Early identification of alcohol abuse: 2: Clinical and laboratory indicators.

Despite awareness of the wide variety of clinical and laboratory abnormalities associated with alcohol abuse, drinking problems often remain undetected in hospital and in general medical practice. The diagnosis of alcohol abuse has been emphasized repeatedly in the literature but far less attention has been paid to indicators that would permit detection of excessive drinking at a stage when intervention might be more effective and less costly. The search for indicators of early alcohol abuse is complicated since many of the medical sequelae of alcoholism are nonspecific and may only be manifested after a number of years of excessive drinking. Part 2 of this two-part series considers various clinical and laboratory features related to alcohol abuse and highlights items that are potentially more sensitive for detecting early stages of problem drinking. Use by physicians of a composite profile of both biomedical and psychosocial indicators of excessive alcohol consumption is recommended for early identification of this problem.     

Glycoconjugates in the detection of alcohol abuse

Up to 30% of all hospital admissions and health-care costs may be attributable to alcohol abuse. Ethanol, its oxidative metabolites, acetaldehyde and ROS (reactive oxygen species), non-oxidative metabolites of alcohol [e.g. FAEEs (fatty acid ethyl esters)] and the ethanol-water competition mechanism are all involved in the deregulation of glycoconjugate (glycoprotein, glycolipid and proteoglycan) metabolic processes including biosynthesis, modification, transport, secretion, elimination and catabolism. An increasing number of new alcohol biomarkers that are the result of alcohol-induced glycoconjugate metabolic errors have appeared in the literature. Glycoconjugate-related alcohol markers are involved in, or are a product of, altered glycoconjugate metabolism, e.g. CDT (carbohydrate-deficient transferrin), SA (sialic acid), plasma SIJ (SA index of apolipoprotein J), CETP (cholesteryl ester transfer protein), β-HEX (β-hexosaminidase), dolichol, EtG (ethyl glucuronide) etc. Laboratory tests based on changes in glycoconjugate metabolism are useful in settings where the co-operativeness of the patient is impaired (e.g. driving while intoxicated) or when a history of alcohol use is not available (e.g. after trauma). In clinical practice, glycoconjugate markers of alcohol use/abuse let us distinguish alcoholic from non-alcoholic tissue damage, having important implications for the treatment and management of diseases.     

Carbohydrate deficient transferrin: a marker for alcohol abuse.

OBJECTIVE--To assess the value of serum carbohydrate deficient transferrin as detected by isoelectric focusing on agarose as an indicator of alcohol abuse. DESIGN--Coded analysis of serum samples taken from patients with carefully defined alcohol intake both with and without liver disease. Comparison of carbohydrate deficient transferrin with standard laboratory tests for alcohol abuse. SETTING--A teaching hospital unit with an interest in general medicine and liver disease. PATIENTS--22 "Self confessed" alcoholics admitting to a daily alcohol intake of at least 80 g for a minimum of three weeks; 15 of the 22 self confessed alcoholics admitted to hospital for alcohol withdrawal; 68 patients with alcoholic liver disease confirmed by biopsy attending outpatient clinics and claiming to be drinking less than 50 g alcohol daily; 47 patients with non-alcoholic liver disorders confirmed by biopsy; and 38 patients with disorders other than of the liver and no evidence of excessive alcohol consumption. INTERVENTION--Serial studies performed on the 15 patients undergoing alcohol withdrawal in hospital. MAIN OUTCOME measure--Determination of relative value of techniques for detecting alcohol abuse. RESULTS--Carbohydrate deficient transferrin was detected in 19 of the 22 (86%) self confessed alcohol abusers, none of the 47 patients with non-alcoholic liver disease, and one of the 38 (3%) controls. Withdrawal of alcohol led to the disappearance of carbohydrate deficient transferrin at a variable rate, though in some subjects it remained detectable for up to 15 days. Carbohydrate deficient transferrin was considerably superior to the currently available conventional markers for alcohol abuse. CONCLUSION--As the technique is fairly simple, sensitive, and inexpensive we suggest that it may be valuable in detecting alcohol abuse.     

Early identification of alcohol abuse: 1. Critical issues and psychosocial indicators for a composite index.

Traditional approaches to the medical management of alcohol-related disorders have met with limited success in altering the prevalence of alcohol abuse. Evidence suggests that identifying early those who drink to excess and intervening with low-cost educational and motivational programs could significantly reduce the prevalence of alcohol-related disabilities. However, physicians must take systematic steps to detect alcohol abuse. Part 1 of this two-part series discusses the need for early identification of individuals who drink to excess and the factors that may either facilitate or hinder the development of effective programs for detecting alcohol abuse. A profile is given of important psychosocial indicators of alcohol abuse, including the classic signs of alcohol abuse, the early manifestations of heavy drinking, the predisposing or high-risk factors for alcohol abuse, and the precipitating events and correlated habits of excessive drinking.     

Prevalence of and risk factors associated with alcohol abuse in Moshi, northern Tanzania

This study aimed to assess the prevalence of and risk factors associated with alcohol abuse among women and men in Moshi in northern Tanzania. Alcohol abuse was measured by a CAGE score of 2-4, versus 0-1 for no alcohol abuse (Ewing, 1984). Crude and adjusted logistic regression models determined odds ratios (OR) and 95% confidence intervals (95% CI) of alcohol abuse by characteristics of, respectively, women with partners (n=1200), women without partners (n=614) and men (n=788) (women's partners). Prevalence of alcohol abuse was 7.0% (95% CI: 5.6-8.4) among women with partners, 9.3% (95% CI: 7.0-11.6) among women without partners, and more than double among men at 22.8% (95% CI: 19.9-25.8). In general, Christians had higher alcohol abuse than Muslims or other religions, as did Chagga men compared with men of other ethnic groups. Other socio-demographic characteristics, such as education or income, were not significant. Sexual behaviours were significant predictors of alcohol abuse. For example, women without partners who reported more than two partners in the last year had higher alcohol abuse compared with women reporting no partners (OR=8.75; 95% CI: 2.37-32.31), as did men reporting it is 'OK to hit a partner' for any reason (OR=1.79; 95% CI: 1.16-2.77) compared with men who did not. HIV-1 infection was not significantly associated with alcohol abuse by women or men. The Christian Church in Moshi should consider raising awareness about the harmful effects of high alcohol use among its adherents. Comprehensive programmes focusing on reducing number of partners and alcohol use, particularly by men, are needed in this community.     

Efficacy of the alcohol use disorders identification test as a screening tool for hazardous alcohol intake and related disorders in primary care: a validity study.

OBJECTIVE: To determine the properties of the alcohol use disorders identification test in screening primary care attenders for alcohol problems. DESIGN: A validity study among consecutive primary care attenders aged 18-65 years. Every third subject completed the alcohol use disorders identification test (a 10 item self report questionnaire on alcohol intake and related problems) and was interviewed by an investigator with the composite international diagnostic interview alcohol use module (a standardised interview for the independent assessment of alcohol intake and related disorders). SETTING: 10 primary care clinics in Verona, north eastern Italy. PATIENTS: 500 subjects were approached and 482 (96.4%) completed evaluation. RESULTS: When the alcohol use disorders identification test was used to detect subjects with alcohol problems the area under the receiver operating characteristic curve was 0.95. The cut off score of 5 was associated with a sensitivity of 0.84, a specificity of 0.90, and a positive predictive value of 0.60. The screening ability of the total score derived from summing the responses to the five items minimising the probability of misclassification between subjects with and without alcohol problems provided an area under the receiver operating characteristic curve of 0.93. A score of 5 or more on the five items was associated with a sensitivity of 0.79, a specificity of 0.95, and a positive predictive value of 0.73. CONCLUSIONS: The alcohol use disorders identification test performs well in detecting subjects with formal alcohol disorders and those with hazardous alcohol intake. Using five of the 10 items on the questionnaire gives reasonable accuracy, and these are recommended as questions of choice to screen patients for alcohol problems.     

Red cell morphology in alcoholics: a new test for alcohol abuse

Scanning electron microscopy has shown that the blood of alcoholics contains a large number of morphologically abnormal red cells. In two groups of alcoholics, the number of morphologically abnormal red cells ranged from 23.1% to 89.3% and 27.4% to 57.3% of total red cells compared to values in healthy controls of 4.5%-12.6% and 27.7%-79.5% in nonalcoholic liver disease patients. A characteristic finding was the presence of triangulocytes: these ranged from 1.2% to 18.0% of total red cells in the alcoholics as compared to 0-0.5% in healthy controls, and 0-1.3% in patients with nonalcoholic liver disease. The presence of elevated numbers of triangulocytes in blood appears to be specific to alcohol abuse. It is not, for example, elevated in nonalcoholic liver disease. No correlation was found between the number of triangulocytes or the number of morphologically abnormal red cells in blood and either the duration of alcohol abuse or the amount of alcohol consumed. Both parameters tended, however, to return to normal values during withdrawal. The mechanism by which alcohol abuse causes the morphologic abnormalities is not known. Preliminary in vitro experiments indicate that it is unlikely to arise as an effect of alcohol on circulating red cells. Based on the data presented, the measurement of the number of triangulocytes in a blood sample, although slow and laborious, may provide a highly specific test for alcohol abuse.     

A parametric comparison of diagnostic accuracy with three ordinal diagnostic groups

Many medical diagnostic studies involve three ordinal diagnostic groups in which the diagnostic accuracy can be summarized by the volume or partial volume under a Receiver Operating Characteristic (ROC) surface. We study in this paper the statistical comparison of diagnostic accuracy from multiple diagnostic tests when three ordinal diagnostic groups are involved. Under the assumption that the multiple diagnostic tests follow a multivariate normal distribution within each diagnostic group, we provide the asymptotic variance and covariance for the maximum likelihood estimates of the volumes under the ROC surfaces from multiple diagnostic tests and propose statistical tests to test whether the diagnostic accuracy as measured by the volume under the ROC surface is the same for multiple diagnostic tests. We also propose a confidence interval estimate to the difference of two volumes under two ROC surfaces. Our approach depends crucially on the assumptions of normal distributions on diagnostic tests, which might not be robust when such assumptions are violated. Finally, we apply our proposed methodology to a real data set of 118 subjects to compare the diagnostic accuracy of early stage Alzheimer's disease (AD) from multiple neuropsychological tests.     

Phytotherapeutic approach to alcohol dependence: New old way?

Alcohol abuse and dependence represent a worldwide problem from both medical and social points of view. In Italy it is estimated that there are about one million alcohol-dependent subjects. The pharmacological treatment of patients with alcohol dependence plays a key role in order to achieve alcohol abstinence and prevent relapse. At present, the possible utility of the complementary medicines in the treatment of alcohol dependence is controversial. In the last years, pre-clinical and clinical data from traditional medicines suggest that novel pharmacological approaches for treatment of alcoholism and alcohol abuse may stem from natural substances. The present review summarizes the findings of the effects of phytotherapy in alcohol addiction.     

不明原因发热的临床综合诊断

不明原因发热是临床常见疑难疾病,其定义随着疾病种类的不断变化及诊断流程的进步而逐步完善。不明原因发热(feverof unknown origin,FUO)病因包括感染性疾病、风湿免疫性疾病及肿瘤性疾病三大类,三大病因各自具有不同临床特征。详细病史采集、全面体格检查及常规实验室检查对诊断FUO至关重要,必要时应及时进行相关影像学及病理学检查,疾病的最终诊断应综合分析病史及实验室检查。     

Basic research on heredity and alcohol: Implications for clinical application

Abstract

Alcoholism has been described as a behavioral condition comprised of symptoms of alcohol dependence and the psycho‐socio‐biologic consequences of chronic alcohol dependence. Progress in clarifying the role of genetic factors in explaining differences in onset of dependence upon alcohol, frequency of consequences of chronic alcohol use, and transmission of patterns of alcoholism within a family pedigree has been based upon use of diagnostic methods that reliably and validly separate alcohol dependence from alcohol abuse. Twin methods, which control for genotypic variation, and adoption studies, which control for differences in rearing, have provided significant support for a genetic vulnerability hypothesis for development of alcoholism and a genetic heterogeneity hypothesis for type of alcoholism. The author reviews data from basic and clinical investigation of two subtypes of alcoholism: one associated with antisocial personality, and one that is “familial” (family‐history‐positive alcoholism). Significant differences in onset and clinical course for these subtypes suggest that differential plans for matching treatment to the individual alcoholic may be warranted.     

Fetal alcohol spectrum disorders among children in a Brazilian orphanage

Background: The objective was to investigate the frequency of fetal alcohol spectrum disorders (FASD) and ophthalmologic anomalies in orphanage children in Brazil. Methods: A prospective study was performed on 94 children living in an orphanage in Brazil. The children were examined by a multidisciplinary team consisting of specialists in pediatrics, neurology, psychology, neuropsychiatry, and ophthalmology. Results: The main reasons for living in the orphanage, in 61% of the children, were negligence, child abuse, and abandonment. Of all the children studied, 50% had mothers with known alcohol abuse and 47% had one or more diagnoses of neurodevelopmental/behavioral and/or cognitive deficits. General developmental delay was found in 18%, intellectual disability in 3%, cognitive impairment in 27%, attention‐deficit/hyperactivity disorder in 14%, and autism in 3%. Altogether 17% had FASD, comprising three children with fetal alcohol syndrome (FAS), six with partial FAS, and seven with alcohol‐related neurodevelopmental disorder. 16% had ophthalmological findings such as poor vision, strabismus, and dysmorphology of the optic nerves. Twenty‐eight children (30%) were adopted from the orphanage; of these, six had FASD (two FAS, three partial FAS, one alcohol‐related neurodevelopmental disorder), five had attention‐deficit/hyperactivity disorder, and eight had developmental delay. Conclusion: Nearly half of the children living in the orphanage had neurodevelopmental disorders and a considerable number showed signs of damage from prenatal alcohol exposure. A broader look at the problem of FASD in Brazil and other South American countries is desirable to document the burden of disease and provide data for targeting prevention efforts. Birth Defects Research (Part A) 103:178–185, 2015. © 2014 Wiley Periodicals, Inc.     

Determining undergraduate curriculum content in plastic surgery

The purpose of this study was to determine the cognitive knowledge and clinical skills related to plastic surgery that are essential for inclusion in an undergraduate curriculum. A questionnaire was distributed to surgical clerkship directors, plastic surgeons, and 1980 graduates of four medical schools. Respondents were asked to rate (0-3) the importance of 74 knowledge items and 28 clinical skills in relation to the knowledge/proficiency necessary for students to achieve prior to graduating from medical school (0 = unnecessary, 3 = indepth knowledge/proficiency important). Results of the questionnaire enabled the determination of mean response scores and the hierarchical ranking of questionnaire items. There was a high degree of correlation between the rankings of the three groups of respondents indicating agreement on knowledge and clinical skills in plastic surgery that are essential, as well as those nonessential, for the competent practice of medicine.     

Clinical disease and laboratory abnormalities in free-ranging desert tortoises in California (1990-1995)

Desert tortoise (Gopherus agassizii) populations have experienced precipitous declines resulting from the cumulative impact of habitat loss and human and disease-related mortality. Diagnosis of disease in live, free-ranging tortoises is facilitated by evaluation of clinical signs and laboratory test results but may be complicated by seasonal and environmental effects. The goals of this study were: 1) to describe and monitor clinical and laboratory signs of disease in adult, free-ranging desert tortoises at three sites in the Mojave Desert of California (USA) between October 1990 and October 1995; 2) to evaluate associations between clinical signs and hematologic, biochemical, serologic, and microbiologic test results; 3) to characterize disease patterns by site, season, and sex; and 4) to assess the utility of diagnostic tests in predicting morbidity and mortality. Venous blood samples were obtained four times per year from tortoises of both sexes at the Desert Tortoise Research Natural Area (DTNA), Goffs/Fenner Valley, and Ivanpah Valley. Tortoises were given a physical examination, and clinical abnormalities were graded by type and severity. Of 108 tortoises, 68.5% had clinical signs of upper respiratory tract disease consistent with mycoplasmosis at least once during the study period. In addition, 48.1% developed moderate to severe shell lesions consistent with cutaneous dyskeratosis. Ulcerated or plaque-like oral lesions were noted on single occasions in 23% of tortoises at Goffs and 6% of tortoises at Ivanpah. Tortoises with oral lesions were significantly more likely than tortoises without lesions to have positive nasal cultures for Mycoplasma agassizii (P = 0.001) and to be dehydrated (P = 0.0007). Nine tortoises had marked azotemia (blood urea nitrogen [BUN] > 100 mg/dl) or persistent azotemia (BUN 63-76 mg/dl); four of these died, three of which had necropsy confirmation of urinary tract disease. Laboratory tests had low sensitivity but high specificity in assessing morbidity and mortality; there was marked discrepancy between serologic and culture results for M. agassizii. Compared with tortoises at other sites, tortoises at DTNA were more likely to be seropositive for M. agassizii. Tortoises at Goffs were significantly more likely to have moderate to severe shell disease, oral lesions, positive nasal cultures for M. agassizii, and increased plasma aspartate aminotransferase activity. The severe disease prevalence in Goffs tortoises likely contributed to the population decline that occurred during and subsequent to this study.     

Prospective survey of veterinary practitioners’ primary assessment of equine colic: clinical features,diagnoses, and treatment of 120 cases of large colon impaction

Background

Large colon impactions are a common cause of colic in the horse. There are no scientific reports on the clinical presentation, diagnostic tests and treatments used in first opinion practice for large colon impaction cases. The aim of this study was to describe the presentation, diagnostic approach and treatment at the primary assessment of horses with large colon impactions.

Methods

Data were collected prospectively from veterinary practitioners on the primary assessment of equine colic cases over a 12 month period. Inclusion criteria were a diagnosis of primary large colon impaction and positive findings on rectal examination. Data recorded for each case included history, signalment, clinical and diagnostic findings, treatment on primary assessment and final case outcome. Case outcomes were categorised into three groups: simple medical (resolved with single treatment), complicated medical (resolved with multiple medical treatments) and critical (required surgery, were euthanased or died). Univariable analysis using one-way ANOVA and Tukey’s post-hoc test, Kruskal Wallis with Dunn’s post-hoc test and Chi squared analysis were used to compare between different outcome categories.

Results

1032 colic cases were submitted by veterinary practitioners: 120 cases met the inclusion criteria for large colon impaction. Fifty three percent of cases were categorised as simple medical, 36.6% as complicated medical, and 9.2% as critical. Most cases (42.1%) occurred during the winter. Fifty nine percent of horses had had a recent change in management, 43% of horses were not ridden, and 12.5% had a recent / current musculoskeletal injury. Mean heart rate was 43bpm (range 26-88) and most cases showed mild signs of pain (67.5%) and reduced gut sounds (76%). Heart rate was significantly increased and gut sounds significantly decreased in critical compared to simple medical cases (p<0.05). Fifty different treatment combinations were used, with NSAIDs (93%) and oral fluids (71%) being administered most often.

Conclusions

Large colon impactions typically presented with mild signs of colic; heart rate and gut sounds were the most useful parameters to distinguish between simple and critical cases at the primary assessment. The findings of seasonal incidence and associated management factors are consistent with other studies. Veterinary practitioners currently use a wide range of different treatment combinations for large colon impactions.

     

Chemical dependency in women. Meeting the challenges of accurate diagnosis and effective treatment.

Women dependent on alcohol or prescribed or nonprescribed psychoactive drugs present special diagnostic challenges to physicians. Chemical dependency likewise has adverse effects on women who are nonusers through the disease of co-dependency. The natural history of chemical dependency in women includes sex-specific differences in presenting signs and symptoms. Collateral medical history may come from a variety of community sources. Diagnoses may also use sex-specific criteria, with simultaneous diagnoses of chemical dependency and co-dependency considered.     

Detection of alcohol abuse and monitoring of alcoholic abstinence using sideroblastic index and gamma-glutamyltransferase

45 hospitalised patients with chronic alcohol abuse observed immediately until that time preceding hospitalisation were examined with the aim of finding out whether examinations of the bone-marrow and gamma-glutamyltransferase (GGT) i.s. may be used for recording the consumption of alcohol and for monitoring the abstinence from alcohol. Bone-marrow puncture was made within 3 days after hospitalisation and was repeated at n = 35 after two weeks on an average. Simultaneously, GGT was determined. Disturbances of iron utilization, which were divided according to frequency and kind of sideroblasts into 4 degrees of seriousness, represented by far the most constant hematological findings. An sideroblastic+ index (SI) was counted, which, in addition to the count of sideroblasts, takes into account even qualitative disturbances. The sideroblastic+ index was increased in 91% (41/45) of patients irrespective of the presence or extent of an anemia so far as iron stores had not been completely depleted because of bleedings. In 71% (32/45) of the patients, gamma-glutamyltransferase (GGT) remained within the pathological range, thus lying significantly (p less than 0.05) below the sensitivity of the sideroblastic index (SI). By taking the increase of SI or GGT as a basis, the rate of recording alcoholics could be improved to 98% (44/45). Abstaining from alcohol caused a highly significant decrease of SI and GGT (p less than 0.005). Thereby, the sideroblasts index predominantly normalised in the period of examination, whereas gamma-glutamyltransferase fell below the pathological range only by way of exception. No significant decrease in the control value of SI and GGT was observed in those patients who did not abstain from alcohol. In comparing the differences of average values between abstaining and non-abstaining persons only SI revealed significant differences (p less than 0.005). SI and GGT complement each other in the control function of drinking behaviour. Under the given circumstances a simultaneous examination enables alcohol abuse to be recorded with nearly 100% of probability. SI is more sensitive and is able to differentiate more clearly between abstaining and non-abstaining. Due to its slower response GGT can indicate former alcohol abuse over a longer period. Concerning doubtful or potentially hepatotoxic+ substances at places of work, the sideroblastic+ index could provide an essential aid in deciding whether alcohol is a disturbing factor.     

Non-Invasive Tools for the Diagnosis of Potentially Life-Threatening Gynaecological Emergencies: A Systematic Review

ObjectiveTo identify non-invasive tools for diagnosis of the major potentially life-threatening gynaecological emergencies (G-PLEs) reported in previous studies, and to assess their diagnostic accuracy.MethodsMEDLINE; EMBASE; Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library) were searched to identify all eligible studies published in English or French between January 1990 and December 2012. Studies were considered eligible if they were primary diagnostic studies of any designs, with a gold standard and with sufficient information for construction of a 2 × 2 contingency table, concerning at least one of the following G-PLEs: complicated ectopic pregnancy, complicated pelvic inflammatory disease, adnexal torsion and haemoperitoneum of any gynaecological origin. Extraction of data and assessment of study quality were conducted by two independent reviewers. We set the thresholds for the diagnostic value of signs retrieved at Sensibility ≥ 95% and LR—≤ 0.25, or Specificity ≥ 90% and LR+ ≥ 4.ResultsWe identified 8288 reports of diagnostic studies for the selected G-PLEs, 45 of which met the inclusion criteria. The methodological quality of the included studies was generally low. The most common diagnostic tools evaluated were transvaginal ultrasound (20/45), followed by medical history (18/45), clinical examination (15/45) and laboratory tests (14/45). Standardised questioning about symptoms, systolic blood pressure<110 mmHg, shock index>0.85, identification of a mass by abdominal palpation or vaginal examination, haemoglobin concentration <10 g/dl and six ultrasound and Doppler signs presented high performances for the diagnosis of G-PLEs. Transvaginal ultrasound was the diagnostic tool with the best individual performance for the diagnosis of all G-PLEs.ConclusionThis systematic review suggests that blood pressure measurement, haemoglobin tests and transvaginal ultrasound are cornerstone examinations for the diagnosis of G-PLEs that should be available in all gynaecological emergency care services. Standardised questioning about symptoms could be used for triage of patients.     

A case-control study of alcohol consumption and drinking behaviour in patients with acute gout.

The alcohol intake and drinking behaviour of 24 patients who presented with acute gout in a family practice over a 5-year period were compared with these features of a control population matched for sex, age, weight and use of hyperuricemia-inducing diuretics. The average weekly alcohol intake of the group with gout was twice that of the control group (p less than 0.02), and a statistically significant relation was found between alcohol abuse and acute gout (p less than 0.05). About half of the patients with gout drank excessively. Acute gout should be considered a possible clinical sign of alcohol abuse.     

Do physicians assess lifestyle health risks during general medical examinations? A survey of general practitioners and obstetrician-gynecologists in Quebec

BACKGROUND: In Canada several guidelines have been published for the screening of lifestyle health risks during general medical examinations. The authors sought to examine the extent to which such screening practices have been integrated into medical practice, to measure physicians'' perceived level of difficulty in assessing these risks and to document physicians'' evaluation of their formal medical training in lifestyle risk assessment. METHODS: An anonymous mail survey was conducted in 1995 in Quebec with a stratified random sample of 1086 general practitioners (GPs) and with all 241 obstetrician-gynecologists (Ob-Gyns). The authors evaluated the proportion of physicians who reported routine assessment (with 90% or more of their patients) of substance use, family violence and sexual history during general medical examinations of adult and adolescent patients; the proportion of those who find inquiring about these issues difficult; and the proportion of those who evaluated their medical training in lifestyle risk assessment as adequate or excellent. RESULTS: The overall response rate was 72.6%. Among adult patients, 82.2% of the GPs reported routinely assessing tobacco use, 67.2% alcohol consumption, 34.2% illicit drug use and 3.2% family violence; the corresponding proportions for assessment among adolescent patients were 77.1%, 61.8%, 52.9% and 5.6%. Comparatively fewer Ob-Gyns reported routinely assessing these issues (56.1%, 28.6%, 20.4% and 1.3% respectively among adults and 62.7%, 35.2%, 26.8% and 2.8% respectively among adolescents). In the area of sexual history, condom use was routinely assessed by more Ob-Gyns than GPs (47.0% v. 28.2%); however, the proportion of Ob-Gyns and GPs was equally low for assessing number of partners (24.8% and 23.1%), sexual orientation (18.8% and 16.9%) and STD risk (26.2% and 21.2%). The vast majority of GPs and Ob-Gyns reported finding it difficult to assess family violence (86.5% and 93.0%) and sexual abuse (92.7% and 92.4% respectively). Over 80% of the physicians felt that they had had adequate or excellent medical training in assessing risk behaviours for heart disease and STD risk. The proportion who felt this way about their training in screening for illicit drug use, family violence and sexual abuse ranged between 12.7% and 31.6%. INTERPRETATION: Although morbidity and mortality associated with smoking, alcohol consumption, illicit drug use, unsafe sexual practices, family violence and sexual abuse have been well documented, routine screening for these risk factors during general medical examinations has yet to be integrated into medical practice.