 devices and we are hopeful to have the full set of results by mid-year.

CHILDREN’S HEALTH Me asureme nt of vital signs in childre n We are continuing our studies aimed at improving the early diagnosis of serious illness in children. We are particularly interested in developing technology to allow more reliable, accurate and less time consuming measurements of vital signs (e.g. temperature, heart and respiratory rates) in children. Professor Tarrasenko’s group has developed technology to allow the measurement of respiratory rates in children using pulse oximetry. We now have studies underway to address the feasibility of this technology in primary care, specifically assessing the reliability of measurement and how well tolerated the device is with both parents and children. If successful, the technology will be trialled in emergency departments and GP surgeries as part of normal child assessment.

Pe rtussis Our current studies are determining the frequency of whooping cough infections within the population, as well as assessing the immune response to vaccination, through the detection of pertussis-specific antibodies. In collaboration with the Health Protection Agency, Dr Anthony Harnden and colleagues are currently using mouth swabs to detect antibody production following vaccination, both in children receiving their pre-school booster and more recently in infants following their primary course of immunisations. We are also tracking the decline in the levels of these antibodies over time. The development of a simple swab for the detection of pertussis exposure has greatly improved the diagnostic options available within primary care, eliminating the need to take blood samples. The information that will be obtained from these studies will greatly enhance our understanding of the prevalence of whooping cough and could potentially influence future vaccination schedules.

Predicting Se rious Illness in Children As part of a European collaboration, we have completed a systematic review of clinical predictions of serious infections in children. This summarises which clinical features offer sufficient accuracy to be “red flags” in children. This group is also pooling data collected from primary and emergency care settings so that we can create better prediction rules for serious infection. So far we have data on about 10 000 children.

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DIAGNOSIS Department of Primary Health Care, NIHR School for Primary Care Research ANTICOAGULATION AND INR SELF-MONITORING In the UK, over 1 million patients are currently receiving anticoagulation therapy.

Regular blood tests to monitor INR levels are necessary to minimize the risk of adverse events such as thrombosis or haemorrhage.

A major aspect of our work is an international collaborative individual patient data meta-analysis of oral anticoagulation self-monitoring. To date, we have data representing 3,603 participants and we are looking forward to receiving 2 further major datasets that have recently been published. A collaborators workshop has been scheduled for October 2009 where the results will be presented and discussed, and the final paper will be drafted by the Collaborative Group. Our study looking at the factors which influence successful self-monitoring is in the early stages of recruitment.

DELIVERING OPTIMAL ANTICOAGULATION CONTROL We have recently started a partnership with the Oxford Anticoagulation Service to investigate the current control of patients on oral anticoagulation therapy and the extent to which current care is optimal. Currently we are focusing on initiation regimes for deep vein thrombosis and are planning a series of record linkage studies to investigate long-term outcomes with INR control in the early and continuing stages of treatment.

METHODOLOGICAL ISSUES IN MONITORING OF CHRONIC DISEAS ES We have explored different models to identify the drift of individuals from the population which help us determine the optimal frequency for monitoring chronic conditions. The Signal (ie change and long term variability) to Noise (biological variability and assay error) ratio allows us to compare different available measures (e.g. Total Cholesterol, LDL, HDL, etc.) to select the one with the highest ratio.

With this setup it is also possible to model the True Positive to False Positive ratio under different scenarios and for different measures/conditions (Cholesterol, HIV, Type II Diabetes, and Blood Pressure).

In March, Dr Richard Stevens presented some methodological work

by MaDOx on validating prediction rules at the SW SAPC conference in Winchester. He is investigating whether it is possible to use published data to validate clinical prediction rules. Our early results, in validating coronary risk scores such as the Framingham equations in a population with diabetes, are encouraging and were well-received at the meeting.

Meanwhile, individual-level data sets remain the gold standard for validating prediction rules, and our international collaboration funded by the HTA on prediction rules in acute childhood infections has progressed to the stage of data sharing between countries, which will allow a definitive analysis of prediction rules in this area.

CHOLES TEROL MONITORING IN OXFORDS HIRE The use of laboratory tests has increased dramatically over the last decades. To assess the rise in use of lipid measurements, and to determine how much of the testing was repeat testing, we analysed the rates of lipid testing (total cholesterol, HDL, and triglyceride) in Oxfordshire during the last 20 years. All tests which were the third or more in a three-year period were considered to be for monitoring. A substantial rise in the number of tests was observed during the past 10 to 15 years, with much of this appearing to be for monitoring purposes rather than for case finding or risk assessment. Mean cholesterol levels generally increased with increasing number of tests performed during each three year period until 1999-2001, but decreased with every repeat test in later years; this may reflect the effectiveness of statins in reducing serum cholesterol and the rise in later years of the use of monitoring during such treatment.

DIABETES MONITORING The Diabetes & Vascular Disease Research Group is developing a series of studies using trial data and statistical modelling techniques in collaboration with the MaDOX Group. Data obtained from the DiGEM trial is being used to investigate optimal strategies for monitoring glycaemia. In addition, we are developing an international collaboration to carry out an individual patient data meta-analysis of the impact of self-monitoring for type 2 diabetes. Funding has also recently been obtained from the HTA to develop clinical and economic models for monitoring renal function in type 2 diabetes.

MADOX Department of Primary Health Care Old Road Campus University of Oxford Oxford, OX3 7LF Contact: ryan.giannone@dphpc.ox.ac.uk Programme Manager, MaDOx

OXFORD MEDICINE . DECEMBER 2009 / 9

Kambia Government Hospital, Sierra Leone January – May 2009 Drs. Per and Janaki Brolin We had been looking for job opportunities in Africa when we spotted the recruitment advertisement on a doctors’ website. Sierra Leone. We hadn’t considered the possibility of spending half a year in a rural hospital in a country known mostly for its recent horrific civil war. However, the challenge was attractive. By January 2008 we had decided that after completing our Foundation training, Sierra Leone would indeed be our destination as doctors.

We spent most of 2008 reading about the country, talking to people who had worked there and fundraising. In the autumn we attended the invaluable Diploma in Tropical Medicine and Hygiene at Liverpool.

Here time and time again Sierra Leone was highlighted by lecturers – the only country where diseases like yellow fever and onchocerciasis are still significant problems, where infant mortality and maternal mortality are amongst the highest in the world. According to WHO statistics, 25% of Sierra Leonean children die before the age of five.

The figures we had read about did not seem real until we actually started working in Kambia.

We arrived in Sierra Leone on 12th January 2009. The four-hour drive from Freetown in a UNICEF-donated Land Rover was bumpy and dusty. Situated in the North, close to the Guinea border and destroyed during the civil war, Kambia Government Hospital was rebuilt in 2002 with funds from the European Union. The hospital has about 60 beds and is meant to provide services for the whole of Kambia District – a population of over 300,000. However, healthcare in Sierra Leone is not free, corruption is rife, fuel is more expensive than in the UK and the roads are atrocious. All these factors mean that people do not readily travel to hospital for treatment. Hence, the hospital was not busy in terms of numbers but almost all the inpatients we saw were critically ill and had usually been unwell for long periods before making their way to hospital as a last resort. We worked together with a local medical officer and an experienced community health officer.

Except for four trained nurses, most of the other staff at the hospital were untrained volunteers. The hospital lacked running water and electricity was very rarely available. The pharmacy was reasonably stocked with basic drugs and medical supplies, but a major problem was that patients had to pay for each individual item, even in dire emergencies.

Obstetrics was a large part of our work. Women in Sierra Leone usually give birth at home with the help of traditional birth attendants.

Most of the women we saw had come in after being in labour for two or three days or because they had had a complication such as a fit or severe bleeding at home. We saw several cases of eclampsia, cerebral malaria in pregnancy and obstructed labour. Fortunately, quinine, magnesium sulphate and oxytocin were readily available.

Eclampsia – a severe disease associated with fitting and high blood pressure in pregnancy, is now rare in the UK. However, in Sierra Leone

routine antenatal check-ups are almost non-existent and simple treatment for high blood pressure is not readily available.

At the same time, it is common to become pregnant at a young age – many girls have been malnourished during childhood and the pelvis has not had time to develop fully. These women often needed emergency Caesarean sections to deliver the baby. At Kambia we had a basically furnished theatre and the local medical officer was experienced in performing Caesarean Sections. A timely operation often saved the life of a woman who had either been bleeding heavily or had been in labour for several days. However, the mortality rate associated with surgery was high and wound infections were almost universal. We suspect this was due to a combination of poor surgical technique, inadequate asepsis, the inability of the patient to afford antibiotics and poor nutritional and psychological status of the women (especially, and sadly not uncommonly, if the baby had not survived).

Indeed the stillbirth and neonatal mortality rates were very high. We both became much more confident in resuscitating newborn babies with a simple bag and mask – skills that we had been taught during our time at Liverpool. This was one aspect of our work which was at times distressing, but also sometimes most rewarding. However, neither of us are trained surgeons, and whether or not we would perform an emergency Caesarean section if the need arose was one question which we had thought about at great length before we had set off for Kambia. Current WHO guidelines for low-resource settings advocate emergency Caesarean sections only in circumstances where the mother’s life is in danger and not solely on the grounds of foetal distress. We were faced with two occasions when the local medical officer was away and women were brought in with an obstetric emergency. The first woman arrived on a Friday with a history of having bled heavily. We had no way of confirming why she had bled, but clinically we suspected placenta praevia (a condition where the placenta lies low in the uterus, thus obstructing the birth canal, an ultrasound scan is usually needed to make the diagnosis). However, the bleeding had settled, the diagnosis was uncertain, and we had previously never performed major surgery – so we decided to watch and wait. On Monday however, the lady began to bleed profusely. The blood bank supply was exhausted and the medical officer had not yet returned. Despite our efforts to resuscitate her, she passed away within a few hours. This experience, for us, was humbling. In the UK it would be unacceptable for a young pregnant woman to bleed to death simply due to lack of resources. The hospital staff, on the other hand, were accustomed to almost routine maternal deaths.

However, we were gaining experience rapidly and on a subsequent occasion, faced with a similar scenario, we mobilised the hospital staff for an early and successful Caesarean Section. Guided by experienced local theatre staff, one of us held the scalpel and delivered a pair of twins while the other – with the help of eager students – resuscitated the twins. The occasional happy outcome was uplifting for all the staff as well as of course for the family.

10 / OXFORD MEDICINE . DECEMBER 2009

In the adult and children’s wards malaria, typhoid and tuberculosis were amongst the commonest diseases. In Kambia, we experienced first hand the effects of the Global Fund initiative to eradicate diseases such as Malaria, TB and AIDS. Good and effective malaria treatment was readily available (free of charge in principle of course, but not in practice!), while the whole treatment course for patients diagnosed with TB or HIV infection was indeed entirely free. As a result we found that paradoxically, patients with HIV – often shunned by family and society – in fact received preferentially better care in hospital than other patients. At the same time children with suspected malaria, who often came in unconscious with the cerebral form of the disease, recovered rapidly with readily available drugs such as quinine and artemisinin-combination therapy. In contrast however, many adults and children came in with serious surgical complications such as bowel obstruction or perforation – in many cases resulting from prolonged typhoid fever. Complications usually arose due to the initial phase of the disease going untreated. We referred some patients with such surgical emergencies to Freetown where better NGO-run facilities were available. However this was only possible in the few cases where the patient was either well enough to travel or could afford the cost of the journey. In any case, these patients rarely survived their illness.

Every time a woman or a child died in hospital we were struck by how easily it was accepted by the relatives - as if it was an expected

and routine part of life for a woman to lose a child or to die in childbirth. Whilst for us, the feeling of knowing what to do, yet being unable to do it was often demoralising as well as humbling. Our short stay gave us an invaluable insight into how lives are lived in a world very different to the one we are accustomed to and how helpless we as individuals can be despite all the training and education we may have received. Nevertheless, despite the obvious suffering, there was never a shortage of smiling faces and cheering children following us wherever we went. We returned from Sierra Leone richer in experience and with the feeling that we had left behind a number of good friends. Our five-month stay was not long enough to make a difference, but we now feel better and more realistically prepared for more long-term work in a similar resource-poor setting. Perhaps it might be Sierra Leone again.

It was the Kambia Appeal, a Cheltenham-based charity with a long history of supporting Kambia Government Hospital, that allowed us this unique opportunity to work in Sierra Leone. We are grateful for the support we received from The Cheltenham Ladies’ College Guild Fund, Bassett Road Surgery, The White House Surgery, students of Edinburgh University and many friends and family who helped us prepare for our five months in Kambia. We hope that reading about our experiences will encourage others to learn more about Sierra Leone and its people.

THE ARAB-ISRAELI CONFLICT — ANOTHER PERSPECTIVE Barry Hoffbrand (retired physician)

Dear Editor, In writing that "the Israelis may be forced to accept a two state solution", Nick Dudley displays a profound ignorance of the history of the ArabIsraeli conflict. The 1947 UN partition plan for Arab and Jewish states was accepted by the Jews but with the foundation of the State of Israel in May 1948 the Arab response was an invasion by five armies aiming to destroy it at birth. In 1967 a second attempt to destroy Israel by force by Egypt Jordan and Syria ended in the Six Day War, with Israel gaining the West Bank, Gaza and the Golan Heights.

The then Israeli government offered to return all this land in return for peace. The Arab response in September 1967 was" No peace, no recognition and no negotiation". This, wrote Abba Eban then Israeli foreign minister, was the first war in history in which the victor sued for peace and the loser called for unconditional surrender.

Yet another opportunity for a viable Palestinian state came in 2000 with the Clinton peace plan which would have seen the settlements largely removed but it was rejected at the last minute by Yasser Arafat who then unleashed the murderous second intifada.

Dudley in his partisan diatribe about the security fence makes no mention of how successful it has been in cutting off suicide bombers from Israel's buses, malls and nightclubs. There is not a squeak from Dudley about the context of Israel's war against Hamas, namely the ceaseless bombardment over eight years of Israel's cities and towns from an organisation dedicated to Israel's destruction.

Yours sincerely Barry Hoffbrand, Queen's 1952 Retired physician

OXFORD MEDICINE . DECEMBER 2009 / 11

SMOKING KILLS The Revolutionary Life of Richard Doll

By Conrad Keating Signal Books Ltd 2009 ISBN 978-1-904955-63-4 What do we need from a biography? Hermione Lee* has written "Whether we think of biography as more like history or more like fiction, what we want from it is a vivid sense of the person," How does Conrad Keating's book satisfy this prime criterion? Overall, I think well. Doll was a difficult man to portray. Uneasy unless working (which he did until death at the age of 92), his wife Joan admitted that he was no family man.

Whilst some described him as sensitive, courteous and kind, others found him detached, hard to get close to if not cold and, on occasion acerbic and ruthless. Some were never really comfortable in his presence and others became devoted, but all admired his intellect.

Through the pages of the book, this complex man does gradually emerge. The son of a doctor and a classical pianist, brought up in Montpelier Square with a family chauffeur, he went to school at Westminster, where after a brief flirtation with fundamentalist Christians, he joined the Young Communist League of Great Britain and remained active in communist circles until after the Hungarian uprising in 1956 .Rejecting the offer of an exhibition in Mathematics at Caius Cambridge he chose instead to study medicine at St Thomas's Hospital Medical School, where he was intolerant of what he perceived as nepotism and the need to be obsequious to seniors. If he remained puritan in many ways through his life and could be described as one of the awkward squad, he nevertheless became in the end "about as established as the Bank of England,"** a knight and a companion of honour.

After the war, in which he had served in both Dunkirk and Crete, it was some time before he found his niche in epidemiology at the Central Middlesex Hospital with Sir Francis Avery Jones. At that time, students at the Middlesex itself came in droves to be taught by Horace Joules and Richard Asher; Joules, also a communist and a superb teacher, would refer to the Middlesex as "the orchid house of the West End".

Doll's extraordinarily distinguished career in epidemiology began with definitive studies on peptic ulcer but progressed most notably to the ill effects of smoking.He went on to study the health risks of asbestos exposure, diet and risk of cancer, the potentially reversible causes of cancer, irradiation, leukaemia and myeloma after nuclear explosion, the possible ill effects of Agent Orange in the Vietnamese war and even controversy about fluoridation of water - a remarkable contribution to the health of mankind. Initially inspired and guided

by Sir Austin Bradford Hill (for whom Doll thought there had been too little recognition that his was the leading role in the first smoking- lung cancer work), he in turn inspired many later protĂŠgĂŠs. But he also had a capacity for scientific dispute, notably with R A Fisher, Richard Passey, Alice Stewart, Lennart Hardell, Malcolm Gardner and Samuel Epstein. As an expert witness he was much involved with medico legal affairs, some of it invoking criticism about his relations with industry, albeit later well refuted.

Of particular interest to Oxford alumni are the chapters relating to Doll as Regius Professor and his role in the genesis of Green College. He was undoubtedly a formidably effective Regius, presiding over the reorganisation of the medical school, the founding of new chairs and the creation of the Institute of Molecular Medicine. He was certainly one of the important figures in the rise of the reputation of the Clinical School, begun by George Pickering and Paul Beeson and critically consummated by the arrival of David Weatherall, Peter Morris, and Alec Turnbull, among others. Gestation of Green College was fraught with problems in its relationship with Osler House - a grave disappointment for Doll. This is well dealt with by Keating as were the chapters on Doll's later years and his continued achievements until near to death. It all makes for interesting reading and the text is laced with personal anecdote which some will enjoy more than others. But the book is longer than it need have been with some repetition, especially concerning the work on smoking. There are parts where it is difficult to distinguish wood for trees. There are mistakes (for instance George Pickering was Master of Pembroke, not Principal of Brasenose, and the index could be more complete - remarkably, Bradford Hill's name is not there). Given the number of people whose views and comments shower the book, it is a pity that there is no biographical annexe to tell the reader who they are or were. It took the author eight years to complete this work. He has produced a detailed account with much to commend it. * Goldsmith's Professor of English Literature and President of Wolfson College Oxford ** Sir Richard Bayliss, one time Physician to Her Majesty, the Queen

John Ledingham

12 / OXFORD MEDICINE . DECEMBER 2009

Elections to the OMA Executive Committee President - Professor Derek Jewell has completed 3 years but is eligible for re-election for a maximum of 3 further years Honorary Secretary - Dr Amanda Salisbury has completed 3 years + 3 years and is therefore not eligible for re-election Honorary Treasurer - Dr Richard Maxwell has completed 3 years + 4 years (by special arrangement) and is not eligible for re-election Nominations for these posts, together with proposer, seconder, and with the permission of the person being nominated, should be sent by 28th February 2010 to: Jayne Todd, Oxford Medical Alumni, Medical Sciences Office, John Radcliffe Hospital, Oxford OX3 9DU ( jayne.todd@medsci.ox.ac.uk )

The 2010 North American Reunion All of Oxford’s North American alumni are invited to gather and celebrate their Oxford experience at our reunion weekend held in the spring every other year.

The 2010 North American Reunion will begin on Friday 16 April and end on Sunday 18 April and will take place at the Waldorf Astoria, New York. The weekend includes drinks parties, academic sessions featuring prominent Oxford academics and alumni and, of course, college gatherings.

Oxford Medical Alumni will meet for brunch on Sunday 18 April at the Waldorf Astoria. We are delighted to welcome past and present members of the medical sciences research and teaching community at Oxford and members of the Osler Society of New York to hear: Professor Michael Bliss “Osler in Oxford” Dr. Bliss is an officer of the Order of Canada. He has been elected as a Fellow of the Royal Society of Canada. His numerous honours include major prizes from the Canadian Historical Association, two City of Toronto Book Awards and two Jason Hannah Medals for medical history from the Royal Society of Canada. He has also been given the Welch Medal from the American Association of the History of Medicine.

One of Canada’s most distinguished historians he is considered the pre-eminent medical historian of his generation.

Professor Alastair Buchan “Oxford medicine” Head of the Medical Science Division and Dean of the Medical School at the University of Oxford.

Neurologist and Neuroscientist in Stroke Medicine, Professor of Stroke Medicine at the University of Oxford. He did his initial training in Medicine and Neurology in Oxford. After specialist training in London, Ontario and New York he was awarded the Heart and Stroke Foundation Professorship in Stroke Research in Alberta. For ten years, he led the Calgary Stroke Programme. Since returning to Oxford in 2005, he has established an Acute Stroke Programme and has been the Translational Research Director for the UK Stroke Research Network. He has led the Oxford Clinical Research Facility, the new Acute Vascular Imaging Centre of which he is the Director, and was the founding Director of the Oxford NIHR Biomedical Research Centre. He became Head of the Medical Sciences Division of the University of Oxford on October 1st.

2008. He is a Fellow of the Academy of Medical Sciences (FMedSci), a Senior Investigator of the NIHR and holds a DSc from the University of Oxford.

VENUE: Meet at 10.30am at the Waldorf Astoria, 301 Park Avenue New York.

OXFORD MEDICINE . DECEMBER 2009 / 13

Obituaries SIR GEORGE GODBER One of the greatest Chief Medical Officers of England August 1908—February 2009 In any history of health services in the UK Sir George Godber will appear near the top of the list of those few influential people who created in the National Health Service a unique health system for the treatment and care of patients and for the prevention of disease.

Unlike the great politicians who were critical to the necessary political decisions leading to its establishment, his was a continuing involvement in the planning, preparations, launch and crucial early years of providing the service in which he remained a leader throughout its first 35 years.

George Godber in his student days was very much an Oxford man.

Brought up in a rural part of Bedfordshire, he gained a scholarship from Bedford College to New College Oxford to study medicine, matriculating in 1927. Some sports were impossible for him as he lost an eye in an accident when ten years old. At Bedford he had developed skills in rowing and continued this interest at Oxford, gaining his Oxford Blue. He rowed number six in 1929 and number two in 1930, on the losing side on both occasions but, typical of his future life, apparently pulling well above his weight as he was only twelve stone five pounds. He was a teetotaller all his life, and so is believed to have made up in marshmallows what his fellow rowers gained from beer and stout. Again typical of him, he made full use of his sober state in carrying his boat colleagues to the coach after his first trial eights dinner. He became secretary to the Boat Club. He was also elected a member of Vincent’s Club, a reflection of his standing among the undergraduates of Oxford.

Graduating BA (Physiology) in 1930, he left Oxford to do his clinical training in the London Hospital; and gained his BM BCH in 1933 and DM in 1939. He held a house officer post in the London Hospital and later said that the London probably had at that time the best nursing staff in all of London; he married one of them, Norma Hathorne Rainey in 1935.

His short period of clinical practice convinced him that the whole health system needed to change so that everyone could have access to health care without any barrier of cost. He felt committed to ensuring that post-war health services were better and fairer than before, were more coordinated, more evenly distributed and better equipped.

It has been said that a strong sense of social justice led him into public health and he went to the London School of Hygiene and Tropical Medicine to gain his DPH, the Diploma in Public Health, in 1936. In 1937 he entered public health in Surrey where his work on communicable diseases attracted the attention of the then Chief Medical Officer of the Department of Health; he joined the department as a medical officer in 1939.

He was immediately caught up in the planning of the emergency health services and his first task in the Department involved him in reviewing services required for maternity care for women who had been moved into the suburbs. With the publication of the Beveridge Report in 1942 and the rise of all party support for a national health service for post war UK, he became part of the planning team. One essential was to be aware of the current state of hospitals and he undertook with a colleague a detailed survey of all hospitals in the

Yorkshire area of England. This experience, together with the regionalisation of the hospital services necessary for a wartime service, emphasised to him and to others the greater efficiency if hospitals in a district worked together, with a regional authority for planning and development and the provision of those specialist services which had to be provided on a regional basis. This was the pattern of hospital services which was used in the new service, agreed by the post war Parliament in 1946 and launched in 1948. For the first few years of the new service, he had close links to the Oxford Region.

In 1950 Godber was appointed to be the Deputy Chief Medical Officer, a role he filled with energy and vision. Already becoming known internationally, in 1951 he was awarded a travelling Fellowship by the World Health Organization, to visit USA and Canada. He was appointed Chief Medical Officer (CMO)in 1960.

There is space here only to list a selection of the health service issues in which he played an essential part. In 1952, the approach to the confidential inquiries into maternal deaths was considerably improved and became a model for learning what had gone wrong without pointing blame; it was later adapted for anaesthetic and surgical deaths. Starting in the 1950s, Godber encouraged local health authorities to provide proper facilities for general practitioners such as purpose built health centres with attached district nursing staff. When it was clear that morale in the GP service was very low, he worked with the then Minister of Health Kenneth Robinson (by chance, the son of a GP) to introduce better conditions for GPs and with more adequate remuneration. In the hospital service, he collaborated with Enoch Powell on the Hospital Plan, so establishing a planning system through regions for improving current hospitals and initiating the very necessary replacement programme. He devoted much effort into ensuring that consultant posts were more equitably distributed both geographically and between specialties.

He worked hard, kept up to date and believed strongly that all doctors and health professionals had to do the same; he was a strong advocate for postgraduate and continuing professional training.

In public health, his leadership role was immense. He was the first CMO to call for firm government action against smoking and one of his regrets was the slowness of governments to introduce firm regulation of the commercial promotion of tobacco, alcohol and unsuitable foods, or to introduce the simplest and safest of preventive measures, the fluoridation of drinking water. He annually addressed a weekend meeting of the Medical Officers of Health for the cities and county boroughs. Invariably the main event of the meeting as he gave (in a closed confidential meeting) a masterly off the cuff survey of public health issues home and abroad, looking ahead to what he thought might be important in the coming year or so. He gave all present the feeling that they were part of an important national service which made a real difference to human health and happiness in England. He even managed to make the chore of having to produce an annual report a worthwhile task, by setting key issues to be covered and by personal follow-up to unusual aspects of any report.

14 / OXFORD MEDICINE . DECEMBER 2009

He gave a detailed review of the origin and early development of the NHS in a lecture given at Green College , Oxford in January 1988.

(BMJ vol 297, 2 July 1988) An important paper, it shows clearly the width of his ideas for modern health care and strongly supports one of his conclusions, that the NHS is one of the greatest social innovations that this country has produced.

In an interview on his reaching the age of 100 (BMJ 2008; 337:a1151) one of his regrets was that he had failed to persuade doctors to embrace a greater management role along the lines outlined in his Cogwheel Reports. Had they done so, he felt general management would not have been introduced in the 1980s. He could have added that Oxford had shown the value of the Cogwheel-type involvement of senior medical staff in the post-Kinsey reforms introduced in the United Oxford Hospitals and transferred into the Oxfordshire Health Authority in 1974. The rest of England missed a real opportunity and allowed the growth of an ‘us and them’ culture between doctors and managers.

From the time he first entered the Department of Health until he retired in 1973, there was hardly a part of the health service in which he had no beneficial influence. He had several personal attributes which made him stand out as a leader in health: his personality and bearing, for he was an impressive figure, with a shock of white hair and a mon-

ocle grasped in his right eye; his manner, quiet but confident and firm when necessary, always well briefed and confident about the evidence; his charisma, for he inspired loyalty in those working with him and provided a much appreciated leadership to others; his vision and his gift of spotting not only where difficulties could arise but also where medical progress could be made; his deep understanding of politicians, their role and how he could get the best out of working with them; his feel for medicine, his support even for issues unpopular at the time, making him admired by all branches and levels of the medical profession; and, surprising perhaps in one who had achieved so much, a disinterest in personal credit and yet he readily gave generous praise to others.

George Godber was undoubtedly one of the great Chief Medical Officers of England Charles Edward Godber: born Willington near Bedford on 4 August 1908; Medical Officer, Ministry of Health 1939; Deputy Chief Medical Officer 1950; CB 1958. Chief Medical Officer, Department of Health and Social Services, Department of Education and Sciences and Home Office, 1960. Retired 1973. KCB 1962, GCB 1971. Hon. DCL Oxford 1973. Chairman of the Health Education Council, 1977-8. Married Norma Hathorne Rainey in 1935 (died 1999) two sons, one daughter.

Died in Milton Keynes on 7 February 2009.

With sadness…

Anthony Auty b 1947; matric.1966 St Catherines, d.2005, aged 61.

Director of MS Clinic and assistant Professor in the Department of Medicine (Neurology), University of Manitoba.

the transition to medicine. He gained his second BM in 1955, with a dependent family but no funds. Joined general practitice in Wokingham after a spell with the Royal Air Force. Fluent in Italian and Arabic.

Geoffrey Bennett b 1926; matric.1944 St Edmund Hall, d.5th May 2008, aged 83. Former Chief Medical Officer to the CAA, and established the concept of Authorised Medical Examiners in the civil air service in 1964.

David Henry Edwards b.1936; matric. 1955 Balliol, d. 14th July 2008 a non-smoker — from lung cancer, aged 73. Following house jobs in Oxford, he worked in Birmingham, London, and Wessex before returning to the Radcliffe Infirmary and the Nuffield Orthopaedic Centre as a senior registrar in orthopaedic surgery. Appointed consultant orthopaedic surgeon in Stoke on Trent in 1975, where he remained until he retired in 1996. His special interest lay in children’s orthopaedics. He was appointed lecturer in orthopaedics at Keele University and helped to establish a chair in traumatic orthopaedics.

Clinical director of the Locomotor Directorate, he was responsible for the emergency department, trauma and orthopaedics, rheumatology and rehabilitation, and physiotherapy across three hospital sites. He secured funding for the building of a new orthopaedic hospital, which opened after he retired. In his leisure time: a freemason, a reader in the Church of England, and a keen bird watcher, but his main hobby was sailing - an RYA national race officer, running yacht racing at Abersoch, North Wales. He leaves a wife, Ann; a daughter and son, both doctors; and four grandchildren.

Bruce R Beveridge b 1932; matric.1961 St Johns, d.4th September 2007, aged 76. Gastroenterologist, Sir Charles Gairdner Hospital, Perth, Australia.

Brian C Davies b 1921; matric.1940 Balliol, d.2nd January 2009, aged 87. President, Osler House Club, General practitioner.

John M Davies b 1925; matric.1942 St Catherine’s, d.20th December 2008, aged 84. Joined the Royal Naval Medical Service in 1952 a career which took him all over the world he eventually became Naval Medical Officer of Health: Mediterranean, the last holder of this post, Senior Medical Officer: HM Dockyard Chatham and surgeon commander in the Royal Fleet Auxiliary. In retirement he lived in Oxfordshire and undertook GP locum duties.

Nicholas A H Daw nay b 1948; matric.1966 Merton, d.5th February 2009, aged 61. JRF, MRC, Lecturer. Postmaster 1966-1970.

Michael S de Mowbray b 1922; matric.1940 Worcester, d.1st August 2008, aged 87. Psychiatrist, St Mary Abbots Hospital.

Hugh S Dodd b 1932; matric.1951 Magdalen, d.29th November 2008 from renal failure after valve transplantation, aged 76. Read Classics but after his studies had been interrupted by national service, and then by the death of his father. On returning to Oxford he made

Frank RM Elgood b 1920; matric.1939 Balliol, d.13th January 2009, aged 89. Paediatrician. Worked at the Radcliffe and enjoyed clinical responsibility when, whilst still a student, he acted as a house physician in the later days of the war when hospital was under staffed. Worked in Medway, Gravesend and Dartford Hospital, gained his doctorate from Oxford, and then worked in Newcastle-upon- Tyne, at Great Ormond Street Hospital, Addenbrooke's, Cardiff and finally Oxford again. 1954-62 worked in general practice whilst at the same time serving as a Clinical Assistant in Paediatrics. From 1962-67 he was consultant paediatrician in Warwick and Stratford-upon-Avon.

Wherever he went he fished!

OXFORD MEDICINE . DECEMBER 2009 / 15

James H Fairley b1927; matric.1947, d.11th May 2008, aged 81.

General practitioner. After qualification and house jobs at Barts, James Hamilton-Fairley spent two years working in General Practice in Corrawa, NSW, Australia. Returning to the UK he joined a practice in Caversham, Berkshire where he spent the rest of his professional life.

William C Gibson b1913; matric 1935 New College, d.28th July 2009, age 95. He leaves three children; two granddaughters; and, a great grandson. He was predeceased by three wives and was also predeceased by two sisters and a brother.

George Godber b 1908; matric.1927 New, d.7th February 2009, aged 100. (A full obituary appears in this journal.)

Ian R Gregg b 1925; matric.1947 Wadham, d.27 April 2009, aged 84. Consultant in respiratory medicine. In general practice in London from 1958 until his retirement in 1987. Much of his research was carried out in association with the then Cardio-Thoracic Institute (later Royal Brompton Hospital, London), where he was Director of an extramural Department of Clinical Epidemiology. His special interests have been the assessment of bronchial airflow by PEF (peak expiratory flow) in collaboration with Dr Martin Wright (1912–2001), the inventor of peakflow meters, the roles of bacterial and virus infection of the bronchi and the epidemiology of asthma worldwide.

Ian K Hart d.10 November 2008. MRC Clinical fellow, lecturer and honorary senior registrar in neurology, Radcliffe Infirmary, 1991 to 1995.

Ewen D A Hay b.1931; matric. 1950 Merton, d.19 December 2007, aged 76. Surgeon Lieutenant RN, 1958-61. GP in Chelsea. 1964-85.

MO to Macmillan Fund, 1964-94. Author of several outstanding histories of London medical societies. David was widely known and respected in the profession, as attested by the huge gathering at his memorial service, where Sir Peter Tapsell gave the address.

William M Keynes b 1924; matric.1964 Christ Church, d.18th February 2009, aged 84. FRCS.

Peter D Oldreive; matric. Pembroke 1951, d.24th June 2009.

Patr ic ia A O’Ne ill matric. St Hilda’s 1968, d.22nd May 2009, aged 69.

Michael JH Piachaud b 1948; matric.1967 Lincoln, d.10th February 2009, aged 60. Consultant Psychiatrist, member of MEDACT and Medical Association for Prevention of War. Thomas G Pickering b 1940; matric.1968 Linacre, d.14th May 2009, aged 69. President, Eastern Regional Chapter, American Society of Hypertension 2005-2007, and an internationally renowned scholar, researcher and clinician in the field of hypertensive cardiovascular disease. Director, Behavioural Cardiovascular Health and Hypertension Program, Columbia Presbyterian Medical Centre. He will be remembered fondly for his intelligence, grace and unfailing humour, and missed by all who knew him as a friend.

Clarence L G Pratt OBE b 1906; matric.1937 Magdalen, d.24th March 2009, aged 102. Fellow, Christ's College Cambridge for nearly 32 years serving as Senior Tutor and Admissions Tutor from 1950 to 1967 and as Praelector from 1954 to 1976. A physiologist, his wartime research into the physical effect of underwater water explosions formed part of the invaluable preparations made before the Normandy landings in 1944.

Cecil J Radw ay matric.1939 Exeter, d.17th April 2009, age 87.

Edward S Robinson b 1926; matric.1949 Exeter, d.4th March 2009, aged 82.

Hector J Sants; matric. 1946 Brasenose. d. 1st July 2009.

Abraham S hannon b 1912; matric 1929 New, d.5th April 2009, aged 96. General practitioner in: Wallasey, Leytonstone, and Petah Tikva, Israel.

David C Turk b 1924; matric 1942 Balliol, d. 15 July 2009, aged 85.

Sukhamay Lahiri b 1933; matric.1956 Jesus, d.2nd May 2009 from prostate cancer, in Philadelphia, aged 76. He accompanied Sir Edmund Hillary on the climbing of Mt. Everest and made several climbs both in the Himalayas and in the Peruvian Andes as he explored high altitude physiology problems. His last trip to Mt. Everest was in 1981 when he performed physiological experiments in the Silver Hut, a temperaturecontrolled cylinder room at about 17,000 ft altitude. He worked at the Downstate Medical Center in New York, Michael Reese Hospital in Chicago, and then the Physiology Department at Penn University. Dr. Lahiri made significant contributions to high altitude and carotid body physiology, being a continuously funded investigator in the area. He received a ten year MERIT Award from the NHLBI in 1996, and the five year Humboldt Research Award granted to a Senior U.S. scientist from the German Alexander von Humboldt Foundation. He was a past President of the International Society for Arterial Chemoreception. He is survived by his wife, Krishna.

Simon Nurick b 1933; matric.1952 Christ Church, d.11th May 2009 from oral cancer, aged 75. Consultant neurologist Brighton and Sussex.

Christopher N Watson b 1924; matric. 1942 University, d 15 January 2009. General practitioner in Harwood and East Keswick, Leeds.

Margaret M Whitty (née Shrubsall) d.12th October 2008. Part time medical officer in chest medicine, public health, and, in particular, family planning in Oxford. President of the Oxford branch of the Medical Women’s Federation.

Donald P Woods matric Keble 1945, d.24th April 2009 aged 81.

General practitioner.

We are anxious to include information about the lives of those who have died and would welcome submissions. These will, where space allows, be published in Oxford medicine. Otherwise they will be placed in the obituaries section of our website www.medsci.ox.ac.uk/oma

Contacting OMA Address: Oxford Medical Alumni Medical Sciences Office John Radcliffe Hospital Oxford OX3 9DU Email: jayne.todd@medsci.ox.ac.uk Website: www.medsci.ox.ac.uk/oma Enquiries: 01865 221690 Fax: 01865 750750

Healthcare and Technology – Professional Networking Event Join us at the Royal Institution, London from 6.30pm on 28 January 2010 for drinks and networking.

There will be a panel discussion on the subject of ‘technology for the health and wealth of society’ where three of Oxford's leading innovators will discuss how their research and the technologies being developed in Oxford's labs will change healthcare in the future. The panel discussion will be chaired by Mr Tom Hockaday (Isis Innovation).

The panel members are: Professor Lionel Tarassenko (Oxford) Dr Helen McShane (Oxford) Dr Peter Wrighton-Smith (Oxford Immunotec)

Professor Lionel Tarassenko is an expert in neural networks, and is director of the new Oxford Institute of Biomedical Engineering. Dr Helen McShane's research has led to a new vaccine for tuberculosis, currently in Phase IIb trials, and Magdalen alumnus Peter WrightonSmith has worked with two of Oxford’s largest spin-outs, Oxford Instruments and Powderject, and now heads diagnostics spin-out Oxford Immunotec.

The panel discussion will be followed by more drinks and canapés.

There are 85 spaces in total, and these will be allocated on a first-come first-served basis.

Previous events have sold out very quickly so we recommend early booking!

To book please go to www.alumni.ox.ac.uk/benefits/careers/professional_networking_events/healthcare_and.html

More information on Oxford University alumni events can be found at www.alumni.ox.ac.uk

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Vice-Chancellor's Reception Join other Oxford alumni and friends at The Royal Society for this exclusive evening with the University’s new Vice-Chancellor, Professor Andrew Hamilton.

17 February 2010 6.30 - 9pm Professor Hamilton was formally admitted as ViceChancellor of the University on 6 October. Professor Hamilton, BSc, MSc, PhD, FRS, read chemistry at the University of Exeter. After studying for a master’s degree at the University of British Columbia, he received his PhD from Cambridge University in 1980 and then spent a post-doctoral period at the Université Louis Pasteur in Strasbourg.

In 1981 he was appointed Assistant Professor of Chemistry at Princeton University then in 1988 served as a department chair and Professor of Chemistry at the University of Pittsburgh. He joined Yale in 1997 and was a Provost of Yale from 2004 until October 2008 where he combined a wide-range of administrative duties with teaching and research.

Achievements during his time as Provost of Yale included the acquisition of the West Campus, the re-establishment of the Yale School of Engineering and Applied Science after a 40-year hiatus, a reform of the tenure process and the significant enhancement of the Yale undergraduate curriculum. In addition to serving as Provost he was Benjamin Silliman Professor of Chemistry and Professor of Molecular Biophysics and Biochemistry.

His research interests lie at the interface of organic and biological chemistry, with particular focus on the use of

synthetic design for the understanding, mimicry and potential disruption of biological processes.

Professor Hamilton’s academic achievements have been widely recognised internationally. In 1999 he received the Arthur C Cope Scholar Award from the American Chemical Society, and in 2004 he was elected a Fellow of the American Association for the Advancement of Science and of the Royal Society.

This evening of drinks and conversation offers an opportunity for alumni to meet Professor Hamilton in person as he reflects on his first term in office and the challenges and opportunities ahead.

As part of the programme, alumni will also have a chance to put their own questions to the Vice-Chancellor.

Questions can be submitted in advance via the online booking form (please note that there is no guarantee that all questions will be raised). Audience questions will be followed by a drinks and canapés reception.

This event will be held in the elegant surroundings of the Royal Society, 6-9 Carlton House Terrace, London (SW1Y 5AG). Professor Hamilton was elected a Fellow of the Royal Society and of the American Association for the Advancement of Science in 2004. His research interests lie at the interface of organic and biological chemistry, and his academic achievements have been widely recognised internationally.

Friends and guests are welcome at this event.

Early booking is recommended for this event and spaces will be allocated on a first-come, first-served basis.

To book please go to www.alumni.ox.ac.uk/news_and_events/events/vicechancellors.html

Oxford Medical Alumni Annual Symposium 27 March 2010 The 2010 Symposium will celebrate approximately 700 years of medical teaching in Oxford. It will be held in the Academic Centre, John Radcliffe Hospital and at the new Osler House and the programme will include a lecture on Sherrington and his legacy (Professor Colin Blakemore); the Oxford Medical Society Lecture will discuss famous Oxford Medical Women (Dame Fiona Caldicott), the establishment of the clinical school (Dr Eric Sidebottom), and an account of Tyngwyk (Dr Simon Smail). Details will follow and will be posted on the website (www.medsci.ox.ac.uk/oma)

Oxford medicine is produced by the Medical Informatics Unit, NDCLS, University of Oxford. Telephone +44 (0)1865 222746.

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