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.     

Protecting the Public from H1N1 through Points of Dispensing (PODs)

In fall 2009, the New York City Department of Health and Mental Hygiene (DOHMH) operated 58 points of dispensing (PODs) over 5 weekends to provide influenza A (H1N1) 2009 monovalent vaccination to New Yorkers. Up to 7 sites were opened each day across the 5 boroughs, with almost 50,000 New Yorkers being vaccinated. The policies and protocols used were based on those developed for New York City's POD Plan, the cornerstone of the city's mass prophylaxis planning. Before the H1N1 experience, NYC had not opened more than 5 PODs simultaneously and had only experienced the higher patient volume seen with the H1N1 PODs on 1 prior occasion. Therefore, DOHMH identified factors that contributed to the success of POD operations, as well as areas for improvement to inform future mass prophylaxis planning and response. Though this was a relatively small-scale, preplanned operation, during which a maximum of 7 PODs were operated on a given day, the findings have implications for larger-scale mass prophylaxis planning for emergencies.     

What Madness Prompts, Reason Writes: New York City September 11–October 2, 2001

This personal narrative describes the use of ethnographic data collection as a means for its author, a New York City resident, to take stock of local reaction and response to the events of September 11 by documenting arid analyzing the writing New Yorkers posted in public spaces during the three weeks following the attacks on the World Trade Center.     

Prevalence of excessive or problem drinkers among patients attending somatic outpatient clinics: a study of alcohol related medical care.

The prevalence of alcohol related morbidity was studied among 2038 patients attending somatic outpatient clinics. A further 76 patients had refused the study, giving an overall drop out rate of 3.6%. Several methods were combined so as to detect as many patients with problem drinking as possible. According to the criteria and definitions employed 17% of men (confidence interval 15% to 19%) and 4% of women (confidence interval 3% to 5%) were excessive consumers of alcohol or problem drinkers. The highest proportion of such patients--that is, 17%--was noted in the emergency rooms (27% of men, 8% of women). At other clinics the proportions varied from 11% to 17% of men and from 2% to 4% of women. The strongest relations between overconsumption of alcohol and consultation at the clinic were among patients attending the medical outpatient clinic and the emergency rooms; in 86% (confidence interval 75% to 97%) and 88% (confidence interval 81% to 95%) of problem drinkers attending these clinics, respectively, alcohol was related to the consultation. Consultations were related to alcohol in 82% of women with excessive or problem drinking and 73% of men defined in this way. There was a tendency to a higher proportion of men with excessive or problem drinking in the age group 40-49 years. These findings show that among patients classified as excessive or problem drinkers attending somatic outpatient clinics there was a close relation between alcohol consumption and utilisation of medical resources, especially in women.     

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.     

Polymorphism of aldehyde dehydrogenase and alcohol sensitivity

The metabolism of acetaldehyde has received considerable attention in the past years owing to its acute and chronic toxic effects in humans. Aldehyde dehydrogenase (ALDH) catalyzes the oxidation of acetaldehyde in liver and other organs. Two major isozymes of hepatic ALDH (ALDH I or E2 and ALDH II or E1), which differ in their structural and functional properties, have been characterized in humans. The ALDH I with a low Km for acetaldehyde is predominantly of mitochondrial origin and ALDH II which has a relatively higher Km is of cytosolic origin. An inherited deficiency of ALDH I isozyme has been found among Japanese and Chinese which is primarily responsible for producing acute alcohol sensitivity symptoms (flushing response) after drinking mild doses of alcohol. Biochemical, immunochemical and molecular genetics data indicate a structural mutation in the ALDH I isozyme gene responsible for the loss in catalytic activity. Population genetic studies indicate a wide prevalence of this ALDH polymorphism among individuals of Mongoloid race. Flushing response to alcohol shows familial resemblances and preliminary family data from Japan, China and Korea hint to an autosomal codominant inheritance for ALDH I isozyme deficiency. The ALDH polymorphism is apparently responsible for the low incidence of alcoholism in Japanese, Chinese and Koreans. Alcohol-induced sensitivity due to ALDH isozyme deficiency may act as an inhibitory factor against excessive alcohol drinking thereby imparting a protection against 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.     

The Geographic Pathology of Coronary Atherosclerosis

The purpose of these studies was to find large groups with significantly less coronary atherosclerosis than New Yorkers and to investigate the possible reasons for these differences. Direct comparison of hearts and measurements of coronary artery wall thickness, autopsy series, and clinical diagnoses of outpatients and hospital admissions revealed that the amount of coronary atherosclerosis and the number of myocardial infarcts is significantly less in East and West Africans compared to New Yorkers matched for age and sex. The factors producing these differences are apparently operative in childhood. East Africans were found to have a shorter blood clot-lysis time, fewer venous (and arterial) thromboemboli and lower serum lipid levels, with a lower relative percentage of serum linoleates, than age-matched New Yorkers.     

Voluntary Alcohol Intake following Blast Exposure in a Rat Model of Mild Traumatic Brain Injury

Alcoholism is a frequent comorbidity following mild traumatic brain injury (mTBI), even in patients without a previous history of alcohol dependence. Despite this correlational relationship, the extent to which the neurological effects of mTBI contribute to the development of alcoholism is unknown. In this study, we used a rodent blast exposure model to investigate the relationship between mTBI and voluntary alcohol drinking in alcohol naïve rats. We have previously demonstrated in Sprague Dawley rats that blast exposure leads to microstructural abnormalities in the medial prefrontal cortex (mPFC) and other brain regions that progress from four to thirty days. The mPFC is a brain region implicated in alcoholism and drug addiction, although the impact of mTBI on drug reward and addiction using controlled models remains largely unexplored. Alcohol naïve Sprague Dawley rats were subjected to a blast model of mTBI (or sham conditions) and then tested in several common measures of voluntary alcohol intake. In a seven-week intermittent two-bottle choice alcohol drinking test, sham and blast exposed rats had comparable levels of alcohol intake. In a short access test session at the conclusion of the two-bottle test, blast rats fell into a bimodal distribution, and among high intake rats, blast treated animals had significantly elevated intake compared to shams. We found no effect of blast when rats were tested for an alcohol deprivation effect or compulsive drinking in a quinine adulteration test. Throughout the experiment, alcohol drinking was modest in both groups, consistent with other studies using Sprague Dawley rats. In conclusion, blast exposure had a minimal impact on overall alcohol intake in Sprague Dawley rats, although intake was increased in a subpopulation of blast animals in a short access session following intermittent access exposure.     

Hypoglycemic coma in chronic alcoholism]

The authors present two cases of chronic alcoholism in two female patients aged 41 and 52 years without diabetes mellitus, in whom hypoglycaemic coma occurred during the abstinence period. Hypoglycaemia in one patient occurred suddenly as a result of fasting within 24 hours following the last alcohol intake, whereas a severe hypoglycaemia in the second patient was developing progressively during 72 hours; patient did not eat much and the last meal took 24 hours before the onset of hypoglycaemic coma. Diagnosis of hypoglycaemic coma was suspected because as no alcohol or acetic acid smell were felt, no alcohol or methanol was detected in blood (tested only in one patient). Adrenergic reactions were not distinct (no excessive sweating, convulsions, tachycardia). The authors suggest, that a severe hypoglycaemia should be considered in patients suspected of alcoholism, and the treatment should start earlier with intravenous glucose administration.     

Has mortality related to alcohol decreased in Sweden?

In Sweden sales of alcohol dropped 17% from 1976 to 1982. Similarly, comparison of data from 1979 and 1982 shows that the mortality from cirrhosis of the liver declined appreciably, by 28% in men and 29% in women. During 1979-82 mortality from pancreatitis also declined noticeably, by 30% in men and 36% in women. By contrast, no decrease occurred in mortality from alcoholic psychosis, alcoholism, or alcohol intoxication. The decrease in mortality from cirrhosis of the liver and pancreatitis is probably explained by a decrease in the consumption of alcohol among an important subgroup of high consumers of alcohol. The lack of a decrease in mortality from alcoholic psychosis, alcoholism, and alcohol intoxication may be because such diagnoses are often made in socially deteriorated, more dependent alcoholic subjects who have not been able to reduce their consumption.     

The Consequences of High Cigarette Excise Taxes for Low-Income Smokers

Background

To illustrate the burden of high cigarette excise taxes on low-income smokers.

Methodology/Principal Findings

Using data from the New York and national Adult Tobacco Surveys from 2010–2011, we estimated how smoking prevalence, daily cigarette consumption, and share of annual income spent on cigarettes vary by annual income (less than $30,000; $30,000–$59,999; and more than $60,000). The 2010–2011 sample includes 7,536 adults and 1,294 smokers from New York and 3,777 adults and 748 smokers nationally. Overall, smoking prevalence is lower in New York (16.1%) than nationally (22.2%) and is strongly associated with income in New York and nationally (P<.001). Smoking prevalence ranges from 12.2% to 33.7% nationally and from 10.1% to 24.3% from the highest to lowest income group. In 2010–2011, the lowest income group spent 23.6% of annual household income on cigarettes in New York (up from 11.6% in 2003–2004) and 14.2% nationally. Daily cigarette consumption is not related to income.

Conclusions/Significance

Although high cigarette taxes are an effective method for reducing cigarette smoking, they can impose a significant financial burden on low-income smokers.     

ANTABUS IN THE TREATMENT OF ALCOHOLISM IN A PRIVATE GENERAL HOSPITAL

In 35 consecutive cases in which patients were admitted to a private hospital for alcoholism, antabus was contraindicated for eight patients and administered to 27. Sixteen patients, followed three to nine months, cooperated fully with treatment and did not return to use of alcohol. In four cases there was at least one episode of drinking, but the patients continued to cooperate with treatment and attained partial success. In seven cases, including three in which antabus was stopped because of organic disease, treatment was unsuccessful. Insufficient insight and lack of family cooperation accounted for four failures.The presence of cardiovascular or hepatic diseases contraindicates antabus. As the test of reaction to alcohol after antabus has been given is hazardous, continuous supervision by nurse and physician throughout the test reaction is mandatory.Sustained results depend upon psychotherapy, family cooperation, careful follow-up, and control of side-reactions to the drug.Antabus as an antagonist to alcohol is not safe enough to permit general use of the drug.     

The role of early life experience and species differences in alcohol intake in microtine rodents

Social relationships have important effects on alcohol drinking. There are conflicting reports, however, about whether early-life family structure plays an important role in moderating alcohol use in humans. We have previously modeled social facilitation of alcohol drinking in peers in socially monogamous prairie voles. We have also modeled the effects of family structure on the development of adult social and emotional behaviors. Here we assessed whether alcohol intake would differ in prairie voles reared by both parents compared to those reared by a single mother. We also assessed whether meadow voles, a closely related species that do not form lasting reproductive partnerships, would differ in alcohol drinking or in the effect of social influence on drinking. Prairie voles were reared either bi-parentally (BP) or by a single mother (SM). BP- and SM-reared adult prairie voles and BP-reared adult meadow voles were given limited access to a choice between alcohol (10%) and water over four days and assessed for drinking behavior in social and non-social drinking environments. While alcohol preference was not different between species, meadow voles drank significantly lower doses than prairie voles. Meadow voles also had significantly higher blood ethanol concentrations than prairie voles after receiving the same dose, suggesting differences in ethanol metabolism. Both species, regardless of rearing condition, consumed more alcohol in the social drinking condition than the non-social condition. Early life family structure did not significantly affect any measure. Greater drinking in the social condition indicates that alcohol intake is influenced similarly in both species by the presence of a peer. While the ability of prairie voles to model humans may be limited, the lack of differences in alcohol drinking in BP- and SM-reared prairie voles lends biological support to human studies demonstrating no effect of single-parenting on alcohol abuse.     

Neuromodulatory role of the endocannabinoid signaling system in alcoholism: an overview

The current review evaluates the evidence that some of the pharmacological and behavioral effects of ethanol (EtOH), including EtOH-preferring behavior, may be mediated through the endocannabinoid signaling system. The recent advances in the understanding of the neurobiological basis of alcoholism suggest that the pharmacological and behavioral effects of EtOH are mediated through its action on neuronal signal transduction pathways and ligand-gated ion channels, receptor systems, and receptors that are coupled to G-proteins. The identification of a G-protein-coupled receptor, namely, the cannabinoid receptor (CB1 receptor) that was activated by Delta(9)-tetrahydrocannabinol (Delta(9)-THC), the major psychoactive component of marijuana, led to the discovery of endogenous cannabinoid agonists. To date, two fatty acid derivatives identified to be arachidonylethanolamide (AEA) and 2-arachidonylglycerol (2-AG) have been isolated from both nervous and peripheral tissues. Both these compounds have been shown to mimic the pharmacological and behavioral effects of Delta(9)-THC. The involvement of the endocannabinoid signaling system in the development of tolerance to the drugs of abuse including EtOH has not been known until recently. Recent studies from our laboratory have demonstrated for the first time the down-regulation of CB1 receptor function and its signal transduction by chronic EtOH. The observed down-regulation of CB1 receptor binding and its signal transduction results from the persistent stimulation of the receptors by the endogenous CB1 receptor agonists, AEA and 2-AG, the synthesis of which has been found to be increased by chronic EtOH treatment. This enhanced formation of endocannabinoids may subsequently influence the release of neurotransmitters. It was found that the DBA/2 mice, known to avoid EtOH intake, have significantly reduced brain-CB1-receptor function consistent with other studies, where the CB1 receptor antagonist SR141716A has been shown to block voluntary EtOH intake in rodents. Similarly, activation of the CB1 receptor system promoted alcohol craving, suggesting a role for the CB1 receptor gene in excessive EtOH drinking behavior and development of alcoholism. Ongoing investigations may lead to the development of potential therapeutic strategies for the treatment of alcoholism.     

Dynamic Responses of Selective Brain White Matter Fiber Tracts to Binge Alcohol and Recovery in the Rat

To determine the dynamics of white matter vulnerability to excessive alcohol consumption, diffusion tensor imaging (DTI) was used in an animal model of alcohol exposure. Quantitative, in vivo fiber tracking results are presented from rats with DTI conducted at 3 time points: baseline; after 4 days of intragastric alcohol to blood alcohol levels of ~250mg/dL; and after one week of recovery. Binge alcohol followed by a week of sobriety resulted in rapidly reversible decreases in fractional anisotropy (FA), a measure of the coherence of fiber tracts, in callosal genu and fimbria-fornix but not splenium; and increases in mean diffusivity (MD), an index of freely diffusing water in tissue, selective to the fimbria-fornix. These effects were confirmed with tract-based spatial statistics (TBSS). The directionality of changes in DTI metrics reproduce those observed in human alcoholism. That a single exposure to binge alcohol can cause substantial transient changes detectable in DTI metrics demonstrates the potential for rapid neuroplasticity.     

Duck plague epizootics in the United States, 1967-1995

In 1967, the first confirmed diagnosis of duck plague (DP) in the USA was made from pekin ducks (Anas platyrhynchos domesticus) on commercial duck farms on Long Island, New York. Within 10 mo, DP was confirmed as the cause of death in migratory waterfowl on a Long Island bay. This paper reviews 120 DP epizootics reported from 1967 to 1995 that involved waterfowl species native to North America or were reported in areas with free-flying waterfowl at risk. Duck plague epizootics occurred in 21 states with the greatest number reported in Maryland (29), New York (18), California (16), and Pennsylvania (13). The greatest frequency of epizootics (86%) was detected during the months of March to June. At least 40 waterfowl species were affected with the highest frequency of epizootics reported in captive or captive-reared ducks including muscovy ducks (Cairina moschata) (68%), mallard ducks (A. platyrhynchos) (18%) and black ducks (A. rubripes) (14%). The greatest number of waterfowl died in three epizootics that involved primarily migratory birds in 1967 and 1994 in New York (USA) and 1973 in South Dakota (USA). The greatest number of DP epizootics reported since 1967 appear to have involved flocks of non-migratory rather than migratory waterfowl; therefore, in our opinion it remains unknown if DP is enzootic in either non-migratory or migratory waterfowl.     

Use of a questionnaire in general practice to increase the recognition of patients with excessive alcohol consumption.

A self administered questionnaire, the health survey questionnaire, was designed to detect excessive alcohol consumption and mailed to patients who were registered with two general practices. Replies were received from 2572(75%) of 3452 patients. Excessive consumption was taken as 42 units of alcohol per week or more for men and 21 units per week or more for women: 1 unit = approximately 10 g ethanol and is equivalent to a half pint of beer, one glass of wine, or one standard measure of spirits. One hundred and twenty men (11%) and 68 women (5%) were identified by their responses to the questionnaire as excessive drinkers. According to their responses, roughly half of these expressed some concern about their drinking. In the practice where a disease register was kept 18 patients had been recorded as heavy drinkers before the study, and an additional 74 were detected by the questionnaire. Within 12 months after the questionnaire survey three groups of respondents were reviewed: (a) the excessive drinkers, (b) those who indicated concern about drinking but did not exceed the limits for excessive consumption, and (c) a random sample of those who were in neither of these two categories. Patients in these three groups were interviewed in a standard fashion to determine their alcohol consumption. Breath alcohol measurement was also carried out and a blood sample taken for the estimation of mean cell volume, gamma glutamyltranspeptidase activity, and serum aspartate transaminase activity. There were highly significant correlations between estimates of consumption obtained by the questionnaire and those obtained at interview except among the women who were excessive consumers, whose responses to the questionnaire indicated levels of consumption that were much higher than those to which they admitted at interview. Stated weekly consumption at interview that was above the limits set for the study was used as the standard measure for comparing the questionnaire with the other indicators of excessive drinking. The questionnaire had a considerably greater estimated sensitivity in detecting male excessive consumers than any of the blood tests. Among the women it apparently performed less well, although the numbers stating excessive consumption at interview were small. Breath alcohol measurement was positive in only a few of the excessive drinkers. The use of this simple and inexpensive instrument is likely to prove widely acceptable to patients in general practice and should result in a considerable increase in the recognition by general practitioners of patients with excessive alcohol consumption.     

Use of enzymes for the diagnosis of alcohol-related organ damage

Elevated levels of serum enzymes are frequently associated not only with alcohol-related organ damage but also with excessive alcohol consumption and alcoholism without significant tissue injury. However, both in the early detection of alcoholism as well as also in the diagnosis of alcohol-related diseases the sensitivities and specificities of these enzyme markers vary considerably. They may be influenced by nonalcohol-related diseases, enzyme-inducing drugs, nutritional factors, metabolic disorders, age, smoking, etc. Consequently, we have neither a single laboratory test--enzyme marker--nor a test combination that is reliable enough for the exact diagnosis between alcohol- and nonalcohol-related organ damage. In most cases it is possible to determine the tissue from which the elevated enzyme is derived, but only occasionally enzyme changes reflect the quantity of the tissue injury. Gamma-glutamyltransferase (GGT) is the most widely used laboratory marker of alcoholism and heavy drinking, detecting 34-85% of problem drinkers and alcoholics. However, the unspecificity of increased serum GGT limits its use for general screening purposes. Its value in the follow-up of various treatment programs, however, is well established. An elevated level of serum aspartate aminotransferase (ASAT) and alanine aminotransferase (ALAT) in an alcoholic or a heavy consumer indicates alcohol-induced organ damage. The use of test combinations significantly improves the information received with single serum enzyme determinations. An ASAT/ALAT ratio greater than 1.5 can be considered as highly suggestive for the alcoholic etiology of the liver injury. Still better discrimination between alcoholic and nonalcoholic origin of the liver disease may be achieved by the determination of the ratio of GGT to alkaline phosphatase. If this ratio exceeds 1.4 the specificity of the finding in favor for alcoholic liver injury is 78%. The determination of the mitochondrial isoenzyme of ASAT also improves the diagnostic value of ASAT determination. The ratio of mitochondrial isoenzyme to total over 4 is highly suggestive for alcohol-related liver injury. In general, however, the determination of serum activities of other enzymes such as ornithine carbamyl transferase, lactate dehydrogenase, isocitrate dehydrogenase, sorbitol dehydrogenase, alcohol dehydrogenase, guanase, aldolase, alkaline phosphatase or glutathione S-transferase do not significantly improve the diagnostic information obtained with more conventional laboratory markers of liver injury.(ABSTRACT TRUNCATED AT 400 WORDS)