title: Leptospirosis

text: Rapid detection of "Leptospira" can be done by quantifying the IgM antibodies using an enzyme-linked immunosorbent assay (ELISA). Typically, "L. biflexa" antigen is used to detect the IgM antibodies. This test can quickly determine the diagnosis and help in early treatment. However, the test specificity depends upon the type of antigen used and the presence of antibodies from previous infections. The presence of other diseases such as Epstein–Barr virus infection, viral hepatitis, and cytomegalovirus infection can cause false-positive results. Other rapid screening tests have been developed such as dipsticks, latex and slide agglutination tests.


title: Leptospirosis

text: The microscopic agglutination test (MAT) is the reference test for the diagnosis of leptospirosis. MAT is a test where serial dilutions of patient sera are mixed with different serovars of "Leptospira". The mixture is then examined under a dark field microscope to look for agglutination. The highest dilution where 50% agglutination occurs is the result. MAT titres of 1:100 to 1:800 are diagnostic of leptospirosis. A fourfold or greater rise in titre of two sera taken at symptoms' onset and three to 10 days of disease onset confirms the diagnosis. During the acute phase of the disease, MAT is not specific in detecting a serotype of "Leptospira" because of cross-reactivity between the serovars. In the convalescent phase, MAT is more specific in detecting the serovar types. MAT requires a panel of live antigens and requires laborious work.


title: Leptospirosis

text: Leptospiral DNA can be amplified by using polymerase chain reaction (PCR) from serum, urine, aqueous humour, CSF, and autopsy specimens. It detects the presence of bacteria faster than MAT during the first few days of infection without waiting for the appearance of antibodies. As PCR detects the presence of leptospiral DNA in the blood it is useful even when the bacteria is killed by antibiotics.


title: Leptospirosis

text: In 1982, the World Health Organization (WHO) proposed the Faine's criteria for the diagnosis of leptospirosis. It consists of three parts: A (clinical findings), B (epidemiological factors), and C (lab findings and bacteriological data). Since the original Faine's criteria only included culture and MAT in part C, which is difficult and complex to perform, the modified Faine's criteria was proposed in 2004 to include ELISA and slide agglutination tests which are easier to perform. In 2012, modified Faine's criteria (with amendment) was proposed to include shortness of breath and coughing up blood in the diagnosis. In 2013, India recommended modified Faine's criteria in the diagnosis of leptospirosis.


title: Leptospirosis

text: Rates of leptospirosis can be reduced by improving housing, infrastructure, and sanitation standards. Rodent abatement efforts and flood mitigation projects can also help to prevent it. Proper use of personal protective equipment (PPE) by people who have a high risk of occupational exposure can prevent leptospirosis infections in most cases.


title: Leptospirosis

text: There is no human vaccine suitable for worldwide use. Only a few countries such as Cuba, Japan, France, and China have approved the use of inactivated vaccines with limited protective effects. Side effects such as nausea, injection site redness and swelling have been reported after the vaccine was injected. Since the immunity induced by one "Leptospira"serovar is only protective against that specific one, trivalent vaccines have been developed. However, they do not confer long-lasting immunity to humans or animals. Vaccines for other animals are more widely available.


title: Leptospirosis

text: Doxycycline is given once a week as a prophylaxis and is effective in reducing the rate of leptospirosis infections amongst high-risk individuals in flood-prone areas. In one study, it reduced the number of leptospirosis cases in military personnel undergoing exercises in the jungles. In another study, it reduced the number of symptomatic cases after exposure to leptospirosis under heavy rainfall in endemic areas.


title: Leptospirosis

text: Most leptospiral cases resolve spontaneously. Early initiation of antibiotics may prevent the progression to severe disease. Therefore, in resource-limited settings, antibiotics can be started once leptospirosis is suspected after history taking and examination.


title: Leptospirosis

text: For mild leptospirosis, antibiotic recommendations such as doxycycline, azithromycin, ampicillin and amoxicillin were based solely on "in vitro" testing. In 2001, the WHO recommended oral doxycycline (2 mg/kg up to 100 mg every 12 hours) for five to seven days for those with mild leptospirosis. Tetracycline, ampicillin, and amoxicillin can also be used in such cases. However, in areas where rickettsia and leptospirosis are both endemic, azithromycin and doxycycline are the drugs of choice.


title: Leptospirosis

text: Based on a 1988 study, intravenous (IV) benzylpenicillin (also known as penicillin G) is recommended for the treatment of severe leptospirosis. Intravenous benzylpenicillin (30 mg/kg up to 1.2 g every six hours) is used for five to seven days. Amoxicillin, ampicillin, and erythromycin may also be used for severe cases. Ceftriaxone (1 g IV every 24 hours for seven days) is also effective for severe leptospirosis. Cefotaxime (1 g IV every six hours for seven days) and doxycycline (200 mg initially followed by 100 mg IV every 12 hours for seven days) are equally effective as benzylpenicillin (1.5 million units IV every six hours for seven days). Therefore, there is no evidence on differences in death reduction when benzylpenicillin is compared with ceftriaxone or cefotaxime. Another study conducted in 2007 also showed no difference in efficacy between doxycycline (200 mg initially followed by 100 mg orally every 12 hours for seven days) or azithromycin (2 g on day one followed by 1 g daily for two more days) for suspected leptospirosis. There was no difference in the resolution of fever and azithromycin is better tolerated than doxycycline.


title: Leptospirosis

text: Outpatients are given doxycycline or azithromycin. Doxycycline can shorten the duration of leptospirosis by two days, improve symptoms, and prevent the shedding of organisms in their urine. Azithromycin and amoxicillin are given to pregnant women and children. Rarely, a Jarisch–Herxheimer reaction can develop in the first few hours after antibiotic administration. However, according to a meta-analysis done in 2012, the benefit of antibiotics in the treatment of leptospirosis was unclear although the use of antibiotics may reduce the duration of illness by two to four days. Another meta-analysis done in 2013 reached a similar conclusion.


title: Leptospirosis

text: For those with severe leptospirosis, including potassium wasting with high kidney output dysfunction, intravenous hydration and potassium supplements can prevent dehydration and hypokalemia. When acute kidney failure occurs, early initiation of haemodialysis or peritoneal dialysis can help to improve survival. For those with respiratory failure, tracheal intubation with low tidal volume improves survival rates.


title: Leptospirosis

text: Corticosteroids have been proposed to suppress inflammation in leptospirosis because "Leptospira" infection can induce the release of chemical signals which promote inflammation of blood vessels in the lungs. However, there is insufficient evidence to determine whether the use of corticosteroids is beneficial.


title: Leptospirosis

text: The overall risk of death for leptospirosis is 5–10%. For those with jaundice, the case fatality can increase up to 15%. For those infected who present with confusion and neurological signs, there is a high risk of death. Other factors that increase the risk of death include reduced urine output, age more than 36 years, and respiratory failure. With proper care, most of those infected will recover completely. Those with acute kidney failure may develop persistent mild kidney impairment after they recover. In those with severe lung involvement, the risk of death is 50–70%. Thirty percent of people with acute leptospirosis complained of long-lasting symptoms characterised by weakness, muscle pain, and headaches.


title: Leptospirosis

text: Eye problems can occur in 10% of those who recovered from leptospirosis in the range from two weeks to a few years post-infection. Most commonly, eye complications can occur at six months after the infection. This is due to the immune privilege of the eye which protects it from immunological damage during the initial phase of leptospiral infection. These complications can range from mild anterior uveitis to severe panuveitis (which involves all three vascular layers of the eye). The uveitis is more commonly happen in young to a middle-aged man and those working in agricultural farming. In up to 80% of those infected, "Leptospira" DNA can be found in the aqueous humour of the eye. Eye problems usually have a good prognosis following treatment or they are self-limiting. In anterior uveitis, only topical steroids and mydriatics (an agent that causes dilation of the pupil) are needed while in panuveitis, it requires periocular corticosteroids. Leptospiral uveitis is characterised by hypopyon, rapidly maturing cataract, free floating vitreous membranes, disc hyperemia and retinal vasculitis.


title: Leptospirosis

text: It is estimated that one million severe cases of leptospirosis occur annually, with 58,900 deaths. Severe cases account for 5–15% of all leptospirosis cases. Leptospirosis is found in both urban and rural areas in tropical, subtropical, and temperate regions. The global health burden for leptospirosis can be measured by disability-adjusted life year (DALY). The score is 42 per 100,000 people per year, which is more than other diseases such as rabies and filariasis.


title: Leptospirosis

text: The disease is observed persistently in parts of Asia, Oceania, the Caribbean, Latin America and Africa. Antarctica is the only place not affected by leptospirosis. In the United States, there were 100 to 150 leptospirosis cases annually. In 1994, leptospirosis ceased to be a notifiable disease in the United States except in 36 states/territories where it is prevalent such as Hawaii, Texas, California, and Puerto Rico. About 50% of the reported cases occurred in Puerto Rico. In January 2013, leptospirosis was reinstated as a nationally notifiable disease in the United States. Research on epidemiology of leptospirosis in high-risk groups and risk factors is limited in India.


title: Leptospirosis

text: The global rates of leptospirosis have been underestimated because most affected countries lack notification or notification is not mandatory. Distinguishing clinical signs of leptospirosis from other diseases and lack of laboratory diagnostic services are other problems. The socioeconomic status of many of the world's population is closely tied to malnutrition; subsequent lack of micronutrients may lead to increased risk of infection and death due to leptospirosis infection. Micronutrients such as iron, calcium, and magnesium represent important areas for future research.


title: Leptospirosis

text: The disease was first described by Adolf Weil in 1886 when he reported an "acute infectious disease with enlargement of spleen, jaundice, and nephritis." Before Weil's description, the disease was known as "rice field jaundice" in ancient Chinese text, "autumn fever", "seven-day fever", and ""nanukayami" fever"<ref name="Elsevier/Saunders"></ref> in Japan; in Europe and Australia, the disease was associated with certain occupations and given names such as "cane-cutter's disease", "swine-herd's disease", and ""Schlammfieber"" (mud fever). It has been known historically as "black jaundice", or "dairy farm fever" in New Zealand. Leptospirosis was postulated as the cause of an epidemic among Native Americans along the coast of what is now New England during 1616–19. The disease was most likely brought to the New World by Europeans.


title: Leptospirosis

text: "Leptospira" was first observed in 1907 in a post mortem kidney tissue slice by Arthur Stimson using silver deposition staining technique. He called the organism "Spirocheta interrogans" because the bacteria resembled a question mark. In 1908, a Japanese research group led by Ryukichi Inada and Yutaka Ito first identified this bacterium as the causative agent of leptospirosis and noted its presence in rats in 1916. Japanese coal mine workers frequently contracted leptospirosis. In Japan, the organism was named "Spirocheta icterohaemorrhagiae". The Japanese group also experimented with the first leptospiral immunisation studies in guinea pigs. They demonstrated that by injecting the infected guinea pigs with sera from convalescent humans or goats, passive immunity could be provided to the guinea pigs. In 1917, the Japanese group discovered rats as the carriers of leptospirosis. Unaware of the Japanese group's work, two German groups independently and almost simultaneously published their first demonstration of transmitting leptospiral infection in guinea pigs in October 1915. They named the organism "Spirochaeta nodosa" and "Spirochaeta Icterogenes" respectively.


title: Leptospirosis

text: Leptospirosis was subsequently recognised as a disease of all mammalian species. In 1933, Dutch workers reported the isolation of "Leptospira canicola" which specifically infects dogs. In 1940, the strain that specifically infects cattle was first reported in Russia. In 1942, soldiers at Fort Bragg, North Carolina, were recorded to have an infectious disease which caused a rash over their shinbones. This disease was later known to be caused by leptospirosis. By the 1950s, the number of serovars that infected various mammals had expanded significantly. In the 1980s, leptospirosis was recognised as a veterinary disease of major economic importance.


title: Leptospirosis

text: In 1982, there were about 200 serovars of "Leptospira" available for classification. The International Committee on Systematic Bacteriology's subcommittee on taxonomy of "Leptospira" proposed classifying these serovars into two big groups: "L. interrogans" containing pathogenic serovars and "L. biflexa" containing saprophytic serovars. In 1979, the leptospiral family of "Leptospiraceae" was proposed. In the same year, "Leptospira illini" was reclassified as the new genus "Leptonema". In 2002, "Lepthangamushi syndrome" was coined to describe a series of overlapping symptoms of leptospirosis with Hantavirus hemorrhagic fever with renal syndrome, and scrub typhus caused by "Orientia tsutsugamushi". In 2005, "Leptospira parva" was classified as "Turneriella". With DNA-DNA hybridisation technology, "L. interrogans" was divided into seven species. More "Leptospira" species have been discovered since then. The WHO established the Leptospirosis Burden Epidemiology Reference Group (LERG) to review the latest disease epidemiological data of leptospirosis, formulate a disease transmission model, and identify gaps in knowledge and research. The first meeting was convened in 2009. In 2011, LERG estimated that the global yearly rate of leptospirosis is five to 14 cases per 100,000 population.


title: Leptospirosis

text: Infected animals can have no, mild, or severe symptoms; the presenting symptoms may vary by the type of animal. In some animals the bacteria live in the reproductive tract, leading to transmission during mating.


title: Leptospirosis

text: Animals also present with similar clinical features when compared to humans. Clinical signs can appear in 5–15 days in dogs. The incubation period can be prolonged in cats. Leptospirosis can cause abortions after 2–12 weeks in cattle, and 1–4 weeks of infection in pigs. The illness tends to be milder in reservoir hosts. The most commonly affected organs are the kidneys, liver, and reproductive system, but other organs can be affected. In dogs, the acute clinical signs include fever, loss of appetite, shivering, muscle pain, weakness, and urinary symptoms. Vomiting, diarrhea, and abdominal pain may also present. Petechiae and ecchymoses may be seen on mucous membranes. Bleeding from the lungs may also be seen in dogs. In chronic presentations, the affected dog may have no symptoms. In animals that have died of leptospirosis, their kidneys may be swollen with grey and white spots, mottling, or scarring. Their liver may be enlarged with areas of cell death. Petechiae and ecchymoses may be found in various organs. Inflammation of the blood vessels, inflammation of the heart, meningeal layers covering the brain and spinal cord, and uveitis are also possible. Equine recurrent uveitis (ERU) is the most common disease associated with "Leptospira" infection in horses in North America and may lead to blindness. ERU is an autoimmune disease involving antibodies against "Leptospira" proteins LruA and LruB cross-reacting with eye proteins. Live "Leptospira" can be recovered from the aqueous or vitreous fluid of many horses with "Leptospira"-associated ERU. Risk of death or disability in infected animals varies depending upon the species and age of the animals. In adult pigs and cattle, reproductive signs are the most common signs of leptospirosis. Up to 40% of cows may have a spontaneous abortion. Younger animals usually develop more severe disease. About 80% of dogs can survive with treatment, but the survival rate is reduced if the lungs are involved.


title: Leptospirosis

text: ELISA and microscopic agglutination tests are most commonly used to diagnose leptospirosis in animals. The bacteria can be detected in blood, urine, and milk or liver, kidney, or other tissue samples by using immunofluorescence or immunohistochemical or polymerase chain reaction techniques. Silver staining or immunogold silver staining is used to detect "Leptospira" in tissue sections. The organisms stain poorly with Gram stain. Dark-field microscopy can be used to detect "Leptospira" in body fluids, but it is neither sensitive nor specific in detecting the organism. A positive culture for leptospirosis is definitive, but the availability is limited, and culture results can take 13–26 weeks for a result, limiting its utility. Paired acute and convalescent samples are preferred for serological diagnosis of leptospirosis in animals. A positive serological sample from an aborted fetus is also diagnostic of leptospirosis.


title: Leptospirosis

text: Various antibiotics such as doxycycline, penicillins, dihydrostreptomycin, and streptomycin have been used to treat leptospirosis in animals. Fluid therapy, blood transfusion, and respiratory support may be required in severe disease. For horses with ERU, the primary treatment is with anti-inflammatory drugs.


title: Leptospirosis

text: Leptospirosis vaccines are available for animals such as pigs, dogs, cattle, sheep, and goats. Vaccines for cattle usually contain "Leptospira" serovar Hardjo and Pomona, for dogs, the vaccines usually contain serovar Icterohaemorrhagiae and Canicola. Vaccines containing multiple serovars do not work for cattle as well as vaccines containing a single serovar, yet the multivalent vaccines continue to be sold. Isolation of infected animals and prophylactic antibiotics are also effective in preventing leptospirosis transmission between animals. Environmental control and sanitation also reduce transmission rates.


title: Anesthesia

text: Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), amnesia (loss of memory), and unconsciousness. An individual under the effects of anesthetic drugs is referred to as being anesthetized.


title: Anesthesia

text: Anesthesia enables the painless performance of procedures that would otherwise cause severe or intolerable pain in a non-anesthetized individual, or would otherwise be technically unfeasible. Three broad categories of anesthesia exist:


title: Anesthesia

text: In preparing for a medical or veterinary procedure, the clinician chooses one or more drugs to achieve the types and degree of anesthesia characteristics appropriate for the type of procedure and the particular patient. The types of drugs used include general anesthetics, local anesthetics, hypnotics, dissociatives, sedatives, adjuncts, neuromuscular-blocking drugs, narcotics, and analgesics.


title: Anesthesia

text: The risks of complications during or after anesthesia are often difficult to separate from those of the procedure for which anesthesia is being given, but in the main they are related to three factors: the health of the individual, the complexity and stress of the procedure itself, and the anaesthetic technique. Of these factors, the individual's health has the greatest impact. Major perioperative risks can include death, heart attack, and pulmonary embolism whereas minor risks can include postoperative nausea and vomiting and hospital readmission. Some conditions, like local anesthetic toxicity, airway trauma or malignant hyperthermia, can be more directly attributed to specific anesthetic drugs and techniques.


title: Anesthesia

text: Different types of anesthesia affect the endpoints differently. Regional anesthesia, for instance, affects analgesia; benzodiazepine-type sedatives (used for sedation, or "twilight anesthesia") favor amnesia; and general anesthetics can affect all of the endpoints. The goal of anesthesia is to achieve the endpoints required for the given surgical procedure with the least risk to the animal.


title: Anesthesia

text: To achieve the goals of anesthesia, drugs act on different but interconnected parts of the nervous system. Hypnosis, for instance, is generated through actions on the nuclei in the brain and is similar to the activation of sleep. The effect is to make people less aware and less reactive to noxious stimuli.


title: Anesthesia

text: Loss of memory (amnesia) is created by action of drugs on multiple (but specific) regions of the brain. Memories are created as either declarative or non-declarative memories in several stages (short-term, long-term, long-lasting) the strength of which is determined by the strength of connections between neurons termed synaptic plasticity. Each anesthetic produces amnesia through unique effects on memory formation at variable doses. Inhalational anesthetics will reliably produce amnesia through general suppression of the nuclei at doses below those required for loss of consciousness. Drugs like midazolam produce amnesia through different pathways by blocking the formation of long-term memories.


title: Anesthesia

text: Nevertheless, a person can have dreams during anesthetic or have consciousness of the procedure despite having no indication of it under anesthetic. It is estimated that 22% of people dream during general anesthesia and 1 - 2 cases per 1000 have some consciousness termed "awareness during general anesthesia". It is unknown whether non-human animals have dreams during general anesthesia.


title: Anesthesia

text: Anesthesia is unique in that it is not a direct means of treatment; rather, it allows the doctor or veterinarian to do things that may treat, diagnose, or cure an ailment which would otherwise be painful or complicated. The best anesthetic, therefore, is the one with the lowest risk to the patient that still achieves the endpoints required to complete the procedure. The first stage in anesthesia is the pre-operative risk assessment consisting of the medical history, physical examination and lab tests. Diagnosing an animal's pre-operative physical status allows the clinician to minimize anesthetic risks. A well completed medical history will arrive at the correct diagnosis 56% of the time which increases to 73% with a physical examination. Lab tests help in diagnosis but only in 3% of cases, underscoring the need for a full history and physical examination prior to anesthetics. Incorrect pre-operative assessments or preparations are the root cause of 11% of all adverse anesthetic events.


title: Anesthesia

text: Safe anesthesia care depends greatly on well-functioning teams of highly trained healthcare workers. The medical specialty centred around anesthesia is called anesthesiology, and doctors specialised in the field are termed anesthesiologists. Additional healthcare professionals involved in anesthesia provision have varying titles and roles depending on the jurisdiction, and include anesthetic nurses, nurse anesthetists, anesthesiologist assistants, anaesthetic technicians, anaesthesia associates, operating department practitioners and anesthesia technologists. International standards for the safe practice of anesthesia, jointly endorsed by the World Health Organization and the World Federation of Societies of Anaesthesiologists, highly recommend that anesthesia should be provided, overseen or led by anesthesiologists, with the exception of minimal sedation or superficial procedures performed under local anesthesia. A trained, vigilant anesthesia provider should continually care for the animal; where the provider is not an anesthesiologist, they should be locally directed and supervised by an anesthesiologist, and in countries or settings where this is not feasible, care should be led by the most qualified local individual within a regional or national anesthesiologist-led framework. The same minimum standards for patient safety apply regardless of the provider, including continuous clinical and biometric monitoring of tissue oxygenation, perfusion and blood pressure; confirmation of correct placement of airway management devices by auscultation and carbon dioxide detection; use of the WHO Surgical Safety Checklist; and safe onward transfer of the patient's care following the procedure.


title: Anesthesia

text: One part of the risk assessment is based on the patients' health. The American Society of Anesthesiologists has developed a six-tier scale that stratifies the patient's pre-operative physical state. It is called the ASA physical status. The scale assesses risk as the patient's general health relates to an anesthetic.


title: Anesthesia

text: The more detailed pre-operative medical history aims to discover genetic disorders (such as malignant hyperthermia or pseudocholinesterase deficiency), habits (tobacco, drug and alcohol use), physical attributes (such as obesity or a difficult airway) and any coexisting diseases (especially cardiac and respiratory diseases) that might impact the anesthetic. The physical examination helps quantify the impact of anything found in the medical history in addition to lab tests.


title: Anesthesia

text: Aside from the generalities of the patient's health assessment, an evaluation of specific factors as they relate to the surgery also need to be considered for anesthesia. For instance, anesthesia during childbirth must consider not only the mother but the baby. Cancers and tumors that occupy the lungs or throat create special challenges to general anesthesia. After determining the health of the animal undergoing anesthetic and the endpoints that are required to complete the procedure, the type of anesthetic can be selected. Choice of surgical method and anesthetic technique aims to reduce risk of complications, shorten time needed for recovery and minimize the surgical stress response.


title: Anesthesia

text: Anesthesia is a combination of the endpoints (discussed above) that are reached by drugs acting on different but overlapping sites in the central nervous system. General anesthesia (as opposed to sedation or regional anesthesia) has three main goals: lack of movement (paralysis), unconsciousness, and blunting of the stress response. In the early days of anesthesia, anesthetics could reliably achieve the first two, allowing surgeons to perform necessary procedures, but many patients died because the extremes of blood pressure and pulse caused by the surgical insult were ultimately harmful. Eventually, the need for blunting of the surgical stress response was identified by Harvey Cushing, who injected local anesthetic prior to hernia repairs. This led to the development of other drugs that could blunt the response leading to lower surgical mortality rates.


title: Anesthesia

text: The most common approach to reach the endpoints of general anesthesia is through the use of inhaled general anesthetics. Each anesthetic has its own potency which is correlated to its solubility in oil. This relationship exists because the drugs bind directly to cavities in proteins of the central nervous system, although several theories of general anesthetic action have been described. Inhalational anesthetics are thought to exact their effects on different parts of the central nervous system. For instance, the immobilizing effect of inhaled anesthetics results from an effect on the spinal cord whereas sedation, hypnosis and amnesia involve sites in the brain. The potency of an inhalational anesthetic is quantified by its minimum alveolar concentration or MAC. The MAC is the percentage dose of anesthetic that will prevent a response to painful stimulus in 50% of subjects. The higher the MAC, generally, the less potent the anesthetic.


title: Anesthesia

text: The ideal anesthetic drug would provide hypnosis, amnesia, analgesia, and muscle relaxation without undesirable changes in blood pressure, pulse or breathing. In the 1930s, physicians started to augment inhaled general anesthetics with intravenous general anesthetics. The drugs used in combination offered a better risk profile to the animal under anesthesia and a quicker recovery. A combination of drugs was later shown to result in lower odds of dying in the first 7 days after anesthetic. For instance, propofol (injection) might be used to start the anesthetic, fentanyl (injection) used to blunt the stress response, midazolam (injection) given to ensure amnesia and sevoflurane (inhaled) during the procedure to maintain the effects. More recently, several intravenous drugs have been developed which, if desired, allow inhaled general anesthetics to be avoided completely.


title: Anesthesia

text: The core instrument in an inhalational anesthetic delivery system is an anesthetic machine. It has vaporizers, ventilators, an anesthetic breathing circuit, waste gas scavenging system and pressure gauges. The purpose of the anesthetic machine is to provide anesthetic gas at a constant pressure, oxygen for breathing and to remove carbon dioxide or other waste anesthetic gases. Since inhalational anesthetics are flammable, various checklists have been developed to confirm that the machine is ready for use, that the safety features are active and the electrical hazards are removed. Intravenous anesthetic is delivered either by bolus doses or an infusion pump. There are also many smaller instruments used in airway management and monitoring the patient. The common thread to modern machinery in this field is the use of fail-safe systems that decrease the odds of catastrophic misuse of the machine.


title: Anesthesia

text: Patients under general anesthesia must undergo continuous physiological monitoring to ensure safety. In the US, the American Society of Anesthesiologists (ASA) has established minimum monitoring guidelines for patients receiving general anesthesia, regional anesthesia, or sedation. These include electrocardiography (ECG), heart rate, blood pressure, inspired and expired gases, oxygen saturation of the blood (pulse oximetry), and temperature. In the UK the Association of Anaesthetists (AAGBI) have set minimum monitoring guidelines for general and regional anesthesia. For minor surgery, this generally includes monitoring of heart rate, oxygen saturation, blood pressure, and inspired and expired concentrations for oxygen, carbon dioxide, and inhalational anesthetic agents. For more invasive surgery, monitoring may also include temperature, urine output, blood pressure, central venous pressure, pulmonary artery pressure and pulmonary artery occlusion pressure, cardiac output, cerebral activity, and neuromuscular function. In addition, the operating room environment must be monitored for ambient temperature and humidity, as well as for accumulation of exhaled inhalational anesthetic agents, which might be deleterious to the health of operating room personnel.


title: Anesthesia

text: Sedation (also referred to as "dissociative anesthesia" or "twilight anesthesia") creates hypnotic, sedative, anxiolytic, amnesic, anticonvulsant, and centrally produced muscle-relaxing properties. From the perspective of the person giving the sedation, the patient appears sleepy, relaxed and forgetful, allowing unpleasant procedures to be more easily completed. Sedatives such as benzodiazepines are usually given with pain relievers (such as narcotics, or local anesthetics or both) because they do not, by themselves, provide significant pain relief.


title: Anesthesia

text: From the perspective of the animal receiving a sedative, the effect is a feeling of general relaxation, amnesia (loss of memory) and time passing quickly. Many drugs can produce a sedative effect including benzodiazepines, propofol, thiopental, ketamine and inhaled general anesthetics. The advantage of sedation over a general anesthetic is that it generally does not require support of the airway or breathing (no tracheal intubation or mechanical ventilation) and can have less of an effect on the cardiovascular system which may add to a greater margin of safety in some patients.


title: Anesthesia

text: When pain is blocked from a part of the body using local anesthetics, it is generally referred to as regional anesthesia. There are many types of regional anesthesia either by injecting into the tissue itself, a vein that feeds the area or around a nerve trunk that supplies sensation to the area. The latter are called nerve blocks and are divided into peripheral or central nerve blocks.


title: Anesthesia

text: A 2018 Cochrane review found moderate quality evidence that regional anesthesia may reduce the frequency of persistent postoperative pain (PPP) from three to 18 months following thoracotomy and three to 1 months following caesarean. Low quality evidence was found three to 12 months following breast cancer surgery. This review acknowledges certain limitations that impact its applicability beyond the surgeries and regional anesthesia techniques reviewed.


title: Anesthesia

text: When local anesthetic is injected around a larger diameter nerve that transmits sensation from an entire region it is referred to as a nerve block or regional nerve blockade. Nerve blocks are commonly used in dentistry, when the mandibular nerve is blocked for procedures on the lower teeth. With larger diameter nerves (such as the interscalene block for upper limbs or psoas compartment block for lower limbs) the nerve and position of the needle is localized with ultrasound or electrical stimulation. Evidence supports the use of ultrasound guidance alone, or in combination with peripheral nerve stimulation, as superior for improved sensory and motor block, a reduction in the need for supplementation and fewer complications. Because of the large amount of local anesthetic required to affect the nerve, the maximum dose of local anesthetic has to be considered. Nerve blocks are also used as a continuous infusion, following major surgery such as knee, hip and shoulder replacement surgery, and may be associated with lower complications. Nerve blocks are also associated with a lower risk of neurologic complications compared to the more central epidural or spinal neuraxial blocks.


title: Anesthesia

text: Central neuraxial anesthesia is the injection of local anesthetic around the spinal cord to provide analgesia in the abdomen, pelvis or lower extremities. It is divided into either spinal (injection into the subarachnoid space), epidural (injection outside of the subarachnoid space into the epidural space) and caudal (injection into the cauda equina or tail end of the spinal cord). Spinal and epidural are the most commonly used forms of central neuraxial blockade.


title: Anesthesia

text: Spinal anesthesia is a "one-shot" injection that provides rapid onset and profound sensory anesthesia with lower doses of anesthetic, and is usually associated with neuromuscular blockade (loss of muscle control). Epidural anesthesia uses larger doses of anesthetic infused through an indwelling catheter which allows the anesthetic to be augmented should the effects begin to dissipate. Epidural anesthesia does not typically affect muscle control.


title: Anesthesia

text: Because central neuraxial blockade causes arterial and venous vasodilation, a drop in blood pressure is common. This drop is largely dictated by the venous side of the circulatory system which holds 75% of the circulating blood volume. The physiologic effects are much greater when the block is placed above the 5th thoracic vertebra. An ineffective block is most often due to inadequate anxiolysis or sedation rather than a failure of the block itself.


title: Anesthesia

text: Nociception (pain sensation) is not hard-wired into the body. Instead, it is a dynamic process wherein persistent painful stimuli can sensitize the system and either make pain management difficult or promote the development of chronic pain. For this reason, preemptive acute pain management may reduce both acute and chronic pain and is tailored to the surgery, the environment in which it is given (in-patient/out-patient) and the individual.


title: Anesthesia

text: Pain management is classified into either pre-emptive or on-demand. On-demand pain medications typically include either opioid or non-steroidal anti-inflammatory drugs but can also make use of novel approaches such as inhaled nitrous oxide or ketamine. On demand drugs can be administered by a clinician ("as needed drug orders") or by the patient using patient-controlled analgesia (PCA). PCA has been shown to provide slightly better pain control and increased patient satisfaction when compared with conventional methods. Common preemptive approaches include epidural neuraxial blockade or nerve blocks. One review which looked at pain control after abdominal aortic surgery found that epidural blockade provides better pain relief (especially during movement) in the period up to three postoperative days. It reduces the duration of postoperative tracheal intubation by roughly half. The occurrence of prolonged postoperative mechanical ventilation and myocardial infarction is also reduced by epidural analgesia.


title: Anesthesia

text: Risks and complications as they relate to anesthesia are classified as either morbidity (a disease or disorder that results from anesthesia) or mortality (death that results from anesthesia). Quantifying how anesthesia contributes to morbidity and mortality can be difficult because an animal's health prior to surgery and the complexity of the surgical procedure can also contribute to the risks.


title: Anesthesia

text: Prior to the introduction of anesthesia in the early 19th century, the physiologic stress from surgery caused significant complications and many deaths from shock. The faster the surgery was, the lower the rate of complications (leading to reports of very quick amputations). The advent of anesthesia allowed more complicated and life-saving surgery to be completed, decreased the physiologic stress of the surgery, but added an element of risk. It was two years after the introduction of ether anesthetics that the first death directly related to the use of anesthesia was reported.


title: Anesthesia

text: Morbidity can be major (myocardial infarction, pneumonia, pulmonary embolism, kidney failure/chronic kidney disease, postoperative cognitive dysfunction and allergy) or minor (minor nausea, vomiting, readmission). There is usually overlap in the contributing factors that lead to morbidity and mortality between the health of the animals, the type of surgery being performed and the anesthetic. To understand the relative risk of each contributing factor, consider that the rate of deaths totally attributed to the patient's health is 1:870. Compare that to the rate of deaths totally attributed to surgical factors (1:2860) or anesthesia alone (1:185,056) illustrating that the single greatest factor in anesthetic mortality is the health of the patient. These statistics can also be compared to the first such study on mortality in anesthesia from 1954, which reported a rate of death from all causes at 1:75 and a rate attributed to anesthesia alone at 1:2680. Direct comparisons between mortality statistics cannot reliably be made over time and across countries because of differences in the stratification of risk factors, however, there is evidence that anesthetics have made a significant improvement in safety but to what degree is uncertain.


title: Anesthesia

text: Rather than stating a flat rate of morbidity or mortality, many factors are reported as contributing to the relative risk of the procedure and anesthetic combined. For instance, an operation on a person who is between the ages of 60–79 years old places the patient at 2.3 times greater risk than someone less than 60 years old. Having an ASA score of 3, 4 or 5 places the person at 10.7 times greater risk than someone with an ASA score of 1 or 2. Other variables include age greater than 80 (3.3 times risk compared to those under 60), gender (females have a lower risk of 0.8), urgency of the procedure (emergencies have a 4.4 times greater risk), experience of the person completing the procedure (less than 8 years experience and/or less than 600 cases have a 1.1 times greater risk) and the type of anesthetic (regional anesthetics are lower risk than general anesthetics). Obstetrical, the very young and the very old are all at greater risk of complication so extra precautions may need to be taken.


title: Anesthesia

text: On 14 December 2016, the Food and Drug Administration issued a Public Safety Communication warning that "repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children's brains." The warning was criticized by the American College of Obstetricians and Gynecologists, which pointed out the absence of direct evidence regarding use in pregnant women and the possibility that "this warning could inappropriately dissuade providers from providing medically indicated care during pregnancy." Patient advocates noted that a randomized clinical trial would be unethical, that the mechanism of injury is well-established in animals, and that studies had shown exposure to multiple uses of anesthetic significantly increased the risk of developing learning disabilities in young children, with a hazard ratio of 2.12 (95% confidence interval, 1.26–3.54).


title: Anesthesia

text: The immediate time after anesthesia is called emergence. Emergence from general anesthesia or sedation requires careful monitoring because there is still a risk of complication. Nausea and vomiting are reported at 9.8% but will vary with the type of anesthetic and procedure. There is a need for airway support in 6.8%, there can be urinary retention (more common in those over 50 years of age) and hypotension in 2.7%. Hypothermia, shivering and confusion are also common in the immediate post-operative period because of the lack of muscle movement (and subsequent lack of heat production) during the procedure. Furthermore, the rare manifestation in the post-anesthetic period may be the occurrence of functional neurological symptom disorder (FNSD).


title: Anesthesia

text: Postoperative cognitive dysfunction (also known as "POCD" and post-anesthetic confusion) is a disturbance in cognition after surgery. It may also be variably used to describe emergence delirium (immediate post-operative confusion) and early cognitive dysfunction (diminished cognitive function in the first post-operative week). Although the three entities (delirium, early POCD and long-term POCD) are separate, the presence of delirium post-operatively predicts the presence of early POCD. There does not appear to be an association between delirium or early POCD and long-term POCD. According to a recent study conducted at the David Geffen School of Medicine at UCLA, the brain navigates its way through a series of activity clusters, or "hubs" on its way back to consciousness. Dr. Andrew Hudson, an assistant professor in anesthesiology states, "Recovery from anesthesia is not simply the result of the anesthetic 'wearing off,' but also of the brain finding its way back through a maze of possible activity states to those that allow conscious experience. Put simply, the brain reboots itself."


title: Anesthesia

text: Long-term POCD is a subtle deterioration in cognitive function, that can last for weeks, months, or longer. Most commonly, relatives of the person report a lack of attention, memory and loss of interest in activities previously dear to the person (such as crosswords). In a similar way, people in the workforce may report an inability to complete tasks at the same speed they could previously. There is good evidence that POCD occurs after cardiac surgery and the major reason for its occurrence is the formation of microemboli. POCD also appears to occur in non-cardiac surgery. Its causes in non-cardiac surgery are less clear but older age is a risk factor for its occurrence.


title: Anesthesia

text: The first attempts at general anesthesia were probably herbal remedies administered in prehistory. Alcohol is one of the oldest known sedatives and it was used in ancient Mesopotamia thousands of years ago. The Sumerians are said to have cultivated and harvested the opium poppy ("Papaver somniferum") in lower Mesopotamia as early as 3400 BCE. The ancient Egyptians had some surgical instruments, as well as crude analgesics and sedatives, including possibly an extract prepared from the mandrake fruit.


title: Anesthesia

text: In China, Bian Que (Chinese: 扁鹊, Wade–Giles: "Pien Ch'iao", c. 300 BCE) was a legendary Chinese internist and surgeon who reportedly used general anesthesia for surgical procedures. Despite this, it was the Chinese physician Hua Tuo whom historians considered the first verifiable historical figure to develop a type of mixture of anesthesia, though his recipe has yet to be fully discovered.


title: Anesthesia

text: Throughout Europe, Asia, and the Americas, a variety of "Solanum" species containing potent tropane alkaloids was used for anesthesia. In 13th-century Italy, Theodoric Borgognoni used similar mixtures along with opiates to induce unconsciousness, and treatment with the combined alkaloids proved a mainstay of anesthesia until the 19th century. Local anesthetics were used in Inca civilization where shamans chewed coca leaves and performed operations on the skull while spitting into the wounds they had inflicted to anesthetize. Cocaine was later isolated and became the first effective local anesthetic. It was first used in 1859 by Karl Koller, at the suggestion of Sigmund Freud, in eye surgery in 1884. German surgeon August Bier (1861–1949) was the first to use cocaine for intrathecal anesthesia in 1898. Romanian surgeon Nicolae Racoviceanu-Piteşti (1860–1942) was the first to use opioids for intrathecal analgesia; he presented his experience in Paris in 1901.


title: Anesthesia

text: The "soporific sponge" ("sleep sponge") used by Arabic physicians was introduced to Europe by the Salerno school of medicine in the late 12th century and by Ugo Borgognoni (1180–1258) in the 13th century. The sponge was promoted and described by Ugo's son and fellow surgeon, Theodoric Borgognoni (1205–1298). In this anesthetic method, a sponge was soaked in a dissolved solution of opium, mandragora, hemlock juice, and other substances. The sponge was then dried and stored; just before surgery the sponge was moistened and then held under the patient's nose. When all went well, the fumes rendered the individual unconscious.


title: Anesthesia

text: The most famous anesthetic, ether, may have been synthesized as early as the 8th century, but it took many centuries for its anesthetic importance to be appreciated, even though the 16th century physician and polymath Paracelsus noted that chickens made to breathe it not only fell asleep but also felt no pain. By the early 19th century, ether was being used by humans, but only as a recreational drug.


title: Anesthesia

text: Meanwhile, in 1772, English scientist Joseph Priestley discovered the gas nitrous oxide. Initially, people thought this gas to be lethal, even in small doses, like some other nitrogen oxides. However, in 1799, British chemist and inventor Humphry Davy decided to find out by experimenting on himself. To his astonishment he found that nitrous oxide made him laugh, so he nicknamed it "laughing gas". In 1800 Davy wrote about the potential anesthetic properties of nitrous oxide in relieving pain during surgery, but nobody at that time pursued the matter any further.


title: Anesthesia

text: On 14 November 1804, Hanaoka Seishū, a Japanese doctor, became the first person to successfully perform surgery using general anesthesia. Hanaoka learned traditional Japanese medicine as well as Dutch-imported European surgery and Chinese medicine. After years of research and experimentation, he finally developed a formula which he named tsūsensan (also known as mafutsu-san), which combined Korean morning glory and other herbs.


title: Anesthesia

text: Hanaoka's success in performing this painless operation soon became widely known, and patients began to arrive from all parts of Japan. Hanaoka went on to perform many operations using tsūsensan, including resection of malignant tumors, extraction of bladder stones, and extremity amputations. Before his death in 1835, Hanaoka performed more than 150 operations for breast cancer. However, this finding did not benefit the rest of the world until 1854 as the national isolation policy of the Tokugawa shogunate prevented Hanaoka's achievements from being publicized until after the isolation ended. Nearly forty years would pass before Crawford Long, who is titled as the inventor of modern anesthetics in the West, used general anesthesia in Jefferson, Georgia.


title: Anesthesia

text: Long noticed that his friends felt no pain when they injured themselves while staggering around under the influence of diethyl ether. He immediately thought of its potential in surgery. Conveniently, a participant in one of those "ether frolics", a student named James Venable, had two small tumors he wanted excised. But fearing the pain of surgery, Venable kept putting the operation off. Hence, Long suggested that he have his operation while under the influence of ether. Venable agreed, and on 30 March 1842 he underwent a painless operation. However, Long did not announce his discovery until 1849.


title: Anesthesia

text: Horace Wells conducted the first public demonstration of the inhalational anesthetic at the Massachusetts General Hospital in Boston in 1845. However, the nitrous oxide was improperly administered and the person cried out in pain. On 16 October 1846, Boston dentist William Thomas Green Morton gave a successful demonstration using diethyl ether to medical students at the same venue. Morton, who was unaware of Long's previous work, was invited to the Massachusetts General Hospital to demonstrate his new technique for painless surgery. After Morton had induced anesthesia, surgeon John Collins Warren removed a tumor from the neck of Edward Gilbert Abbott. This occurred in the surgical amphitheater now called the Ether Dome. The previously skeptical Warren was impressed and stated, "Gentlemen, this is no humbug." In a letter to Morton shortly thereafter, physician and writer Oliver Wendell Holmes, Sr. proposed naming the state produced "anesthesia", and the procedure an "anesthetic".


title: Anesthesia

text: Morton at first attempted to hide the actual nature of his anesthetic substance, referring to it as Letheon. He received a US patent for his substance, but news of the successful anesthetic spread quickly by late 1846. Respected surgeons in Europe including Liston, Dieffenbach, Pirogov, and Syme quickly undertook numerous operations with ether. An American-born physician, Boott, encouraged London dentist James Robinson to perform a dental procedure on a Miss Lonsdale. This was the first case of an operator-anesthetist. On the same day, 19 December 1846, in Dumfries Royal Infirmary, Scotland, a Dr. Scott used ether for a surgical procedure. The first use of anesthesia in the Southern Hemisphere took place in Launceston, Tasmania, that same year. Drawbacks with ether such as excessive vomiting and its explosive flammability led to its replacement in England with chloroform.


title: Anesthesia

text: Discovered in 1831 by an American physician Samuel Guthrie (1782–1848), and independently a few months later by Frenchman Eugène Soubeiran (1797–1859) and Justus von Liebig (1803–1873) in Germany, chloroform was named and chemically characterized in 1834 by Jean-Baptiste Dumas (1800–1884). In 1842, Dr Robert Mortimer Glover in London discovered the anaesthetic qualities of chloroform on laboratory animals.


title: Anesthesia

text: In 1847, Scottish obstetrician James Young Simpson was the first to demonstrate the anesthetic properties of chloroform on humans and helped to popularize the drug for use in medicine. This first supply came from local pharmacists, James Duncan and William Flockhart, and its use spread quickly, with 750,000 doses weekly in Britain by 1895. Simpson arranged for Flockhart to supply Florence Nightingale. Chloroform gained royal approval in 1853 when John Snow administered it to Queen Victoria when she was in labor with Prince Leopold. For the experience of child birth itself, chloroform met all the Queen's expectations; she stated it was "delightful beyond measure". Chloroform was not without fault though. The first fatality directly attributed to chloroform administration was recorded on 28 January 1848 after the death of Hannah Greener. This was the first of many deaths to follow from the untrained handling of chloroform. Surgeons began to appreciate the need for a trained anesthetist. The need, as Thatcher writes, was for an anesthetist to "(1)Be satisfied with the subordinate role that the work would require, (2) Make anesthesia their one absorbing interest, (3) not look at the situation of anesthetist as one that put them in a position to watch and learn from the surgeons technique (4) accept the comparatively low pay and (5) have the natural aptitude and intelligence to develop a high level of skill in providing the smooth anesthesia and relaxation that the surgeon demanded" These qualities of an anesthetist were often found in submissive medical students and even members of the public. More often, surgeons sought out nurses to provide anesthesia. By the time of the Civil War, many nurses had been professionally trained with the support of surgeons.


title: Anesthesia

text: John Snow of London published articles from May 1848 onwards "On Narcotism by the Inhalation of Vapours" in the London Medical Gazette. Snow also involved himself in the production of equipment needed for the administration of inhalational anesthetics, the forerunner of today's anesthesia machines.


title: Anesthesia

text: Alice Magaw, born in November 1860, is often referred to as "The Mother of Anesthesia". Her renown as the personal anesthesia provider for William and Charles Mayo was solidified by Mayo's own words in his 1905 article in which he described his satisfaction with and reliance on nurse anesthetists: "The question of anaesthesia is a most important one. We have regular anaesthetists [on] whom we can depend so that I can devote my entire attention to the surgical work." Magaw kept thorough records of her cases and recorded these anesthetics. In her publication reviewing more than 14,000 surgical anesthetics, Magaw indicates she successfully provided anesthesia without an anesthetic-related death. Magaw describes


title: Anesthesia

text: in another article, "We have administered an anesthetic 1,092 times; ether alone 674 times; chloroform 245 times; ether and chloroform combined 173 times. I can report that out of this number, 1,092 cases, we have not had an accident". Magaw's records and outcomes created a legacy defining that the delivery of anesthesia by nurses would serve the surgical community without increasing the risks to patients. In fact, Magaw's outcomes would eclipse those of practitioners today.


title: Anesthesia

text: The first comprehensive medical textbook on the subject, "Anesthesia", was authored in 1914 by anesthesiologist Dr. James Tayloe Gwathmey and the chemist Dr. Charles Baskerville. This book served as the standard reference for the specialty for decades and included details on the history of anesthesia as well as the physiology and techniques of inhalation, rectal, intravenous, and spinal anesthesia.


title: Anesthesia

text: Of these first famous anesthetics, only nitrous oxide is still widely used today, with chloroform and ether having been replaced by safer but sometimes more expensive general anesthetics, and cocaine by more effective local anesthetics with less abuse potential.


title: Anesthesia

text: Almost all healthcare providers use anesthetic drugs to some degree, but most health professions have their own field of specialists in the field including medicine, nursing and dentistry.


title: Anesthesia

text: Doctors specializing in anaesthesiology, including perioperative care, development of an anesthetic plan, and the administration of anesthetics are known in the US as "anesthesiologists" and in the UK, Canada, Australia, and NZ as "anaesthetists" or "anaesthesiologists". All anesthetics in the UK, Australia, New Zealand, Hong Kong and Japan are administered by doctors. Nurse anesthetists also administer anesthesia in 109 nations. In the US, 35% of anesthetics are provided by physicians in solo practice, about 55% are provided by anesthesia care teams (ACTs) with anesthesiologists medically directing certified registered nurse anesthetists (CRNAs) or anesthesiologist assistants, and about 10% are provided by CRNAs in solo practice. There can also be anesthesiologist assistants (US) or physicians' assistants (anaesthesia) (UK) who assist with anesthesia.


title: Anesthesia

text: There are many circumstances when anesthesia needs to be altered for special circumstances due to the procedure (such as in cardiac surgery, cardiothoracic anesthesiology or neurosurgery), the patient (such as in pediatric anesthesia, geriatric, bariatric or obstetrical anesthesia) or special circumstances (such as in trauma, prehospital care, robotic surgery or extreme environments).


title: Paul Gray (American musician)

text: Paul Dedrick Gray (April 8, 1972 – May 24, 2010) was an American musician, also known as the Pig. He was the bassist, backing vocalist, main songwriter and one of the founding members of the heavy metal band Slipknot, in which he was designated #2.


title: Paul Gray (American musician)

text: Paul Dedrick Gray was born in Los Angeles, California. Later his family relocated to Des Moines, Iowa. He played guitar but switched to bass after he relocated to Iowa. In his youth, Gray performed in bands such as Sudden Infant Death Syndrome, Anal Blast, Vexx, Body Pit, The Have Nots and Inveigh Catharsis.


title: Paul Gray (American musician)

text: At the time of his death, he was one of three original members of Slipknot remaining in the band, and the only one who had maintained his original role in the band due to Clown's switch from main drums to percussion during the early days. He was one of the two members not born in Iowa (the other is Jim Root, who was born in Las Vegas). In 2010, Slipknot released the Download 2009 performance on DVD in memory of Gray.


title: Paul Gray (American musician)

text: Besides Slipknot, Gray filled in as bassist for Unida during their 2003 tour, appeared on the album "Worse Than a Fairy Tale" by the band "Drop Dead, Gorgeous", toured briefly with Reggie and the Full Effect and appeared on the Roadrunner United project, performing bass on "The Enemy" and "Baptized in the Redemption" from the project's album "The All-Star Sessions".


title: Paul Gray (American musician)

text: An award was named after Paul titled "Paul Gray: Best Bassist of the Year", as a tribute to Paul. Slipknot presented the award to Nikki Sixx, of Mötley Crüe and Sixx A.M.


title: Paul Gray (American musician)

text: On May 24, 2010, "The Des Moines Register" reported that Gray had been found dead in room 431 at the TownePlace Suites Hotel in Urbandale, Iowa at about 10:50 a.m. local time. In a 911-call, obtained by TMZ, one of the hotel's proprietors said that a hypodermic needle was found next to Gray's bed, as well as many pills that were apparently scattered across the room. An initial autopsy determined that no foul play or trauma was involved, but could not establish the cause of death.


title: Paul Gray (American musician)

text: On June 21, 2010, the autopsy results showed that Gray had died of an overdose of morphine and fentanyl, and that he had also developed "significant heart disease". The autopsy also revealed traces of the anti-anxiety pill Xanax in his system.


title: Paul Gray (American musician)

text: On the day after Gray's death, May 25, 2010, the band, without their usual masks, held a formal press conference in Des Moines, Iowa. They did not take any questions from the media. The band, as well as Gray's brother, Tony, and wife, Brenna, paid tribute to him.


title: Paul Gray (American musician)

text: A private funeral was held on May 28, 2010. Paul Gray was buried at the Highland Memory Gardens Cemetery in Des Moines, Iowa. On November 8, 2010, items that decorated Gray's grave, including a Buddha statue and gargoyle statue, were stolen. The band responded to this event with a post on their Myspace and Facebook page, asking the robbers to return the stolen items and appealing for information from the public.


title: Paul Gray (American musician)

text: On July 30, Paul Gray was posthumously awarded the "Kerrang!" "Services to Metal" award, which was collected by his Slipknot bandmate Corey Taylor on his behalf.


title: Paul Gray (American musician)

text: Slipknot's former guitarist Donnie Steele filled in on bass guitar for Gray on Slipknot's 2011 Summer tour. Slipknot shows during this time featured Paul's jumpsuit and self-titled album era pig mask on a stand, along with a bass guitar standing next to it. Fans honored Gray with a two-minute silence during the band's headline set at Sonisphere Festival, Knebworth.


title: Paul Gray (American musician)

text: Corey Taylor also got a tattoo of Gray and his number on the back of his left leg, which was documented in the television series "NY Ink", during the second episode of season one.


title: Paul Gray (American musician)

text: In September 2012, Gray's physician Daniel Baldi was charged with involuntary manslaughter relating to Gray's death, as well as the deaths of at least seven others. He was accused of continually writing high-dose prescription narcotics to Gray from December 27, 2005 until his death, despite knowing Gray's history of drug addiction and abuse. The doctor appeared in court on September 27, 2012 to face the charges, to which he pleaded not guilty. On May 1, 2014, jurors found Daniel Baldi not guilty on all seven counts of involuntary manslaughter following two days of deliberation. Gray's wife Brenna had testified during the two-week-long trial that Baldi prescribed the anti-anxiety drug Xanax to her husband, despite knowing he was addicted to the prescription medicine.


title: Paul Gray (American musician)

text: In January 2018, the family received an out of court settlement from a civil lawsuit they had filed against Dr. Daniel Baldi and his former employers. Two months later, the Iowa Board of Pharmacy permanently banned Baldi from being able to prescribe, administer, or dispense controlled substances for the treatment of chronic pain.


title: 2005 UEFA Champions League Final

text: The 2005 UEFA Champions League Final was the final match of the 2004–05 UEFA Champions League, Europe's primary club football competition. The showpiece event was contested between Liverpool of England and Milan of Italy at the Atatürk Olympic Stadium in Istanbul, Turkey on 25 May 2005. Liverpool, who had won the competition four times, were appearing in their sixth final, and their first since 1985. Milan, who had won the competition six times, were appearing in their second final in three years and tenth overall.


title: 2005 UEFA Champions League Final

text: Each club needed to progress through the group stage and knockout rounds to reach the final, playing 12 matches in total. Liverpool finished second in their group behind 2004 runners-up AS Monaco and subsequently beat Bayer Leverkusen, Juventus and Chelsea to progress to the final. Milan won their group ahead of Barcelona and faced Manchester United, Inter Milan and PSV before reaching the final.


title: 2005 UEFA Champions League Final

text: Milan were regarded as favourites before the match and took the lead within the first minute through captain Paolo Maldini. Milan striker Hernán Crespo added two more goals before half-time to make it 3–0. In the second half Liverpool launched a comeback and scored three goals in a dramatic six-minute spell to level the scores at 3–3, with goals from Steven Gerrard, Vladimír Šmicer and Xabi Alonso. The scores remained the same during extra time, and a penalty shoot-out was required to decide the champions. The score was 3–2 to Liverpool when Andriy Shevchenko's penalty was saved by Liverpool goalkeeper Jerzy Dudek. It was Liverpool's fifth European Cup, which meant they were awarded the trophy permanently and the right to wear a multiple-winner badge. Liverpool's comeback gave rise to the final being known as the Miracle of Istanbul, and is regarded as one of the greatest finals in the history of the tournament.


title: 2005 UEFA Champions League Final

text: Teams qualified for the Champions League group stage, either directly or through three preliminary rounds, based on both their position in the preceding domestic league and the strength of that league. Each club needed to progress through the group stage and knockout rounds to reach the final, playing 12 matches in total. Liverpool finished second in their group behind 2004 Champions League runners-up AS Monaco. In Liverpool's final group stage match against Olympiacos on 8 December, Steven Gerrard scored a 25-yard half volley in the 86th minute to send the club through to the knockout round. A strike that saw co-commentator Andy Gray exclaim, "Oh, you beauty!! What a hit son! What a hit!", Gerrard stated it was his most important, if not his best, goal for Liverpool to date. In the knockout rounds, Liverpool beat Bayer Leverkusen, Juventus and Chelsea to progress to the final. The winning goal in the semi-final scored by Luis García was dubbed a ghost goal by Chelsea manager José Mourinho. He did however recognise the atmosphere generated by Liverpool fans in the match: "I felt the power of Anfield, it was magnificent."


title: 2005 UEFA Champions League Final

text: Milan won their group ahead of Barcelona and faced Manchester United, Inter Milan and PSV Eindhoven before reaching the final. Liverpool entered the competition in the third qualifying round after finishing fourth in the 2003–04 FA Premier League. They faced Austrian side Grazer AK and won the first leg 2–0 at Graz after two goals from captain Steven Gerrard. They lost the second leg 1–0 at Anfield but progressed to the group stage by virtue of winning the tie 2–1 on aggregate. Milan entered the competition in the group stage after winning Serie A. The group stages were contested as eight double round-robin groups of four teams, the top two qualifying for the knockout stages. Knockout ties were decided based on home and away matches.


title: 2005 UEFA Champions League Final

text: The final was held at Atatürk Olympic Stadium, it was the first time a European final had been held in Turkey. There were reservations about holding the final in Turkey but UEFA chief executive, Lars-Christer Olsson was satisfied by the assurances of the Turkish authorities: "The conditions there are the same, generally, as for all countries and they have given guarantees, this is important, especially since their experiences last autumn. We have also asked for additional investments in the infrastructure around the stadium and they have agreed to this, too." This was the Liverpool's sixth final and it was their first appearance since the 1985 European Cup Final, when they lost 1–0 to Juventus and were subsequently banned from European competition for six years due to the Heysel Stadium disaster. They had previously won the European Cup on four occasions in 1977, 1978, 1981 and 1984. The match was Milan's tenth appearance in the final. They had won on six occasions (1963, 1969, 1989, 1990, 1994, 2003), and lost three times (1958, 1993, 1995). In total the teams had participated in 14 finals between them. Prior to the game, Milan were assured of entering the Champions League the following season after finishing second in Serie A. Liverpool meanwhile had failed to finish in the top four in the Premier League, and had to win the final to enter the competition the following season. Even if they did win the match, they were not assured of a place after UEFA failed to confirm whether they would allow Liverpool to defend the championship. The Football Association supported Liverpool, stating, "We have already submitted a written request to have an additional place, should they win the Champions League". Milan manager Carlo Ancelotti said "I think a team that wins should have the right to defend it but we may just do the English federation a favour and solve this."


title: 2005 UEFA Champions League Final

text: Each team was allocated 20,000 tickets for the final, out of a total of 69,000. 14,400 tickets were made available to the general public, with half of those allocated through a ballot on UEFA's website, and the other half reserved for Turkish fans by the Turkish Football Federation. The final 14,600 tickets were distributed to UEFA's "football family", consisting of UEFA officials, national football associations, commercial partners and broadcasters. Hotel rooms in the city were scarce, with the 100,000 available quickly booked by travel agents and fans. At least 30,000 Liverpool fans made the trip to Istanbul, but only 20,000 were expected to have tickets. The BBC reported early arrivals were lively but there was no violence and the mood between the two fans was friendly.


title: 2005 UEFA Champions League Final

text: Milan were regarded as favourites and their team included many players who had experienced success in the competition. The most notable was captain Paolo Maldini, who had won the competition four times previously, all with Milan, and Clarence Seedorf who had won the competition three times with three clubs. Liverpool had been considered underdogs throughout the competition, but had beaten more favoured opposition, including Juventus and Chelsea, to reach the final. Liverpool manager Rafael Benítez acknowledged this: "Maybe Milan are favourites, but we have confidence, and we can win". Arsenal manager Arsène Wenger felt Liverpool would win the match: "I fancy Liverpool as Milan look jaded physically and certainly mentally, by losing the [Serie A] title, I think they have never had a better chance than now to beat Milan." Liverpool defender Jamie Carragher was not so optimistic, stating that the Liverpool side were not as good as the one that had won the 2001 UEFA Cup Final: "No disrespect to the squad we have got now but it is obvious we are not as strong as we were when we won the UEFA Cup in 2001. Back then we had a settled team and that season when we went into games against Barcelona and Roma, we always felt we were as good as them."


title: 2005 UEFA Champions League Final

text: Milan were expected to field a 4–4–2 formation, and there was much speculation about who would partner Andriy Shevchenko in attack. Filippo Inzaghi and Jon Dahl Tomasson were touted, but it was expected that on-loan striker Hernán Crespo would be chosen. This was echoed by Milan manager Ancelotti: "I will not say if he will play from the start, but he will definitely play." Liverpool were also expected to adopt a 4–4–2 formation. Dietmar Hamann was expected to start ahead of Igor Bišćan, and when questioned over whether Djibril Cissé or Milan Baroš would start as main striker, Benítez replied, "Both are good enough, maybe both can play, why not?"


title: 2005 UEFA Champions League Final

text: The referee for the final was Manuel Mejuto González, who led an all-Spanish crew of officials. His assistant referees were Oscar Martínez Samaniego and Clemente Ayete Plou, and the fourth official was Arturo Daudén Ibáñez. Mejuto González was only the third Spanish referee to officiate a European Cup final, following Manuel Díaz Vega in 1996 and José María Ortiz de Mendíbil in 1969.


title: 2005 UEFA Champions League Final

text: Liverpool fielded a 4–4–1–1 formation, with the surprise inclusion in the squad being Harry Kewell, who played just behind Milan Baroš, who himself had been picked ahead of Djibril Cissé. The inclusion of Kewell meant Dietmar Hamann was left on the substitutes' bench and Xabi Alonso and Steven Gerrard started in the centre of midfield. Milan fielded a 4–4–2 diamond formation, with Hernán Crespo preferred to Jon Dahl Tomasson and Filippo Inzaghi, who was not included in the match day squad. Liverpool lined up in their red home kit, whilst Milan wore a changed strip of all white. Liverpool won the toss and kicked off.


title: 2005 UEFA Champions League Final

text: Milan scored within the first minute of the match after captain Paolo Maldini volleyed in an Andrea Pirlo free kick that had been conceded by Djimi Traoré. The goal made Maldini the oldest scorer in the history of the competition. Liverpool responded almost immediately; John Arne Riise, who was picked out by a corner kick from Steven Gerrard, hit a volley from the edge of the penalty box. His shot was cleared only for Gerrard to cross in from the right wing, which Sami Hyypiä headed towards goal producing a save out of Dida. Milan almost extended their lead in the 13th minute, after Crespo's header was cleared off the goal line by Luis García. A few minutes later, Liverpool made a substitution after Harry Kewell picked up a groin injury; he was replaced by Vladimír Šmicer. Soon after, Kaká passed through to Andriy Shevchenko who put his shot past Liverpool goalkeeper Jerzy Dudek, but Shevchenko was adjudged to have been in an offside position and the goal did not stand. Shevchenko had another chance to score a few minutes later; after being played onside by Traore, his shot was saved by Dudek after he came under pressure from the Liverpool defence. Luis García had two chances to score following Shevchenko's shot; the first shot from the edge of the penalty area went well over the crossbar and after he was headed through by Baroš his next shot went wide. Straight after this attack, Crespo went through on goal only to be flagged for offside. Almost immediately after this, Liverpool had a penalty claim turned down after Alessandro Nesta allegedly handballed. Milan countered and scored; Kaka dribbled the ball into the Liverpool half and passed to Shevchenko, who passed to Crespo at the far post to score and make it 2–0. Minutes later, Crespo extended Milan's lead with a chip over Dudek after Kaka provided the assist to make it 3–0.


title: 2005 UEFA Champions League Final

text: At the start of the second half, Liverpool made a substitution with Dietmar Hamann replacing Steve Finnan and also changed to a 3–4–2–1 formation to reduce the deficit, with Riise and Šmicer on the flanks, Alonso and Hamann as holding midfielders and Gerrard playing as an attacking midfielder. Liverpool had the best chance early on with Xabi Alonso sending an effort from narrowly past Milan's right hand post. Two minutes later, Shevchenko forced a save from Dudek with a strong free-kick from just outside the Liverpool box.


title: 2005 UEFA Champions League Final

text: A minute after this, Liverpool scored through captain Gerrard, who connected with Riise's cross and lofted a header past Dida. Soon afterwards, Liverpool scored again as Šmicer beat Dida with a long-range shot into the bottom left-hand corner to leave Liverpool a goal behind. Three minutes after Šmicer's goal, Liverpool were awarded a penalty, after Gerrard made a run into the Milan box for Baros' lay-off and was brought down by Gennaro Gattuso. Xabi Alonso's penalty was saved, but he scored from the rebound to equalise for Liverpool. Milan and Liverpool had chances to take the lead after this, but Clarence Seedorf and Riise failed to score.


title: 2005 UEFA Champions League Final

text: Milan almost took the lead in the 70th minute, after Dudek dropped a low cross towards Shevchenko, whose effort was cleared off the line by Traore. Gerrard then had a chance to score but he sent his shot over the crossbar. About ten minutes later García could not control a pass from Gerrard which led to a Milan attack, Crespo played the ball back to Kaka, whose subsequent shot was blocked by Jamie Carragher. A number of substitutions were made before the end of full-time with Liverpool replacing Milan Baroš with Djibril Cissé, while Milan replaced Hernán Crespo and Clarence Seedorf with Jon Dahl Tomasson and Serginho respectively. Milan had the last chance before full-time but Kaka failed to direct Jaap Stam's header towards goal, meaning the final would go to extra time for the 13th time in the competition's history.


title: 2005 UEFA Champions League Final

text: Liverpool kicked off the first half of extra time. Pirlo had a chance in the early stages, but he put his shot over the crossbar. Tomasson came close in the later stages of the first period of extra time, but he could not make contact with the ball. Šmicer required treatment for cramp towards the end of the first period, as a number of Liverpool players felt fatigued. Liverpool had the most of the early exchanges after winning two corners, but could not score. Shortly afterwards, Milan made their final substitution, replacing Gennaro Gattuso with Rui Costa.


title: 2005 UEFA Champions League Final

text: The best chance of the second half of extra time came in the 117th minute (three minutes from penalties) when Shevchenko shot at goal. Dudek saved, only for it to rebound back out to Shevchenko, who again shot from under , which Dudek saved again, pushing the shot over the bar. Liverpool had one last chance at the end of extra time, but John Arne Riise's free kick was blocked, and following this the referee signalled the end of extra time, which meant a penalty shoot-out would decide the championship.


title: 2005 UEFA Champions League Final

text: Liverpool and Milan had each won their last European Cups after winning penalty shoot-outs, and it was also the second time in three years that the final would be decided this way; previously, in the 2003 all-Italian final at Old Trafford, Milan had defeated Juventus 3–2. Milan were first to take a penalty, but Serginho – who had taken Milan's first penalty in 2003 and scored – shot over the crossbar after attempts from Dudek to distract him, which mimicked Bruce Grobbelaar's "spaghetti legs" antics during the shootout in the 1984 final against Roma. Dietmar Hamann took Liverpool's first penalty and, despite having a broken toe, he scored to put Liverpool 1–0 up. Andrea Pirlo was next for Milan, and his penalty was saved by Dudek who dived low to his right. Cisse then scored his penalty to put Liverpool 2–0 up. Tomasson scored Milan's next penalty to make the score 2–1 in Liverpool's favour. Riise was next for Liverpool, but his penalty was saved by Dida. Kaká then scored the subsequent penalty to level the scores at 2–2. Šmicer took the next Liverpool penalty and scored with his eventual last competitive kick for Liverpool to put them on the brink of victory.


title: 2005 UEFA Champions League Final

text: Shevchenko, who had scored the decisive penalty against Juventus' Gianluigi Buffon in 2003, then had to score to keep Milan in the shootout. He hit his penalty straight down the middle of the goal and Dudek went down to his right, but blocked the shot with his left hand to give Liverpool a 3–2 win in the shoot-out.


title: 2005 UEFA Champions League Final

text: Liverpool's triumph marked their fifth European Cup and the first by an English team since Manchester United had defeated Bayern Munich in the 1999 final in Barcelona. By winning the European Cup for a fifth time, Liverpool earned the privilege of wearing a multiple-winner badge and the right to keep the trophy (under normal competition rules, the winning club can keep the trophy for only 10 months, as they must deliver it to UEFA two months before the next year's final). Liverpool were given ownership of the trophy every winner had held aloft since 1995 (after Milan were permanently given the previous trophy after their fifth win in 1994). The 2005–06 participants competed for a new identical trophy. The rule to keep the trophy, which had been in effect since the 1968–69 season, was changed for the 2009–10 season so that the actual trophy remained with UEFA at all times. Liverpool became the fifth and final club to be given this honour after Real Madrid, Ajax, Bayern Munich and Milan – all of whom had either won at least five times (six in Real Madrid's case) or three times consecutively.


title: 2005 UEFA Champions League Final

text: Liverpool celebrated their victory by parading the trophy around Liverpool in an open-top double-decker bus the day after the final. They were cheered by approximately 1 million supporters, with an estimated 300,000 fans located around St George's Hall – the final destination of the parade. Business experts estimated that one in five workers took time off following the victory. It was also estimated that Liverpudlians drank around 10,000 bottles of champagne after the match, with supermarket chain Sainsbury's stating: "We've never seen anything like it. We would usually expect to sell this much champagne at Christmas".


title: 2005 UEFA Champions League Final

text: Liverpool manager Rafael Benítez admitted after the match that the manner of his side's victory had stunned him and he stated: "My problem is that I don't have words to express the things that I feel at this moment". Praise for Liverpool also came from outside England, including from Argentine legend Diego Maradona, who said, "Even the Brazil team that won the 1970 World Cup could not have staged a comeback with Milan leading 3–0...The English club proved that miracles really do exist. I've now made Liverpool my English team. They showed that football is the most beautiful sport of all. You knew they could defend, but the team showed they could play too and wrote a page in the history books. The match will last forever. The Liverpool supporters didn't let me go to sleep the night before. There were 10 of them to every three Milan supporters. They showed their unconditional support at half-time when they were losing 3–0 and still they didn't stop singing."


title: 2005 UEFA Champions League Final

text: Benítez was also prepared to break up his winning side after the final with a number of players expected to leave the club to make way for new arrivals. One of those leaving was Vladimír Šmicer, who had scored Liverpool's second goal in Istanbul, and whose contract was known not to be renewed before the final, meaning he entered knowing the final was his last game for the club. Milan were similarly astonished at the manner in which they had lost the final. Manager Carlo Ancelotti said, "We had six minutes of madness in which we threw away the position we had reached until then". The result compounded Milan's failure to win Serie A a week before the match. Milan's vice-president, Adriano Galliani, played down the loss, asserting: "Even if we come second in the league, and second in the Champions League, this is not a disastrous season for us". Captain Paolo Maldini was less optimistic, stating that the reverse was a "huge disappointment", but he added that Milan would accept the defeat and "go out with their heads high".


title: 2005 UEFA Champions League Final

text: Much discussion after the final centered on the future of Liverpool captain Steven Gerrard who had been linked with a move to rivals Chelsea. Gerrard stated in the immediate aftermath of the victory, "How can I think of leaving Liverpool after a night like this?" Media reports then quoted Gerrard as saying he wished to leave Liverpool, citing events that had occurred in the month after the Champions League victory as the reason. On 6 July, however, Liverpool chief executive Rick Parry released a statement confirming that Gerrard would remain at the club, and Gerrard signed a new four-year contract on 8 July. He ultimately never played for another club in Europe, as he departed for the Los Angeles Galaxy of Major League Soccer a decade later.


title: 2005 UEFA Champions League Final

text: Despite winning the competition, Liverpool's place in next season's Champions League was still in doubt. Prior to the 2005 Champions League Final, The Football Association had decided on 5 May that only the top four finishers in the Premier League would qualify and Liverpool ended their domestic season in fifth place behind Everton. UEFA initially maintained that each country could only have four Champions League spots and suggested that the FA could nominate Liverpool instead of Everton. Liverpool faced a three-week wait to discover if they would be allowed to defend their title as all previous winners of the competition had done. UEFA came to a decision on 10 June, confirming that both Everton and Liverpool would be able to compete in the Champions League; however, Liverpool were entered into the first qualifying round, and were given no "country protection"; meaning they could face another English club at any stage of the competition. The UEFA Executive Committee also amended the regulations for future competitions so that the holders would have the right to defend their title and therefore qualify automatically, though at the expense of the lowest placed team in those countries that had more than one qualifier.


title: 2005 UEFA Champions League Final

text: As champions, Liverpool faced CSKA Moscow (winners of the 2005 UEFA Cup Final) in the 2005 UEFA Super Cup, held on 26 August. Liverpool won the match 3–1 after extra time. Liverpool's victory in Istanbul also meant they qualified for the 2005 FIFA Club World Championship. Liverpool beat Deportivo Saprissa 3–0 in the semi-final, and played Copa Libertadores champions São Paulo in the final, losing 1–0.


title: 2005 UEFA Champions League Final

text: Both teams retained a number of players who played in this final for the rematch in the 2007 final in Athens, which Milan won 2–1. Many players who played in this game also played for their clubs' legends teams, Liverpool Legends and Milan Glorie, in Liverpool's 2019 Legends Game at Anfield; Robbie Fowler and Cissé put Liverpool 2–0 up before Pirlo and Giuseppe Pancaro brought Milan level. Gerrard then scored in the final minute of play to give Liverpool a 3–2 win. The match raised an estimated £1 million for the LFC Foundation.


title: 2005 UEFA Champions League Final

text: In a 2011 poll conducted by "UEFA.com", Dudek's double save from Shevchenko in the 117th minute was voted the greatest Champions League moment of all time, ahead of Zinedine Zidane's left-footed volley against Bayer Leverkusen in the 2002 final and Ole Gunnar Solskjær's injury-time winner against Bayern Munich in 1999 for Manchester United. On the second save from inside 3 yards, Dudek wrote in his autobiography: "They called the 2005 Champions League final the 'Miracle of Istanbul'. Well, this was my miracle. The save of my career. Of my life." When asked to explain his saves after the game, an emotional Dudek said he took inspiration from Pope John Paul II (a fellow Pole and goalkeeper in his youth) who died in April, the month before the final. "I'm dedicating this to the memory of John Paul. I had contact with him during his life and I've felt the inspiration since his death. I can't account for it." Dudek dubbed it the "Hand of Pope", an allusion to Diego Maradona dubbing his infamous first goal in the 1986 World Cup quarter final the "Hand of God".


title: 2005 UEFA Champions League Final

text: The 2014 British comedy movie "One Night in Istanbul" is set in Istanbul on the night of the final, and includes some footage from the match.


title: 2005 UEFA Champions League Final

text: The 2011 British sports drama "Will" (starring Liverpool fan Damian Lewis) centres on the trials and tribulations in the lives of two main fictional characters: eleven-year-old Will Brennan and Bosnian footballer Alek, and their trek to see Liverpool play Milan in the 2005 Champions League Final.


title: 2005 UEFA Champions League Final

text: The final is discussed in author John Green's podcast "The Anthropocene Reviewed," and the essay was later adapted for the Green's book of the same name"."


title: Third-wave feminism

text: Third-wave feminism is an iteration of the feminist movement that began in the early 1990s, prominent in the decades prior to the fourth wave. Grounded in the civil-rights advances of the second wave, Gen X and early Gen Y generations third-wave feminists born in the 1960s and 1970s embraced diversity and individualism in women, and sought to redefine what it meant to be a feminist. The third wave saw the emergence of new feminist currents and theories, such as intersectionality, sex positivity, vegetarian ecofeminism, transfeminism, and postmodern feminism. According to feminist scholar Elizabeth Evans, the "confusion surrounding what constitutes third-wave feminism is in some respects its defining feature."


title: Third-wave feminism

text: The third wave is traced to the emergence of the riot grrrl feminist punk subculture in Olympia, Washington, in the early 1990s, and to Anita Hill's televised testimony in 1991 (to an all-male, all-white Senate Judiciary Committee) that African-American judge Clarence Thomas had sexually harassed her. The term "third wave" is credited to Rebecca Walker, who responded to Thomas's appointment to the Supreme Court with an article in "Ms." magazine, "Becoming the Third Wave" (1992). She wrote:


title: Third-wave feminism

text: Walker sought to establish that third-wave feminism was not just a reaction, but a movement in itself, because the feminist cause had more work ahead. The term "intersectionality"—to describe the idea that women experience "layers of oppression" caused, for example, by gender, race and class—had been introduced by Kimberlé Crenshaw in 1989, and it was during the third wave that the concept flourished. As feminists came online in the late 1990s and early 2000s and reached a global audience with blogs and e-zines, they broadened their goals, focusing on abolishing gender-role stereotypes and expanding feminism to include women with diverse racial and cultural identities.


title: Third-wave feminism

text: The rights and programs gained by feminists of the second wave served as a foundation for the third wave. The gains included Title IX (equal access to education), public discussion about the abuse and rape of women, access to contraception and other reproductive services (including the legalization of abortion), the creation and enforcement of sexual-harassment policies for women in the workplace, the creation of domestic-abuse shelters for women and children, child-care services, educational funding for young women, and women's studies programs.


title: Third-wave feminism

text: Feminist leaders rooted in the second wave such as Gloria E. Anzaldúa, bell hooks, Cherríe Moraga, Audre Lorde, Maxine Hong Kingston, and other feminists of color, sought to negotiate a space within feminist thought for consideration of race. Cherríe Moraga and Gloria E. Anzaldúa had published the anthology "This Bridge Called My Back" (1981), which, along with "All the Women Are White, All the Blacks Are Men, But Some of Us Are Brave" (1982), edited by Akasha (Gloria T.) Hull, Patricia Bell-Scott, and Barbara Smith, argued that second-wave feminism had focused primarily on the problems of white women. The emphasis on the intersection between race and gender became increasingly prominent.


title: Third-wave feminism

text: In the interlude of the late 1970s and early 1980s, the feminist sex wars arose as a reaction against the radical feminism of the second wave and its views on sexuality, therein countering with a concept of "sex-positivity" and heralding the third wave.


title: Third-wave feminism

text: Another crucial point for the start of the third wave is the publication in 1990 of "Gender Trouble: Feminism and the Subversion of Identity" by Judith Butler, which soon became one of the most influential works of contemporary feminist theory. In it, Butler argued against homogenizing conceptions of "women", which had a normative and exclusionary effect not only in the social world more broadly but also within feminism. This was the case not only for racialized or working-class women, but also for masculine, lesbian or non-binary women. Besides, she outlined her theory of gender as performativity, which posited that gender works by enforcing a series of repetitions of verbal and non-verbal acts that generate the "illusion" of a coherent and intelligible gender expression and identity, which otherwise lack any essential property. Lastly, Butler developed the claim that there is no resource to a "natural" sex, but that what we call such is always already culturally mediated, and therefore inseparable from gender. These views were foundational for the field of queer theory, and played a major role in the development of third-wave feminist theories and practices.


title: Third-wave feminism

text: The emergence of riot grrrl, the feminist punk subculture, in the early 1990s in Olympia, Washington, marked the beginning of third-wave feminism. The triple "r" in "grrrl" was intended to reclaim the word "girl" for women. Alison Piepmeier writes that riot grrrl and Sarah Dyer's "Action Girl Newsletter" formulated "a style, rhetoric, and iconography for grrrl zines" that came to define third-wave feminism, and that focused on the viewpoint of adolescent girls. Based on hard-core punk rock, the movement created zines and art, talked about rape, patriarchy, sexuality, and female empowerment, started chapters, and supported and organized women in music. An undated Bikini Kill tour flier asked "What is Riot grrrl?":


title: Third-wave feminism

text: Riot grrrl was grounded in the DIY philosophy of punk values, adopting an anti-corporate stance of self-sufficiency and self-reliance. Its emphasis on universal female identity and separatism often appeared more closely allied with second-wave feminism. Bands associated with the movement included Bratmobile, Excuse 17, Jack Off Jill, Free Kitten, Heavens to Betsy, Huggy Bear, L7, Fifth Column, and Team Dresch.


title: Third-wave feminism

text: Riot grrrl culture gave people the space to enact change on a macro, meso and micro scale. As Kevin Dunn explains:Using the do-it-yourself ethos of punk to provide resources for individual empowerment, Riot Grrrl encouraged females to engage in multiple sites of resistance. At the macro-level, Riot Grrrls resist society's dominant constructions of femininity. At the meso-level, they resist stifling gender roles in punk. At the micro-level, they challenge gender constructions in their families and among their peers.The demise of riot grrrl is linked to commodification and misrepresentation of its message, mainly through media coverage. Writing in "Billboard" magazine, Jennifer Keishin Armstrong states:


title: Third-wave feminism

text: El Hunt of "NME" states, "Riot grrrl bands in general were very focused on making space for women at gigs. They understood the importance of giving women a platform and voice to speak out against abusers. For a lot of young women and girls, who probably weren't following the Riot grrrl scene at all, The Spice Girls brought this spirit into the mainstream and made it accessible."


title: Third-wave feminism

text: In 1991, Anita Hill, when questioned, accused Clarence Thomas, an African-American judge who had been nominated to the United States Supreme Court, of sexual harassment. Thomas denied the accusations, calling them a "high-tech lynching". After extensive debate, the United States Senate voted 52–48 in favor of Thomas. In response, "Ms. Magazine" published an article by Rebecca Walker, entitled "Becoming the Third Wave", in which she stated: "I am not a post-feminism feminist. I am the third wave." Many had argued that Thomas should be acquitted because of his plans to create opportunities for people of color. When Walker asked her partner his opinion and he said the same thing, she asked: "When will progressive black men prioritize my rights and well-being?" She wanted racial equality but without dismissing women.


title: Third-wave feminism

text: In 1992, dubbed the "Year of the Woman", four women entered the United States Senate to join the two already there. The following year, another woman, Kay Bailey Hutchison, won a special election, bringing the number to seven. The 1990s saw the US's first female Attorney General (Janet Reno) and Secretary of State (Madeleine Albright), as well as the second woman on the Supreme Court, Ruth Bader Ginsburg, and the first US First Lady, Hillary Clinton, to have had an independent political, legal and activist career.


title: Third-wave feminism

text: Arguably the biggest challenge to third-wave feminism was that the gains of second-wave feminism were taken for granted, and the importance of feminism not understood. Baumgardner and Richards (2000) wrote: "[F]or anyone born after the early 1960s, the presence of feminism in our lives is taken for granted. For our generation, feminism is like fluoride. We scarcely notice that we have it—it's simply in the water."