Alcohol liaison in action. The Canterbury experience.

In the changing health service, cooperation between disciplines is essential and innovation important to improve the service for people whose health is at risk or damaged. We describe our response to the challenge of liaison between different disciplines when faced with a multifaceted problem that needs the contribution of medical and psychiatric teams and community workers. Although this method of work has been applied to alcohol misuse, it could also be applied to other clinical problems. Liaison can be successful if these is an identified need and the different groups share a desire to work together. To stimulate the liaison and maintain momentum there need to be driving forces, be they clinical, practical or economic, also a shared philosophy and language, a conceptual base in the care of that group of patients, mutual respect and agreed working arrangements. Psychiatry and medicine operating together can ensure that these patients are treated with fairness and respect. They can tap into resources not easily available to either discipline separately, and so create original and exciting services. They can discover other agencies and individuals in their communities who will cooperate with them in obtaining funds and in pressurising statutory bodies to develop much needed services.

Prevalence of dyspepsia: the epidemiology of overlapping symptoms.

Studies of the epidemiology of dyspepsia have been complicated by the use of different symptom definitions, subject populations and time frames of investigation. Published figures for the prevalence of dyspepsia vary from 20% to 40%, of which perhaps only a quarter can be attributed to peptic ulcer disease. General practitioners see only a fraction of the dyspepsia within the community, the majority of which is either ignored or treated by self-medication. However, dyspepsia still accounts for about 3-4% of all general practice consultations and for about 14% of all patients attending. In about half of all cases, even extensive investigation reveals no underlying organic lesion. There has been much recent interest in the clinical value of grouping dyspeptic symptoms into particular subtypes. These have been called ulcer-like, dysmotility-like and reflux-like. Although these patterns have descriptive value, there is no evidence that they result from discrete pathophysiological processes. Indeed, studies both in general practice and in the community show a large degree of overlap between them.

Detection of antibodies to acetaldehyde-albumin conjugates in alcoholic liver disease.

The principal metabolite of ethanol, acetaldehyde, conjugates with various proteins that form antibody-inducing neo-antigens. We have analysed sera from patients with biopsy-proven alcoholic liver disease (hepatitis = 10, cirrhosis = 11, steatosis = 3) and controls = 19 (normal teetotallers and 6 non-alcoholic liver disease). Sera were examined with an enzyme-linked immunoabsorbent assay (ELISA) for antibodies binding preferentially to an acetaldehyde-albumin conjugate. Reactive sera from alcohol misusers were then purified using an amino-hexyl Sepharose affinity column. Antibodies binding to the acetaldehyde-albumin epitopes were significantly raised (P < 0.005) in all groups of alcohol misusers, and were present in greatest titre in those with alcoholic hepatitis. These antibodies were successfully purified using the gel affinity column. We conclude that alcohol misusers have significant titres of antibodies reacting to the acetaldehyde-albumin complex. The role of these antibodies remains nuclear, but may be related to the initiation of an inflammatory response and tissue damage following ethanol consumption.

Rapid onset of blindness due to meningeal carcinomatosis from an oesophageal adenocarcinoma.

We report a 49 year old man who presented with left leg weakness, frontal headache, impaired concentration and dysphagia. He was thought to have a benign oesophageal stricture on barium swallow and oesophagoscopy though this was not initially biopsied. During admission his vision deteriorated so that he could only recognize bright light. Repeat oesophagoscopy demonstrated an oesophageal adenocarcinoma. The diagnosis of meningeal carcinomatosis was confirmed at post-mortem. Sudden bilateral blindness is a common feature of meningeal carcinomatosis but, as this is rare, it is not commonly considered in the differential diagnosis of visual loss. The visual loss can be explained by vascular insufficiency in association with tumour cuffing of the subarachnoid space of the optic nerve sheath, by neuronal toxins, or other, as yet unknown, mechanisms.

Serum CA 12-5 concentrations and CA 12-5/CEA ratios in patients with epithelial ovarian cancer.

In attempts to increase the specificity of the CA 12-5 test the ratio of CA 12-5 and CEA concentrations has been determined in 155 cancer patients, all of whom had an increased serum CA 12-5. The patients included 47 with epithelial ovarian cancer, 38 with colorectal cancer, 24 with cervical cancer, 20 with lung cancer, 17 with gastric cancer, and 9 with pancreatic cancer. The CA 12-5/CEA ratio in serum of patients with ovarian cancer ranged from 30 to 920 (mean 251), whereas in other types of cancer the highest ratio was 240 and the mean was 13. All 47 patients with ovarian cancer, but only 7 of the 108 patients with other types of cancer, showed a CA 12-5/CEA ratio greater than 25. About 10% of the patients with gastric or colorectal cancer but none of those with other types of cancer showed an increased ratio. As the predictive value of a CA 12-5/CEA ratio of less than 25 excluding ovarian cancer is 100%, we recommend measuring the CEA concentration in all those with increased CA 12-5 and calculation of the CA 12-5/CEA ratio.

Liver scintiscanning as a screening test in the detection of alcoholic cirrhosis.

Ninety-nine patients with alcohol related problems underwent a liver scintiscan and biopsy. The scan changes were graded and compared with the histological changes found from percutaneous liver biopsy. The overall correlation between scan and biopsy changes was poor. However, scintiscanning was found to be highly sensitive (90%) in detecting cirrhosis and for this reason is useful as a screening test in selecting alcoholic patients for biopsy.

Chemotherapy in pancreatic cancer: results of a controlled, prospective, randomised, multicentre trial.

Forty patients with inoperable pancreatic cancer were included in a prospective, randomised, controlled trial of multiple chemotherapy. The survival of 19 untreated control patients was compared with that of 21 patients who received an initiation course of intravenous fluorouracil, cyclophosphamide, methotrexate, and vincristine given over five days followed by intravenous fluorouracil and mitomycin given over three or five days at six-week intervals thereafter. Median survival in treated patients was 44 weeks, which was significantly longer than the nine weeks seen in controls. In patients without metastases median survival was 48 weeks in the treated group and 12 weeks in controls. In patients with metastases it was 30 weeks in treated patients and seven weeks in controls. The treatment was well tolerated and seemed to confer a significant prolongation of survival, comparing favourably with previous reports of chemotherapy with or without radiotherapy. If the results are confirmed this regimen may be useful in district general hospital practice.

Liver damage due to perhexiline maleate.

Two middle-aged men, who had received perhexiline in recommended dosage, showed clinical and histological evidence of severe hepatic damage, and one of them died. Histological study of the livers showed a striking resemblance to alcoholic hepatitis.

Chemotherapy in advanced gastric cancer: a controlled, prospective, randomised multi-centre study.

Seventy-six patients with advanced gastric adenocarcinoma were studied in a prospecitive, randmoised, controlled trial using vincristine, methotrexate, cyclophosphamide, and 5-fluorouracil in an initiation course and mitomycin-C with 5-fluorouracil as maintenance therapy. Thirty-seven patients were inoperable and 39 had the primary tumour resected with histological evidence of residual disease. Survival in the inoperable group was short and showed no significant difference between treated and control patients. The median survival times for treated and control groups were 9.5 and 9.0 weeks respectively. In the resected patients there was no difference in ultimate overall survival between the groups but up to 20 weeks there was a suggestion that the probability of survival in treated patients was higher (P = 0.06). The patients were well-matched and it is concluded that chemotherapy has had an early effect but that a further trial with more detailed stratification, particularly of staging and histological grade, is needed. No patient received treatment for longer than two years and unacceptable toxicity occurred in only two patients. Nausea occurred more frequently in the treated group but was short-lived and clinically manageable.

A case of Mollaret's meningitis associated with a lymphoma.

A patient with recurrent benign meningitis (Mollaret's meningitis) responding to treatment with colchicine by a reduction in frequency of attacks who has subsequently developed a non-Hodgkin's lymphoma is described.

Malignant carcinoid tumour with gangrene of the small intestine.

Four patients with a malignant carcinoid tumour of the small bowel (three had the carcinoid syndrome) developed gangrene of the small intestine. Attention is drawn to this seldom recognized complication, as early surgery may be life saving.

Experimental hepatic necrosis: studies on coagulation abnormalities, plasma clearance, and organ distribution of 125I-labelled fibrinogen.

Studies in the rat with hepatic necrosis induced by carbon tetrachloride showed that the abnormalities in one-stage coagulation tests and the increased catabolism of fibrinogen were similar to those found in man with acute viral or drug-induced hepatic necrosis. Determination of the distribution of the radioactive label shows that excessive deposition was maximal in the liver but also occurred in the spleen. The appearance is delayed by heparin but accelerated by tranexamic acid.