Denying treatment to drug and alcohol-dependent patients.

There has been a concerted move in the West to reduce health care expenditure and multiple moves have been made to achieve these cost reductions. Many approaches have been taken including the restriction of services to subsets within the population. Drug and alcohol dependent patients have often been targeted as individuals and as groups who should not be seen as having equal access to certain forms of therapy. In this article it is argued that many of these decisions are inappropriate and in many instances they are not based on evidence which suggests that patients who are dependent may do just as well as non-dependent patients with some forms of treatment. It is argued that clinicians should regard each individual patient separately and make decisions that are appropriate to the clinical setting rather than taking a policy decision to restrict treatment to dependent individuals.

Factors affecting the yield of viable cells of Corynebacterium pseudotuberculosis in a liquid medium.

Growth of Corynebacterium pseudotuberculosis in an undefined liquid medium was studied with the aim of obtaining uniform, single-cell suspensions of the organism suitable for experimental infection. Adequate yields of viable cells were shown to be dependent on a fermentable substrate and a buffering system in a medium containing Tween 80. The development of Nutrient Tween 80 Broth for the culture of C. pseudotuberculosis is considered to be a significant advance particularly for studies involving animal inoculation.

The case for liver transplantation in end-stage alcoholic liver disease.

Liver transplantation is now a routine procedure and is seen as a valid treatment option for end-stage liver disease. Alcoholism has been regarded as a relative or absolute contraindication to liver transplantation in many transplant units. Recent data document a success rate for transplantation in alcoholic patients that equals that in other patient groups. Issues relating to the ethical and scientific arguments surrounding this complex area of treatment are discussed. It is concluded that individual patients should be assessed in their own right for this treatment option. It is argued that patient groups should not be denied access to specific life-saving treatments.

A 12-month prospective comparison of court-diverted with self-referred heroin users.

Forty-seven heroin users referred by the Drug and Alcohol Court Assessment Programme (DACAP) were compared with 45 self-referred heroin users at 12 months post-presentation. Data at presentation indicated distinct subpopulations were generated by each referral source. Differences were recorded in age, heroin use, marital status, educational level, employment history and age of onset of anti-social behaviour. The DACAP scheme exerted an earlier health intervention effect in a sample experiencing dysfunction in other areas, principally legally and socially. Prospective data demonstrated that both samples reported significant reductions in the proportion using heroin. Differences between samples evident at presentation were expressed prospectively, in rates of employment, incarceration and involvement in methadone maintenance programmes. The limitations of diverting clientele from the legal system to the treatment system is discussed in light of these results.

Hepatitis B.

Hepatitis B remains a major public health problem around the world. The discovery of the hepatitis C virus has diverted interest from hepatitis B to this new virus and the epidemic associated with it, but hepatitis B remains a significant pathogen for millions of people worldwide. The World Health Organization has suggested that universal vaccination of children against hepatitis B should be implemented in an attempt to reduce the enormous morbidity and mortality associated with infection of this virus group. The review seeks to identify all the newer discoveries relating to hepatitis B that have been made in the past decade. Reference is made to the appearance of hepatitis B mutants which are able to infect patients previously infected with the wild strain of the virus. The implications of mutants on vaccination programmes is raised, as are issues relating to treatment of hepatitis B infection.

The carbohydrate-deficient transferrin test in hospital practice.

We report an experience in two hospital populations of the use of a commercially available kit for the detection of carbohydrate-deficient transferrin (CDT). Patients from a drug and alcohol unit and a gastroenterology clinic at two hospitals were selected for the study. Sera were used from blood samples collected for routine biochemical assays. All patients had a specific alcohol history taken by one clinician and CDT results were correlated with reported alcohol intake by the patient and where relevant by their relatives. Sensitivity and specificity of the CDT assay were calculated using an alcohol intake of 60 g/day as the cut-off point for detection of heavy drinking. The CDT assay had a specificity of 95%; a sensitivity of 80% and a 90% positive and 89% negative predictive value. The severity and type of liver disease had little influence on the CDT result and a high alcohol intake was the only predictor of a raised CDT concentration. The assay provided information not available from routine investigations in some patients and also proved useful in monitoring patients over periods of up to 4 years. The test has a role in the evaluation of patients in a hospital practice where routine histories of alcohol intake may lack sensitivity and where other diseases may cause routine liver tests to be unreliable.

A 40 month follow-up of pregnant drug using women treated at Westmead Hospital.

A 40 month follow-up of 84 women admitted to a study of the outpatient management of pregnant heroin users is reported. Fifty-eight of the patients were on methadone at the time of their delivery while a further 26 remained on heroin at delivery. The whereabouts of 61 patients were identified at the time of follow-up but only 46 consented to interview. Twenty-three could not be traced even utilising the services of the Departments of Corrective Services and Community Services. The general health of mothers and babies was reported as good to excellent and only one child was in the care of the State. Many patients on methadone at delivery had exited the programme whereas those on heroin at delivery were likely to be on methadone programmes at follow-up. A majority of all patients had had no new legal charges laid in the 12 months preceding the interview and if any charges had been laid they were likely to be traffic offences. Drug use, on the other hand, continued to be a problem even in those on methadone programmes. Up to 75% of patients in one group reported intermittent use of heroin and other drugs and these self reports were confirmed by urine testing. The data suggest that methadone does lead to a reduction in criminal activity and in daily drug usage but it does not completely abolish drug seeking behaviour. Overall, the results suggest that the use of methadone is safe for mother and baby and it has positive benefit in the management of pregnant drug users.

Practical issues in the methadone management of pregnant heroin users.

Methadone management of pregnant heroin-using patients has become a standard approach to this particular population of patients. This paper discusses the establishment and running of an out-patient stabilization programme and highlights areas of difficulty experienced in this exercise. Guidelines are suggested for those who wish to establish such a service in the future.

Frequency and consequence of caseous lymphadenitis in sheep and lambs slaughtered at a Western Australian abattoir.

A total of 8,711 sheep in 3 distinct age/sex groups were examined to determine for occurrence and extent of caseous lymphadenitis after slaughter at a major Western Australian abattoir. An adaptation of current mean inspection procedures to provide a numerical weighted evaluation according to number, site, and size of lesions was used to determine extent of involvement. Frequency in slaughter populations was estimated to be 3.4 +/- 0.6% for lambs, 41.8 +/- 3.9% for mixed-age rams, and 53.7 +/- 1.5% for adult ewes at 95% confidence intervals. The results confirmed that frequency increased with age, but also revealed increases in extent of involvement and occurrence of visceral lesions, particularly in association with lesions of the body. Nevertheless, lesions occurred more frequently in the body than in the viscera. However, the mean visceral involvement was greater than mean body involvement in all groups, and the ratio was found to be more or less constant. Visceral involvement was found to be more extensive in rams than in ewes. Difficulties associated with complexity of current inspection procedures were also recorded. The relevance of these findings to pathogenesis and postmortem disposition after slaughter is discussed. It is suggested that current postmortem inspection criteria should be reevaluated.

Traditional Chinese medicine prevents inflammation in CCl4-related liver injury in mice.

Alternative medicines are being increasingly used and investigated in the management of a variety of disorders. Hepatitis is a common indication for the use of alternative therapies but evidence for the efficacy of many compounds is lacking. We have utilized a well-defined model of liver injury to study the efficacy of three herbal products designed to assist in the management of liver disease. Mice were exposed to carbon tetrachloride (CCL4) given intragastrically after they had been pretreated for five days with either saline or one of four doses of silymarin extract or CH100 (a Chinese herbal medicine comprising of 19 herbs) or one of two doses of CH101 (a Chinese herbal preparation designed to reduce fibrosis). Animals were sacrificed 24 hours after receiving CCL4. Liver enzymes and hepatic histology formed the basis for evaluating efficacy of the treatments. Each of the alternative medicines reduced the alanine amino transferase (ALT) elevation demonstrated after CCL4 injection. The high dose CH100 regimen was most effective in protecting against injury and this was confirmed with hepatic histology. Other doses of CH100, CH101 and silymarin were not shown to provide protection against the histological damage. In conclusion, Silymarin, CH100 and CH101 are able to reduce ALT elevation in animals exposed to CCL4. High dose CH100 provides protection from hepatocyte necrosis in this model. The data add to our understanding of the capacity some herbal medicines have to modify the reaction of the liver to a variety of insults and suggest the value of studying these agents further in human liver diseases.

Pathogenesis of caseous lymphadenitis in sheep and goats.

The progress of caseous lymphadenitis in sheep and goats is described as involving primary wound infection, lymphatic and haematogenous dissemination, and secondary infection of lymph nodes and various visceral organs. This is followed by elimination or containment of infection, the latter being represented by the characteristic caseous lesions. Resistance to infection is complex involving components of both the specific and non-specific host response. The role of these in pathogenesis is discussed. Bacterial factors including the phospholipase exotoxin and cytotoxic lipid contribute to pathogenesis at a local level with little likelihood of systemic effect in the natural disease. In a disease such as caseous lymphadenitis, lesion site, size or number do not indicate severity of disease but rather, reflect the ability of the host to mount a cellular response to infection.

The isolation of Bordetella bronchiseptic from an outbreak of canine pneumonia.

This report describes an outbreak of bronchitis and bronchopneumonia among young dogs in a breeding kennel following the introduction of two pups from another area. Bordetella bronchiseptica was isolated in heavy culture from affected animals which responded well to antibacterial therapy. There was no evidence of distemper virus involvement. Important bacteriological properties of Bord. bronchiseptica are discussed particularly as they relate to its known pathogenicity in the young of several species of animal. During the outbreak reported, it was noted that only young pups were clinically affected and it is suggested that Bord. bronchiseptica may be pathogenic in a certain age-group within the canine population. This seems to require further investigation.

Prevalence and distribution of caseous lymphadenitis in feral goats.

A total of 2,920 feral goats from pastoral areas of Western Australia were examined and the prevalence of caseous lymphadenitis was estimated to be 7.8 +/- 0.9% in goats presented for slaughter. Head, body and visceral lesions were present in 49.3%, 46.7% and 12.3% of affected goats, respectively. A comparison with previously reported data from sheep has been made and significant differences are discussed. Lung lesions were relatively uncommon in goats, whereas the distribution of carcase lesions was similar between the species. Multiple lesions appear to be less common in goats than in sheep.

Alcohol and the liver. A review of pathogenetic mechanisms and newer treatment approaches.

A great deal has been learned about the hepatotoxicity of ethanol in the past two decades. Possible mechanisms of hepatic damage have been elucidated in animal and human experimental situations, and much has been learned about those factors which may hasten or facilitate the production of liver injury. All the answers to the difficult question of individual susceptibility have yet to be provided. Some progress has been made in the management of alcohol related liver injury, but again much more needs to be made. Abstinence remains the cornerstone of therapy in patients with alcoholic hepatitis and cirrhosis. The roles of colchicine, amino-acid therapy and propylthiouracil are still being determined. The most important message for the physician in 1983 remains: Prevent alcohol related liver disease.