Human Rights and Review of the Involuntary Status of Patients with a Mental Illness: Kracke after Momcilovic

Arguably, Australia's most significant judicial pronouncement on the human rights of those with mental illnesses was made in 2009 by Justice Bell, the then President of the Victorian Civil and Administrative Tribunal (“VCAT”). The decision is an exhaustive analysis of the application of the Charter of Human Rights and Responsibilities Act 2006 (Vic) to the involuntary status of a person subject to a community treatment order in Victoria. It occurred in the context of delays in the conduct of reviews of the status of a mentally ill person by Victoria's Mental Health Review Board (“the Board”). The outcome of the hearing was a declaration that the Board had breached the person's human rights to a fair hearing, even though the person's involuntary status on a community treatment order was not disturbed by VCAT. Whilst some important aspects of Justice Bell's decision concerning the general methodology to be applied when analysing human rights were overturned in the subsequent Court of Appeal decision of R v Momcilovic [2010] VSCA 50, the latter decision did not concern mental health and so leaves Kracke as the most detailed articulation and analysis of human rights within this difficult sphere.     

Sexual Surrogate Partner Therapy: Legal and Ethical Issues

The Ben Lewin film The Sessions has drawn attention again to the potential role for sexual surrogate partners and sex workers in enabling persons with disabilities and impairments to give expression to their sexual needs and desires. However, away from the big screen, the ethics of registered health practitioners in themselves engaging in such therapies are highly problematic. Difficult too is the role of such practitioners in being ‘the therapist’ responsible for enabling or brokering sexual contact between their patients and those offering such services for financial reward. In some jurisdictions, arrangements involving sexual surrogate therapy (especially where the therapist benefits from it financially) may not be lawful. Further, in spite of many assertions one way and the other, there are no data enabling evaluation of the success rates of the interventions of sexual surrogates or sex workers. Whether positive outcomes to such interactions are likely in most circumstances, given that the provision of services is predicated upon idealised attachments, is questionable. It is also unclear whether sexual surrogates’ adherence to an ethical code effectively ameliorates the potential for counter-therapeutic consequences from the commodification of intimacy, and it is far from straightforward to identify what steps should be taken by the referring health practitioner to select a suitable provider of sexual services to their patient or client, and then to monitor whether the arrangement is achieving its objectives.     

Microbial contamination assessment of cryostored autogenous cranial bone flaps: should bone biopsies or swabs be performed?

Background

Autogenous cranioplasty infection requiring bone flap removal is under-recognised as a major complication causing significant morbidity. Microbial contamination of stored bone flaps may be a significant contributing factor. Current infection control practices and storage procedures vary. It is not known whether ‘superficial’ swabs or bone cultures provide a more accurate assessment.

Method

Twenty-five skull flaps that were cryo-stored for more than 6 months were studied. Two swab samples (superficial and deep) and a bone biopsy sample were taken from each skull flap sample and cultured. Half blood agar and half chocolate agar plates were inoculated with the swabs for anaerobic and aerobic cultures respectively. The bone biopsy samples were cultured in brain-heart broth and subcultured similar to the swabs for 5 days.

Results

Incidence of microbial contamination was 20 % in the bone flaps studied. One swab culture and five bone biopsy cultures were positive for bacterial growth, all of which contained Propionibacterium acnes (p?=?0.014). Positive cultures were from bone flaps stored less than 18 months, whereas no growth was obtained from bone flaps that were stored longer (p?=?0.014).

Conclusions

Bone biopsy culture is a more sensitive technique of assessing microbial contamination of cryo-stored autogenous bone flaps than swab cultures. The clinical implications of in vitro demonstration of microbial contamination require further study.     

Familial pattern of corticosteroids and their metabolism in adult human subjects--the Scottish Adult Twin Study

Corticosteroids are important in the regulation of normal physiology and are key factors in regulating cardiovascular physiology and disease, the development of which is known to have a genetic component. However, there is little information on the extent to which plasma and urine steroid levels are determined by familial and genetic factors. We have examined basal and ACTH-stimulated plasma steroid levels and 24-h corticosteroid metabolite excretion rates in 146 pairs of adult twins [75 monozygotic (MZ); 71 dizygotic (DZ)]. Intraclass correlation coefficients were measured for all variables; several plasma steroid measurements were strongly related in both (MZ) and (DZ) twins, consistent with a familial pattern. These included basal levels of 11-deoxycortisol and aldosterone. ACTH-stimulated plasma aldosterone levels were also significantly correlated, to a significant degree, in both MZ and DZ twins. The index of 11beta-hydroxysteroid dehydrogenase activity (tetrahydrocortisol + allotetrahydrocortisol/tetrahydrocortisone) and of the more specific index of activity of the type 2 isoform of this enzyme (urine free cortisol/cortisone) also correlated, to a similar degree, in DZ and MZ twins. In contrast, for the basal and ACTH-stimulated plasma concentrations and 24-h urine excretion rates of several corticosteroids, there was evidence of significant heritability (H2), in that correlation in MZ twins was greater than in DZ. For example, basal plasma corticosterone concentrations (B) (H2 = 0.44), basal and stimulated 11-deoxycorticosterone concentrations (DOC) (H2 = 0.44 and 0.41, respectively), stimulated 11-deoxycortisol concentrations (H2 = 0.53), and the index of 11beta-hydroxylase activity DOC/B (H2 = 0.49) were all significantly heritable. For the urinary variables, 24-h tetrahydrodeoxycortisol (H2 = 0.59) and free aldosterone (H2 = 0.56) were significantly heritable. Our data provide the first evidence that plasma and urine levels of important glucocorticoids and mineralocorticoids show a strong familial pattern, and in some instances, there is evidence of a genetic component to this. This suggests that corticosteroids have a plausible role in essential hypertension that has a similar heritable component.     

Interleukin-6 enhances growth factor-dependent proliferation of the blast cells of acute myeloblastic leukemia

The effects of recombinant interleukin-6 (IL-6) on the proliferation of blast precursors present in the peripheral blood of patients with acute myeloblastic leukemia (AML) was investigated. IL-6 had little effect by itself; however, it synergized with granulocyte macrophage colony- stimulating factor (GM-CSF) and interleukin-3 (IL-3) in the stimulation of AML blast colony formation. Responsiveness of blast progenitors to IL-6 was heterogeneous. On normal bone marrow cells the same synergy was observed on granulocyte and monocyte precursors (GM-CFC), while there was no significant effect on erythroid and multipotential precursors.