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.     

Clinical versus laboratory detection of alcohol abuse: the alcohol clinical index.

To determine reliable indicators of alcohol abuse a comprehensive set of clinical and laboratory information was acquired from three groups of subjects with a wide range of drinking histories: 131 outpatients with alcohol problems, 131 social drinkers, and 52 patients from family practice. Findings from clinical examination provided greater diagnostic accuracy than laboratory tests for detecting alcohol abuse. Logistic regression analysis produced an overall accuracy of 85-91% for clinical signs, 84-88% for items from the medical history, and 71-83% for laboratory tests in differentiating the three groups. Further analyses showed 17 clinical signs and 13 medical history items that formed a highly diagnostic instrument (alcohol clinical index) that could be used in clinical practice. A probability of alcohol abuse exceeding 0.90 was found if four or more clinical signs or four or more medical history items from the index were present. Despite recent emphasis on the laboratory diagnosis of alcohol abuse simple clinical measures seem to provide better diagnostic accuracy.     

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.     

Use and abuse of performance indicators.

An audit was performed by this department after allegations by the regional health authority of low productivity. It was found that the health authority had underestimated the number of operations performed in 1983 by only 5%, but an inexact classification and grading of operations had led to errors in the performance indicators of 19.8% for the "weighted number of operations" and 34.5% for the "number of major operations per consultant." When the throughput of orthopaedic departments in districts was compared by the regional health authority it was found that such errors in performance indicators had been further compounded by the inconsistent use of population data and incorrect data on medical staffing. Medical practitioners and the health authorities are alerted to this amplification of inaccurate data. Other methods for assessing trauma and orthopaedic surgery are proposed, such as a simplification of the Office of Population Censuses and Surveys classification of surgical operations, grading operations based on time spent in the operating theatre, and provision of computer programs to code for diagnosis and operation when writing discharge summaries.     

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.     

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.     

Piloting a social-ecological index for measuring flood resilience: A composite index approach

Global increases in the magnitude and frequency of flood events have raised concerns that traditional flood management approaches may not be sufficient to deal with future uncertainties. There is a need to move towards approaches that manage the resilience of the system to floods by understanding and managing drivers of vulnerability and adaptive capacity. Here we pilot an approach to measure the resilience of a system to a flood. A method is presented in which indicators are used to measure and map the spatial distribution of the levels of flood resilience across a landscape. Using three flood affected municipalities in South Africa, 24 resilience indicators related to floods and its relevant social, ecological, infrastructural and economic aspects are selected, and integrated into a composite index using a principal components analysis (PCA). A fifth component of institutional resilience is used to explore levels of disaster planning, mitigation and public awareness capacities and where these can be increased. The PCA transformed the 24 variables into four main components, the first of which was strongly correlated with underlying social variables, while the second and third correlated well with economic and ecological variables respectively. Distinct spatial variation of flood resilience was found across the study area, with highest flood resilience in main cities, and lowest in wards located on the periphery of cities often the location of peri-urban informal settlements. The disaggregation of underlying indicators showed wards with lowest flood resilience also had the lowest social, economic and ecological resilience. The flood resilience index was sensitive to the exclusion of all three components highlighting the importance of capturing the multidimensionality of flood resilience. The approach allows for a simple, yet robust index able to include an array of datasets generally available in flood prone areas with potential to disaggregate and trace variables for management and decision making.     

Importance of alcohol and drug abuse in psychiatric emergencies.

Three cases of acute bilateral renal cortical necrosis, each with a different clinical course, are discussed. One patient spontaneously recovered renal function after prolonged oliguria. This case should be added to the small number of similar case reports in the literature. The second patient recovered adequate renal function temporarily, but eventually required chronic hemodialysis and renal transplantation. There was pathological evidence of progression from focal to massive cortical necrosis. The third patient never regained renal function, but is well after dialysis and transplantation.The influence of modern theories of pathogenesis of the disease, and increased availability of dialysis, are discussed in relation to the initial prognostic assessment of the patient with cortical necrosis.     

Cost-effectiveness of peer-delivered interventions for cocaine and alcohol abuse among women: a randomized controlled trial

Aims

To determine whether the additional interventions to standard care are cost-effective in addressing cocaine and alcohol abuse at 4 months (4 M) and 12 months (12 M) from baseline.

Method

We conducted a cost-effectiveness analysis of a randomized controlled trial with three arms: (1) NIDA''s Standard intervention (SI); (2) SI plus a Well Woman Exam (WWE); and, (3) SI, WWE, plus four Educational Sessions (4ES).

Results

To obtain an additional cocaine abstainer, WWE compared to SI cost $7,223 at 4 M and $3,611 at 12 M. Per additional alcohol abstainer, WWE compared to SI cost $3,611 and $7,223 at 4 M and 12 M, respectively. At 12 M, 4ES was dominated (more costly and less effective) by WWE for abstinence outcomes.

Conclusions

To our knowledge, this is the first cost-effectiveness analysis simultaneously examining cocaine and alcohol abuse in women. Depending on primary outcomes sought and priorities of policy makers, peer-delivered interventions can be a cost-effective way to address the needs of this growing, underserved population.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01235091","term_id":"NCT01235091"}}NCT01235091     

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.     

National biodiversity risk assessment: a composite multivariate and index approach

Due to the shortage of financial resources for international conservation assistance, the setting of priorities for this assistance is an important issue. A national biodiversity risk assessment index (NABRAI) is constructed to quantify national conservation performances and identify nation states of critical conservation concern. The index, which contains measures of biodiversity stock, flow and response measures, attempts to overcome several weaknesses present in other models used to prioritize nations for conservation assistance. Multivariate analyses of the index as well as economic and biodiversity resources reveal significant positive correlations between the NABRAI values and population density as well as land area exposed to high disturbance intensity. The combination of the multivariate analyses and the interpretation of NABRAI values allows for prioritization of biodiversity risk among the global community and can thus serve as an indicator of current priorities for policy makers. The present study also suggests two methods to incorporate a better understanding of biodiversity risk in models of conservation priorities; by including a wider range of variables and by developing a theoretical foundation for the relationship between the categories of variables used in the model.     

Critical issues in preparing for a mass casualty event: highlights from a new community planning guide

To assist community planners in allocating scarce resources in a mass casualty event, the Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) and the Office of the Assistant Secretary for Preparedness and Response collaborated with leading experts on a series of issue papers on preparedness and response. These papers were presented at an expert meeting in Washington, DC, in June 2006. The papers, revised based on meeting discussions, have been published by AHRQ as Mass Medical Care with Scarce Resources: A Community Planning Guide.     

Biodegradation kinetic behaviors of n-butyl alcohol and sec-butyl alcohol in a composite bead biofilter

Biodegradation kinetic behaviors of n-butyl alcohol and sec-butyl alcohol in a composite bead biofilter were investigated. The microbial growth rate of n-butyl alcohol was greater than that of sec-butyl alcohol in the inlet concentration range of 50–300 ppm. The microbial growth rate was inhibited at higher inlet concentration, and the inhibitive effect in the concentration range of 50–150 ppm was more pronounced than that in the concentration range of 150–300 ppm. The degree of inhibitive effect for n-butyl alcohol was more sensitive than that for sec-butyl alcohol in the concentration range of 50–150 ppm. The zero-order kinetic with the diffusion rate limitation could be regarded as the most adequate biochemical reaction model. For the biochemical reaction process, the biochemical reaction rate coefficient of n-butyl alcohol was greater than that of sec-butyl alcohol in the inlet concentration range of 50–300 ppm. The biochemical reaction rate coefficient was decreased with increasing inlet concentration. The inhibitive effect for sec-butyl alcohol was more pronounced than that for n-butyl alcohol. The factor of the chemical structure of compound was more predominant in the microbial growth and biochemical reaction processes. The maximum elimination capacity of n-butyl alcohol and sec-butyl alcohol were 55.7 and 20.9 g C h^?1 m^?3 bed volume, respectively. The primary alcohol was easily biodegraded by the microbial.     

Kinetic characteristics of n-butyl alcohol and iso-butyl alcohol in a composite bead air biofilter

Kinetic characteristics of n-butyl alcohol and iso-butyl alcohol in a composite bead biofilter were investigated. The microbial growth rate of n-butyl alcohol was greater than that of iso-butyl alcohol in the average inlet concentration range of 50-300 ppm. The microbial growth rate was inhibited at higher inlet concentration, and the inhibitive effect in the concentration range of 50-150 ppm was more pronounced than that in the concentration range of 150-300 ppm. The degree of inhibitive effect for n-butyl alcohol was more sensitive than that for iso-butyl alcohol in the concentration range of 50-150 ppm. The zero-order kinetic with the diffusion rate limitation could be regarded as the most adequate biochemical reaction model. The biodegradation rate of n-butyl alcohol was greater than that of iso-butyl alcohol in the average inlet concentration range of 50-300 ppm. The biochemical reaction rate was also inhibited at higher inlet concentration, and the inhibitive effect for iso-butyl alcohol was more pronounced than that for n-butyl alcohol. The factor of the chemical structure of compound was more predominant in the microbial growth and biochemical reaction processes. The maximum elimination capacity of n-butyl alcohol and iso-butyl alcohol were 55.7 and 34.8 g C h(-1)m(-3) bed volume, respectively. The compound with no side group in the main chain would be easier biodegraded by the microbial.     

Critical Early Roles for col27a1a and col27a1b in Zebrafish Notochord Morphogenesis,Vertebral Mineralization and Post-embryonic Axial Growth

Background

Fibrillar collagens are well known for their links to human diseases, with which all have been associated except for the two most recently identified fibrillar collagens, type XXIV collagen and type XXVII collagen. To assess functions and potential disease phenotypes of type XXVII collagen, we examined its roles in zebrafish embryonic and post-embryonic development.

Methodology/Principal Findings

We identified two type XXVII collagen genes in zebrafish, col27a1a and col27a1b. Both col27a1a and col27a1b were expressed in notochord and cartilage in the embryo and early larva. To determine sites of type XXVII collagen function, col27a1a and col27a1b were knocked down using morpholino antisense oligonucleotides. Knockdown of col27a1a singly or in conjunction with col27a1b resulted in curvature of the notochord at early stages and formation of scoliotic curves as well as dysmorphic vertebrae at later stages. These defects were accompanied by abnormal distributions of cells and protein localization in the notochord, as visualized by transmission electron microscopy, as well as delayed vertebral mineralization as detected histologically.

Conclusions/Significance

Together, our findings indicate a key role for type XXVII collagen in notochord morphogenesis and axial skeletogenesis and suggest a possible human disease phenotype.     

Public health: Youth substance use and abuse: challenges and strategies for identification and intervention

Public health initiatives to distribute nicotine replacement therapy free of charge as a means of promoting smoking cessation are ongoing. Are there enough smokers interested in using nicotine replacement therapy to have a substantial impact on the prevalence of smoking if this aid were distributed free to all interested smokers? We conducted a telephone survey of 825 randomly selected daily smokers aged 18 years or older who had smoked at least 10 cigarettes per day at some point in their lives. Overall, 58.9% of the respondents said they would be interested in nicotine replacement therapy if it were offered for free. Of those interested, almost all (93.8%) said that they would use the nicotine replacement therapy to help them quit for good. There were differences in the levels of interest: smokers who intended to quit were more interested in using the nicotine replacement therapy than those who planned to reduce or maintain their smoking.Nicotine replacement therapy significantly increases a smoker''s chances of quitting.¹ It is widely available in Canada and can be obtained over the counter, usually at a cost to the consumer. Several public health initiatives have explored the advantages of free distribution of nicotine replacement therapy as a means of promoting smoking cessation.^2,3 Based on the popularity of these mass distribution efforts, it has been suggested that giving free nicotine replacement therapy to all interested smokers could have an important impact on the prevalence of smoking.²This statement assumes that a substantial proportion of smokers would actually be interested in receiving free nicotine replacement therapy and would use it in an attempt to quit. Previous studies^4,5 have reported a high level of interest among smokers; however, their results may reflect a response bias rather than a true intention to use nicotine replacement therapy. Health care professionals need to know how receptive smokers are to using nicotine replacement therapy. We sought to evaluate smokers'' attitudes by asking novel questions about their interest in receiving free nicotine replacement therapy and what they would do if they received it.     

Determination of carbohydrate-deficient transferrin separated by lectin affinity chromatography for detecting chronic alcohol abuse.

Carbohydrate-deficient transferrin (CDT) has been established as a valuable biological marker for detecting chronic alcohol abuse. To improve the diagnostic efficiency, we studied new CDT determination procedures involving the use of lectin affinity chromatography with Allomyrina dichotoma agglutinin (allo A) and Trichosanthes japonica agglutinin I (TJA-I) to isolate the CDT isoforms CDT-allo A and CDT-TJA, respectively. These procedures, based on detection of the CDT-allo A and CDT-TJA isoforms in sera, showed high sensitivity (100% and 98%, respectively) and high specificity (93% and 85%, respectively). These results demonstrate that the new procedures involving the use of lectin affinity chromatography are more useful for isolating markers in the CDT test than the conventional charge-based separation method.