Screening and diagnosis of alcoholism in the primary care setting.

As many as 20% of patients seeing their primary physicians may suffer from alcohol abuse and dependence. Often the problem goes unrecognized. In this article I summarize what is known regarding the natural history, risk factors, and available screening techniques for alcoholism. Ultimately, a diagnosis of alcoholism is based on a patient''s history, and there are various approaches to obtaining a thorough alcohol history and overcoming patient denial regarding an alcohol problem. Primary physicians have an important role in educating patients about alcoholism.     

Medical Care of the Alcoholic Patient

Alcoholism is an illness that constitutes a major health problem at all levels of society. The physician should accept his responsibility to prevent it and to care for the alcoholic. If he knows that one of his patients is drinking immoderately, he should warn him of the outlook. A patient''s acquired dependence on alcohol may be overt, or revealed only on examination for organic disease or emotional disturbance. The diagnosis may be accepted reluctantly, or denied despite positive evidence, but the patient should be persuaded to give up drinking. He may require psychiatric help or advice from a social worker. He may be so ill as to require treatment in hospital, and hospitals must recognize the urgency of such admissions. Discharge from hospital does not end treatment, for alcoholism is a chronic disease, requiring long-term planning, persistent follow-up and enduring sympathy by the physician, who must always be as available to his alcoholic patient as he is to his patient with diabetes, epilepsy or cardiac disease.     

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.     

Pathogenesis and management of alcoholic liver injury.

The present paper is devoted to overview the basic concepts of ethanol-induced hepatic injury and therapeutic modalities by which alcoholic liver disease can be alleviated. The role of alcohol dehydrogenase of both hepatic and gastric origin as well as the importance of the number one metabolite acetaldehyde are discussed, furthermore the effects of microsomal ethanol oxidizing system are also described. The features of the major clinicopathological consequences of alcohol abuse fatty liver, alcoholic hepatitis are briefly outlined, and the basic pathogenetic mechanisms that lead to cirrhosis--cell necrosis, regeneration and fibroplasia--are shown. The understanding of the pathophysiology of alcohol-induced liver injury may improve the therapy with drugs and nutritional factors, and allow successful prevention through the early recognition of heavy drinkers before their social or medical disintegration. In the management of alcoholic liver diseases, among the true hepatoprotective agents a naturally occurring flavonoid silymarin and an active methyl-donor metabolite S-adenosyl-L-methionine seem to be promising. An antifibrotic treatment with colchicine might also be of importance. Further prospective, well-designed, controlled clinical trials are still warranted to evaluate real efficacy of these drugs. The hepatic consequences of alcohol abuse may be treatable, however, prevention would be the true resolution of the major global health problem of alcoholism.     

Alcohol and aldehyde dehydrogenase polymorphisms and risk for suicide: a preliminary observation in the Japanese male population

Epidemiological studies have shown that excessive alcohol consumption is a potent risk factor to develop suicidal behavior. Genetic factors for suicidal behavior have been observed in family, twin, and adoption studies. Because alcohol dehydrogenase (ADH1B) His47Arg and mitochondrial aldehyde dehydrogenase (ALDH2) Glu487Lys single nucleotide polymorphisms (SNPs), which affect alcohol metabolism, have been reported to exert significant impacts on alcohol consumption and on the risk for alcoholism in East Asia populations, we explored associations of the two functional SNPs with suicide using a case–control study of 283 completed suicides and 319 control subjects in the Japanese population. We found that the inactive ALDH2 allele (487Lys) was significantly less frequent in the completed suicides (19.3%) than in the controls (29.3%), especially in males, whereas this was not the case in females. The males bearing alcoholism‐susceptible homozygotes at both loci (inactive ADH1B Arg/Arg and active ALDH2 Glu/Glu genotypes) have a 10 times greater risk for suicide compared with the males bearing alcoholism‐protective homozygotes at both loci. Our data show the genetic impact of the two polymorphisms on suicidal behavior in the Japanese population, especially in males. Because we did not verify the daily alcohol consumption, the association of these SNPs with suicide might be due to alcoholism itself. Further studies using case–control subjects, which verifies the details of current and past alcohol consumption and diagnosis for alcoholism, are required to confirm these findings.     

Alcoholism and pathways to recovery: new survey results on views and treatment options

Almost 19 million Americans require treatment for an "alcohol problem"; however, only 2.4 million have been diagnosed and just 139,000 receive medication to treat it. Chronic heavy drinking contributes to cardiovascular illnesses, liver disease, cancer, and psychiatric disorders. Imaging studies demonstrate structural changes in the human brain with prolonged exposure to alcohol. Alcoholism can thus be described as an acquired brain dysfunction with specific neurochemical and neuroanatomic pathways. There is a need to intervene early because the average age of alcohol experimentation is 11-13 years--delaying onset reduces the rate of alcoholism. A survey sponsored by the Community Anti-Drug Coalitions of America (CADCA) set out to measure the attitudes and misperceptions of 1000 adults from the general population plus 300 physicians and 503 individuals in recovery from alcohol use disorder (AUD) to better understand approaches toward alcohol treatment. In these surveys, 74% of the general public indicated that alcoholism affects their daily lives, with 41% reporting having to encourage a loved one to seek help for an alcohol problem. The vast majority (= 80%) indicated a stigma toward alcoholics. Denial or refusal to admit severity and fear of social embarrassment were the top 2 reasons for not seeking help. The majority of the general population believes that alcoholism is caused partly by moral weakness. The survey revealed that most Americans are open to medications to treat alcoholism if physician-recommended and if it could reduce alcohol cravings and maintain abstinence. In the past 55 years, only 3 medications (disulfiram, naltrexone, and acamprosate) have been US Food and Drug Administration (FDA)-approved for the treatment of AUD, each with unique mechanisms of action.     

Alcohol abstention and premature mortality in middle-aged men.

A series of middle-aged men were investigated for total mortality up to five years after completing a questionnaire on alcohol consumption administered during a preventive medical screening programme in Malmö, Sweden. The aim was to test the hypothesis that small amounts of alcohol are beneficial to general and cardiovascular health. Relative mortality was increased among the men who had reported non-use of alcohol in the screening questionnaire. Most of these men, however, had chronic disease as the reason for their abstention, or even a past history of alcoholism.     

ALCOHOLISM IN SAN FRANCISCO—A Community Study and Recommended Program

In a community health council study of alcoholism in San Francisco it was suggested that alcoholism be considered a disease that afflicts an individual, affects his family, constitutes a major public health problem and produces social and economic disorder in the community. It is recommended that alcoholism, like many other diseases, be approached through a broad program of professional and public education, research into epidemiology and study of more effective methods of prevention, treatment, and rehabilitation, and that patient services commensurate with the scope of the problem be provided. Specific recommendations emphasized the role of the medical profession and related professions and facilities in the prevention and control of alcoholism.     

Indications for surgery in necrotizing pancreatitis.

The decision to operate on a patient with severe acute pancreatitis is often difficult and requires mature clinical judgment. Indications that are widely accepted include to establish the differential diagnosis, when the surgeon is concerned that the symptoms are due to a disease other than pancreatitis for which an operation is mandatory; in persistent and severe biliary pancreatitis, when an obstructing gallstone is lodged in the ampulla of Vater and cannot be managed endoscopically; in the presence of infected pancreatic necrosis; and to drain a pancreatic abscess, if percutaneous drainage does not produce the desired result. Other indications that are less well defined and somewhat controversial are the presence of sterile pancreatic necrosis involving 50% or more of the pancreas, when the pancreatitis persists despite maximal medical therapy, and when a patient''s condition deteriorates. For these last three indications, guidelines have been presented that permit a logical approach to management, although uncertainty remains. Surgeons should strive to describe in detail and precisely the clinical state of their patients at the time that an operation is done, as well as the findings and technical details of the operation. This should allow further refinement in the management of this vexing problem.     

Neurologic effects of alcoholism.

Alcoholism, a worldwide disorder, is the cause of a variety of neurologic disorders. In this article we discuss the cellular pathophysiology of ethanol addition and abuse as well as evidence supporting and refuting the role of inheritance in alcoholism. A genetic marker for alcoholism has not been identified, but neurophysiologic studies may be promising. Some neurologic disorders related to longterm alcoholism are due predominantly to inadequate nutrition (the thiamine deficiency that causes Wernicke''s encephalopathy), but others appear to involve the neurotoxicity of ethanol on brain (alcohol withdrawal syndrome and dementia) and peripheral nerves (alcoholic neuropathy and myopathy).     

Management of alcoholism in the primary care setting.

Primary care physicians can play an important role in managing alcoholic patients. Identifying and treating alcoholism early, before it has interfered with patients'' relationships and work, may increase the likelihood of prolonged recovery. Simple office interventions can help motivate patients to abstain and seek treatment. People who abuse alcohol and are unwilling to abstain can benefit from a recommendation to reduce their intake of alcohol. For alcohol-dependent patients who decide to stop drinking, primary care physicians often can manage withdrawal on an outpatient basis. Selecting an appropriate treatment program for each alcoholic patient is important, and referral to a specialist to assist in matching patients to treatments is often necessary. Primary care physicians also can help prevent relapse. Although disulfiram is of limited value, primary care physicians can support recovery by identifying coexistent psychosocial problems, helping patients to restructure their lives, and ensuring continuity of care.     

À propos de quelques questions éthiques soulevées par la maladie d’Alzheimer

This paper tackles two ethical problems often raised by Alzheimer’s disease and associated disorders: the issue of diagnosis disclosure and the issue of autonomy (or consent). The first part of the paper begins with a critical analysis of the literature on diagnosis disclosure. The authors try to understand why the problem is such a hotly debated issue. They then propose some theoretical and practical perspectives. For example, they suggest that one should allow the patients themselves to designate the persons who should be informed about their health status. They also wonder whether it is really coherent to communicate the diagnosis without discussing its known consequences. The second part of the paper begins with an analytical presentation of the problems one encounters when attempting to respect the autonomy of alzheimer patients. Then the authors discuss the interests and the limits of the proposed solutions to these problems. Finally, they discuss the analyses by two contemporary philosophers (Dworkin and Jaworska) concerning the question: to what extent does Alzheimer’s disease undermine the capacity for autonomy?     

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.     

Health promotion in the general practice consultation: a minute makes a difference.

OBJECTIVE--To see whether extending appointment length from seven and a half minutes or less to 10 minutes per patient would increase health promotion in general practice consultations. DESIGN--Controlled trial of 10 minute appointments. Consultations were compared with control surgeries in which the same doctors booked patients at their normal rate (median six minutes per patient). SETTING--10 general practices in Nottinghamshire. SUBJECTS--16 general practitioners were recruited. Entry criteria were a booking rate of eight or more patients an hour, a wish for longer consultations, and plans to increase appointment length. MAIN OUTCOME MEASURES--Duration of consultations; recording of blood pressure, weight, and cervical cytology in the medical record; recording of advice about smoking, alcohol, diet, exercise, and immunisation in the medical record; reporting of the above activities by patients. RESULTS--Mean consultation times were 8.25 minutes in the experimental sessions and 7.04 and 7.16 minutes in the control sessions. Recording of blood pressure, smoking, alcohol consumption, and advice about immunisation was significantly more frequent in the experimental sessions, and the proportion of consultations in which one or more items of health education were recorded in the medical notes increased by an average of over 6% in these sessions. Patients more often reported discussion of smoking and alcohol consumption and coverage of previous health problems in the experimental sessions. There was little change in discussion of exercise, diet, and weight or cervical cytology activity. CONCLUSIONS--Shortage of time is a major factor in general practitioners'' failure to realise their potential in health promotion. General practice should be organised so that doctors can run 10 minute appointment sessions.     

The Medical Practitioner,Alcoholism and Motivation

Adverse influences on motivation for recovery from alcoholism must be searched for in three areas: society, the medical practitioner and the patient. Society is ambivalent because there is a vicarious release through identification with the cheerful “drunk” coupled with unconscious envy and resentment leading to punitive action.The current “alcohol culture” decrees that to drink is to be well, not to drink is to be ill.The medical profession attempts to suppress, deny, rationalize or reject the problem of alcoholism because it involves a change in attitude and recognition of limitations.The alcoholic patient has a notorious lack of motivation, but this must be recognized as a symptom of his disease, and with certain techniques this symptom is treatable. Furthermore, motivation fluctuates and many opportunities for treatment are available when the medical practitioner can detect that motivation is high. At times a coercive approach is required, at times a permissive one; and the optimal use of such approaches will increase the motivation to an effective level.     

PTSD and alcoholism

PTSD is the development of symptoms after a distressful response. 52.20% of the respondents suffering from PTSD used to drink either moderately or excessively during the war. Some of their alcoholism stems from the pre-war period. According to our researches, more than one fifth (22.92%) of the respondents with PTSD consume alcohol more than they used to before the war. PTSD is frequently associated with chronic alcoholism as a kind of "self-healing". Alcoholism problem is particularly unfavourably reflected on the family of a PTSD patient, whose quality of life is already poor, due to their basic disease. Treatment of alcoholism with PTSD patients is rather demanding; emerging of PTSD is noticeable with a part of the staff who treat chronic alcoholism; what is noticed was the similarity in the intensity and frequency of the stressful responses, which is proportional to the one noticed with the staff treating AIDS patients. Chronic alcoholics are the source of strong and repetitive traumas for those who try to treat them. That is why the concern for the counter-transference responses is important while treating alcoholism.     

Alcohol and the emergency service patient.

To determine the prevalence of alcohol use in casualty patients breath-alcohol analysis was performed on 702 patients attending the accident and emergency department of a large teaching hospital during the evening. Forty per cent of patients had consumed alcohol before attending and 32% had a blood alcohol concentration exceeding 17.4 mmol/l (80 mg/100 ml). Clinical assessment of intoxication resulted in a false-negative diagnosis in 10% of inebriated patients, indicating that an objective measurement of the blood alcohol concentration by a test, such as breath-alcohol analysis, may be of additional value. These findings confirm that a high proportion of emergency-service patients are affected by alcohol and suggest that alcoholism treatment facilities need to be integrated with accident and emergency services.     

Integrated control of Chagas disease for its elimination as public health problem - A Review

Chagas disease or American trypanosomiasis is, together with geohelminths, the neglected disease that causes more loss of years of healthy life due to disability in Latin America. Chagas disease, as determined by the factors and determinants, shows that different contexts require different actions, preventing new cases or reducing the burden of disease. Control strategies must combine two general courses of action including prevention of transmission to prevent the occurrence of new cases (these measures are cost effective), as well as opportune diagnosis and treatment of infected individuals in order to prevent the clinical evolution of the disease and to allow them to recuperate their health. All actions should be implemented as fully as possible and with an integrated way, to maximise the impact. Chagas disease cannot be eradicated due because of the demonstrated existence of infected wild triatomines in permanent contact with domestic cycles and it contributes to the occurrence of at least few new cases. However, it is possible to interrupt the transmission of Trypanosoma cruzi in a large territory and to eliminate Chagas disease as a public health problem with a dramatic reduction of burden of the disease.     

Alcohol and high-density lipoproteins.

High-density lipoproteins (HDL) have been shown to be negatively associated with coronary heart disease; some epidemiologic evidence also suggests that alcohol may protect against coronary heart disease, but other evidence shows the opposite. Alcohol ingestion and even alcoholism may be associated with higher serum HDL levels, but the levels tend to return to normal within 2 weeks with abstinence from alcohol. The relation between HDL and alcoholism, however, is complex, since in addition to alcohol itself several other factors have to be considered. Liver disease and cigarette smoking tend to decrease the serum HDL level in alcoholic persons, while certain hormonal and nutritional influences and the concomitant use of other microsomal-enzyme-inducing drugs may lead to increased HDL levels. On balance, while alcohol per se may increase the serum HDL level, alcoholism--particularly alcoholic liver disease--probably negates the HDL-related protection against coronary heart disease.