The value of the CAGE in screening for alcohol abuse and alcohol dependence in general clinical populations: a diagnostic meta-analysis

Alcohol-associated liver disease: Epidemiology and management

Alcohol is the leading cause of preventable liver morbidity and mortality worldwide, as it is also the most frequent cause of advanced liver disease. Alcohol-associated liver disease (ALD) covers different phenotypes ranging from steatosis to the development of inflammation (steatohepatitis), fibrosis and ultimately, in a proportion of patients, the development of liver cirrhosis and its associated complications. ALD has a complex pathogenesis that includes the interplay of both genetic and environmental factors, yet the precise mechanisms are largely unknown. Alcohol-associated hepatitis (AH) is a severe clinical presentation of ALD, which is characterized by abrupt jaundice and clinical decompensations of liver disease. AH occurs in a percentage of patients with underlying ALD and active alcohol consumption. Currently, there are no approved targeted therapies able to interfere in the pathogenesis of ALD and halt the progression of the disease, therefore alcohol abstinence is the most effective measure to improve prognosis in this patient population. In this regard, alcohol cessation remains the first-line treatment in all stages of alcohol disease. In patients with advanced ALD nonresponding to medical therapy, liver transplantation is the only approach that improves prognosis, and it should be considered in patients with decompensated cirrhosis. In the last years, AH has emerged as a new indication of early liver transplantation in non-responders to medical therapy, with promising results in highly selected patients. In this review, we provide an update on the epidemiology, risk factors, natural history, diagnosis, pathogenesis, and current treatments for ALD, taking into account the importance of assessing and managing alcohol consumption as the etiological factor and the main driver of prognosis in patients with ALD.

Feasibility of delivering a virtual 1-day acceptance and commitment therapy workshop to rural veterans through community partnerships

Background

This single-arm, open pilot study examined the feasibility and initial efficacy of a 1-day virtual Acceptance and Commitment Therapy (ACT) group workshop for distressed veterans.

Methods

We collaborated with veteran-serving community-based organizations to enhance outreach to veterans, especially those in rural areas. Veterans completed a baseline assessment and two follow-up assessments (1 month, 3 months) after workshop participation. Feasibility outcomes included reach (workshop recruitment and completion rates; veteran characteristics) and acceptability (open-ended survey question about satisfaction). Clinical outcomes included psychological distress (Outcome Questionnaire-45), stressor-related distress (PTSD Checklist-5), community reintegration (Military to Civilian Questionnaire), and meaning and purpose (PROMIS Short Form). Psychological flexibility (Action and Acceptance Questionnaire-II) - the proposed change mechanism underlying ACT - was also measured.

Results

Sixty-four veterans (50% rural, 39% self-identified as female) participated in a virtual workshop (97.1% completion rate). Overall, veterans liked the format and interactive nature of workshops. Convenience was noted as a benefit, while connectivity issues were highlighted as a drawback. Veterans showed improvements in psychological distress (F(2,109) = 3.30; p = 0.041), stressor-related distress (F(2,110) = 9.50; p = 0.0002), community reintegration (F(2,108) = 4.34; p = 0.015), and meaning and purpose (F(2,100) = 4.06; p = 0.020) over time. No between-group differences were detected, based on rurality or gender.

Conclusion

Pilot findings were promising and warrant a larger randomized trial to assess the efficacy of the 1-day virtual ACT workshop. Integrating community-engaged and participatory-research designs can enhance the external validity of these future studies and promote greater health equity.

Spectrum, Screening, and Diagnosis of Alcohol-related Liver Disease

Alcohol-related liver disease (ALD) represents one of the leading causes of chronic liver disease and is a major cause of liver-related deaths worldwide. ALD encompasses a range of disorders including simple steatosis, alcoholic steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma. Patients with underlying ALD and continued heavy alcohol consumption can also develop an episode of acute-on-chronic liver injury called alcohol-associated hepatitis, the most severe form of the disease, which portends a poor prognosis. The most important risk factor for the development of ALD is the amount of alcohol consumed. Individual susceptibility to progression to advanced fibrosis among heavy drinkers is likely determined by a combination of behavioral, environmental, genetic, and epigenetic factors, but the mechanisms are largely unknown. The only effective therapy for ALD is prolonged alcohol abstinence. Diagnosis of ALD involves assessing patients for alcohol use disorder and signs of advanced liver disease. In clinical practice, the histological assessment for ALD diagnosis is uncommon, and it is usually based on the medical history, clinical manifestations, and laboratory and imaging tests. Several promising biomarkers that can have both diagnostic and prognostic value in patients with ALD have been identified in recent years. This review provides an overview of the clinical spectrum of ALD, the diagnostic approach of the disease from different perspectives as well as current diagnostic and prognostic biomarkers.

Meta-analysis of diagnostic test accuracy studies with multiple thresholds for data integration

OBJECTIVES

The objective of this study is to introduce methods to use all of the information without omission when individual studies provide multiple effect sizes according to multiple cut-off values (thresholds) during diagnostic test accuracy (DTA) for data integration. For diagnostic test meta-analysis, a general performance method for synthesizing data according to one cut value in one study and a performance method for synthesizing data according to two or more cut values in one study were compared and analyzed.

METHODS

As sample data for meta-analysis of DTA studies, 13 DTA studies on prostate cancer (34 effect sizes including total cut-offs) were collected. The summary statistics were calculated and the summary line was analyzed using the "meta", "mada", and "diagmeta" packagesof the R software.

RESULTS

The summary statistics of the random effect model univariate analysis of the "meta" package with a single cut-off corresponding to the highest Youden index in a single study and those of the bivariate analysis of the "mada" package were highly similar. However, in the bivariate analysis of the "diagmeta" package including all cut-off values, the sensitivity decreased and the specificity increased as the amount of data increased.

CONCLUSIONS

Considering the heterogeneity of the summary receiver op erating characteristic curve and the use of all given cut-offs, the use of the bivariate analysis model of the "diagmeta" package is recommended. This study focused on practical methods of DTA rather than theoretical concepts for use by researchers whose fields of study are non-statistics related. By performing this study, we hope that many researchers will use R software to determine the DTA more easily, and that there will be greater interest in related research.

Pre-screening Ability of the Functional-Belief-Based Alcohol Use Questionnaire (FBAQ) among Chiang Mai University Undergraduates: An External Validation Study

BACKGROUND

High-risk drinking behavior is common in university students, which often leads to negative consequences. Several standard screening tools to identify high-risk drinkers have been validated in this domain. However, most tools rely on drinking frequency and require standard drink calculations. The Functional-Belief-Based Alcohol use Questionnaire (FBAQ) was recently proposed as a pre-screening tool for high-risk drinkers in the young adult population. We aimed to validate the pre-screening accuracy of the FBAQ when applied to external data of university undergraduates.

METHODS

Data from two prospective cross-sectional surveys of Chiang Mai University undergraduates were used for validation of the FBAQ. A high-risk drinker was defined as a person with the 12-month AUDIT score ≥ 8. Pre-screening performance and accuracy indices were presented separately for dataset I, dataset II, and the combined dataset. The pooled area under the receiver operating characteristic curve (AuROC), sensitivity, and specificity were estimated using individual patient data meta-analysis methods.

RESULTS

From the two datasets, 1641 students were included, 811 students in 2019 and 830 students in 2020. Of these, 387 (23.6 %) students were classified as high-risk drinkers. The combined AuROC of the FBAQ score was 0.83 (95 %CI 0.75-0.92) in discriminating high-risk drinkers. The pooled sensitivity and specificity at the FBAQ score cutoff ≥ 6 were 92.8 % (95 %CI 88.0-95.7 %) and 51.6 % (95 %CI 41.1-62.0 %).

CONCLUSIONS

In this external validation, the FBAQ shows excellent discriminative ability and is proven to be highly sensitive in detecting high-risk drinkers among Chiang Mai University undergraduates. Therefore, incorporating the FBAQ as a pre-screening tool to the AUDIT could make the initiation of the screening process easier and reduce extensive AUDIT evaluations in students with low risk.

Group Support for Smoking Cessation: Importance of the Smoker's Choice for Better Outcomes

Smoking cessation method effectiveness is discussed among socially disadvantaged smokers. Our aim was to measure real-life effectiveness of the choice of a multi-component group intervention in comparison with individual usual care. We report an observational study (N = 100). Disadvantaged smokers were screened with a validated tool. We designed a multi-component structured behavioural group intervention, delivered in weekly group sessions during 6 weeks. Usual care consisted of individual visits. Both groups received free nicotine replacement therapy. We observed 33 smokers participating in the group intervention, while 67 received usual care. Abstinence at 6 weeks was 24.2% (n = 8) in the group intervention versus 11.9% (n = 8) in usual care (p = .115). Also, 36.4% (n = 12) of group intervention patients had reduced their cigarette consumption versus 16.4% (n = 11) in usual care (p = .026). In addition, 6.1% (n = 2) dropped out of group versus 31.3% (n = 21) in usual care (p = .005). Finally, 6 months after their first visit, 15.2% (n = 5) of group intervention patients and 4.5% (n = 3) in usual care were abstinent (p = .111). Group intervention choice versus usual care might facilitate smoking abstinence, reduction, and follow-up adherence.

Increased Reward-Related Activation in the Ventral Striatum During Stress Exposure Associated With Positive Affect in the Daily Life of Young Adults With a Family History of Depression. Preliminary Findings

Background: Being the offspring of a parent with major depression disorder (MDD) is a strong predictor for developing MDD. Blunted striatal responses to reward were identified in individuals with MDD and in asymptomatic individuals with family history of depression (FHD). Stress is a major etiological factor for MDD and was also reported to reduce the striatal responses to reward. The stress-reward interactions in FHD individuals has not been explored yet. Extending neuroimaging results into daily-life experience, self-reported ambulatory measures of positive affect (PA) were shown to be associated with striatal activation during reward processing. A reduction of self-reported PA in daily life is consistently reported in individuals with current MDD. Here, we aimed to test (1) whether increased family risk of depression is associated with blunted neural and self-reported reward responses. (2) the stress-reward interactions at the neural level. We expected a stronger reduction of reward-related striatal activation under stress in FHD individuals compared to HC. (3) the associations between fMRI and daily life self-reported data on reward and stress experiences, with a specific interest in the striatum as a crucial region for reward processing. Method: Participants were 16 asymptomatic young adults with FHD and 16 controls (HC). They performed the Fribourg Reward Task with and without stress induction, using event-related fMRI. We conducted whole-brain analyses comparing the two groups for the main effect of reward (rewarded > not-rewarded) during reward feedback in control (no-stress) and stress conditions. Beta weights extracted from significant activation in this contrast were correlated with self-reported PA and negative affect (NA) assessed over 1 week. Results: Under stress induction, the reward-related activation in the ventral striatum (VS) was higher in the FHD group than in the HC group. Unexpectedly, we did not find significant group differences in the self-reported daily life PA measures. During stress induction, VS reward-related activation correlated positively with PA in both groups and negatively with NA in the HC group. Conclusion: As expected, our results indicate that increased family risk of depression was associated with specific striatum reactivity to reward in a stress condition, and support previous findings that ventral striatal reward-related response is associated with PA. A new unexpected finding is the negative association between NA and reward-related ventral striatal activation in the HC group.

Prevalence, clustering and combined effects of lifestyle behaviours and their association with health after retirement age in a prospective cohort study, the Nord-Trøndelag Health Study, Norway

Background

Lifestyle behaviours are potential risk factors for disease and mortality, but less is known about the association with health in retirement age. The aim of this paper was to study the prevalence, clustering and combined effects of lifestyle behaviours and their association with health outcomes in the first decade after retirement in a Norwegian cohort.

Methods

Participants were 55–64-year-olds at baseline in the Nord-Trøndelag Health Survey 2 (HUNT2, 1995–97) who also participated in HUNT3 (2006–08). Logistic regression analyses were used to investigate the association of daily smoking, physical inactivity, risky alcohol consumption, disturbed sleep duration, excessive sitting time and low social participation before retirement with self-rated health (n = 4022), life satisfaction (n = 5134), anxiety (n = 4461) and depression (n = 5083) after retirement, 11 years later.

Results

Low social participation and physical inactivity were the most prevalent lifestyle behaviours (41.1 and 40.6%). Risky alcohol consumption and disturbed sleep were the lifestyle behaviours most strongly associated with poor self-rated health, poor life satisfaction and anxiety after retirement (OR’s = 1.39–1.92). Physical inactivity was additionally associated with depression (OR = 1.44 (1.12–1.85)). Physical inactivity had the largest population attributable fractions for reducing poor self-rated health and depression (14.9 and 8.8%). An increasing number of lifestyle risk behaviours incrementally increased the risk for the adverse health outcomes.

Conclusions

Risky alcohol consumption and disturbed sleep duration were most strongly associated with poor health outcomes after retirement age. On a population level, increased physical activity before retirement had the largest potential for reducing adverse health outcomes after retirement age.

Alcohol-related liver disease: Clinical practice guidelines by the Latin American Association for the Study of the Liver (ALEH)

Alcohol-related liver disease (ALD) is a major cause of advanced chronic liver disease in Latin-America, although data on prevalence is limited. Public health policies aimed at reducing the alarming prevalence of alcohol use disorder in Latin-America should be implemented. ALD comprises a clinical-pathological spectrum that ranges from steatosis, steatohepatitis to advanced forms such as alcoholic hepatitis (AH), cirrhosis and hepatocellular carcinoma. Besides genetic factors, the amount of alcohol consumption is the most important risk factor for the development of ALD. Continuous consumption of more than 3 standard drinks per day in men and more than 2 drinks per day in women increases the risk of developing liver disease. The pathogenesis of ALD is only partially understood and recent translational studies have identified novel therapeutic targets. Early forms of ALD are often missed and most clinical attention is focused on AH, which is defined as an abrupt onset of jaundice and liver-related complications. In patients with potential confounding factors, a transjugular biopsy is recommended. The standard therapy for AH (i.e. prednisolone) has not evolved in the last decades yet promising new therapies (i.e. G-CSF, N-acetylcysteine) have been recently proposed. In both patients with early and severe ALD, prolonged abstinence is the most efficient therapeutic measure to decrease long-term morbidity and mortality. A multidisciplinary team including alcohol addiction specialists is recommended to manage patients with ALD. Liver transplantation should be considered in the management of patients with end-stage ALD that do not recover despite abstinence. In selected cases, increasing number of centers are proposing early transplantation for patients with severe AH not responding to medical therapy.

Smoking in relation to anxiety and depression: Evidence from a large population survey: The HUNT study

Smoking is reported to be associated with depression and anxiety. The present study (a) examines these associations taking comorbidity into account, (b) investigates possible confounders, (c) examines how former smokers compared to current and never-smokers in terms of anxiety and depression, and if anxiety and depression decline by time since cessation. Participants (66%) aged 20–89 years in a population-based health survey (N = 60,814) were screened employing the HADS. (a) The association with smoking was strongest in comorbid anxiety depression, followed by anxiety, and only marginal in depression. Associations were stronger in females and younger participants. (b) Variables partly accounting for the association comprised somatic symptoms, socio-demographics, alcohol problems, and low physical activity. (c) Anxiety and depression were most common in current smokers, followed by quitters, and then never-smokers. No decline in anxiety or depression was found with time since cessation. Previous studies of associations between depression and smoking might have overestimated the association when ignoring comorbid anxiety.

Factors Associated With Opiate Use Among Psychiatric Inpatients: A Population-Based Study of Hospital Admissions in Ontario, Canada

Background:

Use of opiates, including synthetic opioids, is associated with a number of negative consequences, including increased risk of opioid use disorders and other mental health conditions. However, studies are limited in examining patterns of opiate use among persons in inpatient psychiatry, particularly those that consider the relationship between pain and opiate use.

Objective:

This study examined the prevalence in the prior 12 months to admission and patterns of opiate use and pain in a population-based study of persons admitted to inpatient psychiatry in Ontario, Canada.

Methods:

We conducted retrospective cross-sectional study of 165 434 persons admitted to inpatient psychiatry between January 1, 2006 and December 31, 2017. Using data from the Resident Assessment Instrument for Mental Health, we examined prevalence and factors associated with opiate use in the prior 12 months by a number of patient characteristics, including demographics, mental and physical health status, concurrent substance use, pain severity and frequency, and health region of residence.

Results:

The prevalence of opiate use within 12 months of admission was 7.5%, between 17% and 22% among those experiencing daily pain, and 27% among persons with a primary substance use disorder. Multivariable analyses revealed strong associations among demographic and clinical variables with opiate use (c = 0.91), including being of younger age, use of other substances, greater frequency and severity of pain, and health region of residence.

Conclusion:

The strong relationship between pain and opiate use in this population, and the regional variation in this pattern, supports the need for integrated care for mental illness and substance use, and therapeutic approaches to pain management that reduce risks of problems associated with substance use for persons with mental health conditions.

Alcoholic Liver Disease: Alcohol Metabolism, Cascade of Molecular Mechanisms, Cellular Targets, and Clinical Aspects

Alcoholic liver disease is the result of cascade events, which clinically first lead to alcoholic fatty liver, and then mostly via alcoholic steatohepatitis or alcoholic hepatitis potentially to cirrhosis and hepatocellular carcinoma. Pathogenetic events are linked to the metabolism of ethanol and acetaldehyde as its first oxidation product generated via hepatic alcohol dehydrogenase (ADH) and the microsomal ethanol-oxidizing system (MEOS), which depends on cytochrome P450 2E1 (CYP 2E1), and is inducible by chronic alcohol use. MEOS induction accelerates the metabolism of ethanol to acetaldehyde that facilitates organ injury including the liver, and it produces via CYP 2E1 many reactive oxygen species (ROS) such as ethoxy radical, hydroxyethyl radical, acetyl radical, singlet radical, superoxide radical, hydrogen peroxide, hydroxyl radical, alkoxyl radical, and peroxyl radical. These attack hepatocytes, Kupffer cells, stellate cells, and liver sinusoidal endothelial cells, and their signaling mediators such as interleukins, interferons, and growth factors, help to initiate liver injury including fibrosis and cirrhosis in susceptible individuals with specific risk factors. Through CYP 2E1-dependent ROS, more evidence is emerging that alcohol generates lipid peroxides and modifies the intestinal microbiome, thereby stimulating actions of endotoxins produced by intestinal bacteria; lipid peroxides and endotoxins are potential causes that are involved in alcoholic liver injury. Alcohol modifies SIRT1 (Sirtuin-1; derived from Silent mating type Information Regulation) and SIRT2, and most importantly, the innate and adapted immune systems, which may explain the individual differences of injury susceptibility. Metabolic pathways are also influenced by circadian rhythms, specific conditions known from living organisms including plants. Open for discussion is a 5-hit working hypothesis, attempting to define key elements involved in injury progression. In essence, although abundant biochemical mechanisms are proposed for the initiation and perpetuation of liver injury, patients with an alcohol problem benefit from permanent alcohol abstinence alone.

Alcoholic steatohepatitis (ASH) and alcoholic hepatitis (AH): cascade of events, clinical aspects, and pharmacotherapy options

INTRODUCTION

Clinicians caring for patients with alcoholic hepatitis (AH) are often confronted with the question of the best pharmacotherapy to be used.

AREAS COVERED

This article covers metabolic aspects of alcohol as the basis of understanding pharmacotherapy and to facilitate choosing the drug therapeutic options for patients with severe AH.

EXPERT OPINION

Alcoholic steatohepatitis (ASH) and alcoholic hepatitis (AH) as terms are often used interchangeably in scientific literature but a stringent differentiation is recommended for proper clarity. As opposed to ASH, the clinical course of AH is often severe and requires an effective drug treatment strategy, in addition to absolute alcohol abstinence and nutritional support. Drug options include corticosteroids as a first choice and pentoxifylline, an inhibitor of phosphodiesterase, as a second line therapy, especially in patients with contraindications for a corticosteroid therapy such as infections or sepsis. At seven days under corticosteroids, treatment should be terminated in non-responders, and patients must then be evaluated for liver transplantation. Pentoxifylline is not effective as a rescue therapy for these patients. Other treatments such as infliximab, propylthiouracil, N-acetylcysteine, silymarin, colchicine, insulin and glucagon, oxandrolone, testosterone, and polyunsaturated lecithin are not effective in severe AH. For liver transplantation, few patients will be eligible.

Recent trends in liver transplantation for alcoholic liver disease in the United States

AIM

To examine temporal changes in the indications for liver transplantation (LT) and characteristics of patients transplanted for alcoholic liver disease (ALD).

METHODS

We performed a retrospective cohort analysis of trends in the indication for LT using the United Network for Organ Sharing (UNOS) database between 2002 and 2015. Patients were grouped by etiology of the liver disease and characteristics were compared using χ² and t-tests. Time series analysis was used identifying any year with a significant change in the number of transplants per year for ALD, and before and after eras were modeled using a general linear model. Subgroup analysis of recipients with ALD was performed by age group, gender, UNOS region and etiology (alcoholic cirrhosis, alcoholic hepatitis and hepatitis C - alcoholic cirrhosis dual listing).

RESULTS

Of 74216 liver transplant recipients, ALD (n = 9400, 12.7%) was the third leading indication for transplant after hepatitis C and hepatocellular carcinoma. Transplants for ALD, increased from 12.8% (553) in 2002 to 16.5% (1020) in 2015. Time series analysis indicated a significant increase in the number of transplants per year for ALD in 2013 (P = 0.03). There were a stable number of transplants per year between 2002 and 2012 (linear coefficient 3, 95%CI: -4.6, 11.2) an increase of 177 per year between 2013 and 2015 (95%CI: 119, 234). This increase was significant for all age groups except those 71-83 years old, was observed for both genders, and was incompletely explained by a decrease in transplants for hepatitis C and ALD dual listing. All UNOS regions except region 9 saw an increase in the mean number of transplants per year when comparing eras, and this increase was significant in regions 2, 3, 4, 5, 6, 8, 10 and 11.

CONCLUSION

There has been a dramatic increase in the number of transplants for ALD starting in 2013.

Meta-analysis of test accuracy studies using imputation for partial reporting of multiple thresholds

Introduction

For tests reporting continuous results, primary studies usually provide test performance at multiple but often different thresholds. This creates missing data when performing a meta‐analysis at each threshold. A standard meta‐analysis (no imputation [NI]) ignores such missing data. A single imputation (SI) approach was recently proposed to recover missing threshold results. Here, we propose a new method that performs multiple imputation of the missing threshold results using discrete combinations (MIDC).

Methods

The new MIDC method imputes missing threshold results by randomly selecting from the set of all possible discrete combinations which lie between the results for 2 known bounding thresholds. Imputed and observed results are then synthesised at each threshold. This is repeated multiple times, and the multiple pooled results at each threshold are combined using Rubin's rules to give final estimates. We compared the NI, SI, and MIDC approaches via simulation.

Results

Both imputation methods outperform the NI method in simulations. There was generally little difference in the SI and MIDC methods, but the latter was noticeably better in terms of estimating the between‐study variances and generally gave better coverage, due to slightly larger standard errors of pooled estimates. Given selective reporting of thresholds, the imputation methods also reduced bias in the summary receiver operating characteristic curve. Simulations demonstrate the imputation methods rely on an equal threshold spacing assumption. A real example is presented.

Conclusions

The SI and, in particular, MIDC methods can be used to examine the impact of missing threshold results in meta‐analysis of test accuracy studies.

A comparison of bivariate, multivariate random-effects, and Poisson correlated gamma-frailty models to meta-analyze individual patient data of ordinal scale diagnostic tests

Individual patient data (IPD) meta-analyses are increasingly common in the literature. In the context of estimating the diagnostic accuracy of ordinal or semi-continuous scale tests, sensitivity and specificity are often reported for a given threshold or a small set of thresholds, and a meta-analysis is conducted via a bivariate approach to account for their correlation. When IPD are available, sensitivity and specificity can be pooled for every possible threshold. Our objective was to compare the bivariate approach, which can be applied separately at every threshold, to two multivariate methods: the ordinal multivariate random-effects model and the Poisson correlated gamma-frailty model. Our comparison was empirical, using IPD from 13 studies that evaluated the diagnostic accuracy of the 9-item Patient Health Questionnaire depression screening tool, and included simulations. The empirical comparison showed that the implementation of the two multivariate methods is more laborious in terms of computational time and sensitivity to user-supplied values compared to the bivariate approach. Simulations showed that ignoring the within-study correlation of sensitivity and specificity across thresholds did not worsen inferences with the bivariate approach compared to the Poisson model. The ordinal approach was not suitable for simulations because the model was highly sensitive to user-supplied starting values. We tentatively recommend the bivariate approach rather than more complex multivariate methods for IPD diagnostic accuracy meta-analyses of ordinal scale tests, although the limited type of diagnostic data considered in the simulation study restricts the generalization of our findings.

Correlates of depression in self-neglecting older adults: A cross-sectional study examining the role of alcohol abuse and pain in increasing vulnerability

Self-neglect among older adults results in increased morbidity and mortality rates. Depression is strongly linked to self-neglect and when untreated, severely complicates management of health and functional outcomes. The study aims to identify factors correlated with depression to inform approaches to service recruitment and retention that improve long-term outcomes. The sample included urban community-dwelling older adults (n = 96) 65 years of age and older with Adult Protective Services-substantiated self-neglect. All participants completed a range of validated cognitive, functional, and self-report demographic and clinical measures around health and mental health functioning. A secondary data analysis using multivariable logistic regression revealed that a positive screen for alcohol abuse, low self-rated health, and higher self-reported pain were associated with significantly higher odds of self-reported depression. Further research is needed to understand the temporality between these correlates and depression and to inform prevention and intervention practices for self-neglecting older adults.

Use of Family CAGE-AID questionnaire to screen the family members for diagnosis of substance dependence

BACKGROUND & OBJECTIVES

CAGE-AID questionnaire is a short, useful screening tool for substance dependence. Assessment of one family member for the screening of substance dependence in the family could be useful in clinical practice and research. In this study, we aimed to assess the validity of the Family CAGE-AID questionnaire for the diagnosis of substance dependence.

METHODS

Cross-sectional assessments using CAGE-AID and Family CAGE-AID questionnaires were conducted both for the study participants (n = 210) and their family members. The participants were recruited from two different treatment settings: a treatment seeking population from a de-addiction centre, and non-treatment seekers for substance use disorders from the psychiatry outpatient department. ICD-10 criteria and subsequent detailed clinical interview by a trained psychiatrist were used for the final diagnosis of substance dependence.

RESULTS

In the psychiatry outpatient group, the scores on CAGE-AID and Family CAGE-AID questionnaires were significantly correlated with the ICD-10 symptom score (r=0.81 and 0.70, respectively). In the same group, inter-rater agreement of the Family CAGE-AID was good with CAGE-AID and moderate with ICD-10 diagnosis of substance dependence (Cohen's kappa 0.78 and 0.61, respectively). A cut-off score of three on Family CAGE-AID was found to be 95·8 per cent sensitive and 100 per cent specific.

INTERPRETATION & CONCLUSIONS

Family CAGE-AID questionnaire is a valid screening instrument for the diagnosis of substance dependence, with acceptable sensitivity and specificity of a cut-off score of three. The simplicity and the brevity of such an instrument can be valuable in the clinical settings of developing countries and also for epidemiological studies.

Contribution of Swedish moist snuff to the metabolic syndrome: A wolf in sheep's clothing?

Aim: Combined effects of genetic and environmental factors underlie the clustering of cardiovascular risk factors in the metabolic syndrome (MetSy). The aim was to investigate associations between several lifestyle factors and MetSy, with a focus on the possible role of smokeless tobacco in the form of Swedish moist snuff (snus). Methods: A population-based longitudinal cohort study within the Västerbotten Intervention Programme in Northern Sweden. All inhabitants at the ages of 30, 40, 50, and 60 are invited to participate in a health survey that includes a questionnaire on psychosocial conditions and lifestyle and measurement of biological variables. Individuals examined in 1990—94 (n=24,230) and who also returned for follow-up after 10 years were included (total of 16,492 individuals: 46.6% men and 53.4% women). Regression analyses were performed. MetSy was the outcome and analyses were adjusted for age, sex, alcohol abuse, and family history of CVD and diabetes. Results: Ten-year development of MetSy was associated with high-dose consumption of snus at baseline (OR 1.6 [95% CI 1.26—2.15]), low education (2.2 [1.92—2.63]), physical inactivity (1.5 [1.22—1.73]) and former smoking (1.2 [1.06—1.38]). Snus was associated with separate components of MetSy, including triglycerides (1.6, 1.30—1.95), obesity (1.7 [1.36—2.18]) but not hypertension, dysglycemia and low HDL cholesterol. Conclusions: MetSy is independently associated with high consumption of snus, even when controlling for smoking status. The finding is of public health interest in societies with widespread use of snus. More research is needed to better understand the mechanisms underlying this effect.

Time-Site Survey of Substance Use, Sexual Behaviours, and HIV-Testing Practices among Women Attending Social Venues in Prague

AIM

The rates of HIV acquired through heterosexual contact are increasing in the Czech Republic. This study explored potential HIV risk associa-tions with alcohol, illicit drugs and sexual behaviours among adults from a community-based sample attending gay- and non-gay venues in Prague.

METHODS

Women attending bars, cafes and beer gardens in central Prague responded to the self-administered, time-site survey. Alcohol use was measured by the AUDIT-C and CAGE questionnaires. Sexual network structuring identified number, gender and coital frequency with current and recent sexual partners. Statistical analysis included central tendency, chi-square and logistic regression. Female participants (n=124) ranged from 18 to 67 years of age (mean 29 years); 25% self-identified as non-heterosexual.

RESULTS

We found alcohol to be the preferred drug of choice. Younger heterosexual women with new and casual sexual partners were more likely to use alcohol excessively. Women with children reported the least alcohol use. Sixty percent of the sample had never used condoms; condom-use was associated with longer relationship duration and discussions about HIV status with a sexual partner; non-use tended to occur among unmarried women with multiple male partners in short, serial sexual relationships. Women who sought HIV testing tended to be younger and more self-identified as non-heterosexual. Protective practices were rarely reported even when HIV transmission increases via heterosexual sexual partnering.

CONCLUSION

Further research is recommended regarding cultural and contextual influences on HIV risk behaviours among Czech women.

Modelling multiple thresholds in meta-analysis of diagnostic test accuracy studies

BACKGROUND

In meta-analyses of diagnostic test accuracy, routinely only one pair of sensitivity and specificity per study is used. However, for tests based on a biomarker or a questionnaire often more than one threshold and the corresponding values of true positives, true negatives, false positives and false negatives are known.

METHODS

We present a new meta-analysis approach using this additional information. It is based on the idea of estimating the distribution functions of the underlying biomarker or questionnaire within the non-diseased and diseased individuals. Assuming a normal or logistic distribution, we estimate the distribution parameters in both groups applying a linear mixed effects model to the transformed data. The model accounts for across-study heterogeneity and dependence of sensitivity and specificity. In addition, a simulation study is presented.

RESULTS

We obtain a summary receiver operating characteristic (SROC) curve as well as the pooled sensitivity and specificity at every specific threshold. Furthermore, the determination of an optimal threshold across studies is possible through maximization of the Youden index. We demonstrate our approach using two meta-analyses of B type natriuretic peptide in heart failure and procalcitonin as a marker for sepsis.

CONCLUSIONS

Our approach uses all the available information and results in an estimation not only of the performance of the biomarker but also of the threshold at which the optimal performance can be expected.

Toward quantifying the abuse liability of ultraviolet tanning: A behavioral economic approach to tanning addiction

Many adults engage in ultraviolet indoor tanning despite evidence of its association with skin cancer. The constellation of behaviors associated with ultraviolet indoor tanning is analogous to that in other behavioral addictions. Despite a growing literature on ultraviolet indoor tanning as an addiction, there remains no consensus on how to identify ultraviolet indoor tanning addictive tendencies. The purpose of the present study was to translate a behavioral economic task more commonly used in substance abuse to quantify the "abuse liability" of ultraviolet indoor tanning, establish construct validity, and determine convergent validity with the most commonly used diagnostic tools for ultraviolet indoor tanning addiction (i.e., mCAGE and mDSM-IV-TR). We conducted a between-groups study using a novel hypothetical Tanning Purchase Task to quantify intensity and elasticity of ultraviolet indoor tanning demand and permit statistical comparisons with the mCAGE and mDSM-IV-TR. Results suggest that behavioral economic demand is related to ultraviolet indoor tanning addiction status and adequately discriminates between potential addicted individuals from nonaddicted individuals. Moreover, we provide evidence that the Tanning Purchase Task renders behavioral economic indicators that are relevant to public health research. The present findings are limited to two ultraviolet indoor tanning addiction tools and a relatively small sample of high-risk ultraviolet indoor tanning users; however, these pilot data demonstrate the potential for behavioral economic assessment tools as diagnostic and research aids in ultraviolet indoor tanning addiction studies.

Transient and 2-Dimensional Shear-Wave Elastography Provide Comparable Assessment of Alcoholic Liver Fibrosis and Cirrhosis

BACKGROUND & AIMS

Alcohol abuse causes half of all deaths from cirrhosis in the West, but few tools are available for noninvasive diagnosis of alcoholic liver disease. We evaluated 2 elastography techniques for diagnosis of alcoholic fibrosis and cirrhosis; liver biopsy with Ishak score and collagen-proportionate area were used as reference.

METHODS

We performed a prospective study of 199 consecutive patients with ongoing or prior alcohol abuse, but without known liver disease. One group of patients had a high pretest probability of cirrhosis because they were identified at hospital liver clinics (in Southern Denmark). The second, lower-risk group, was recruited from municipal alcohol rehabilitation centers and the Danish national public health portal. All subjects underwent same-day transient elastography (FibroScan), 2-dimensional shear wave elastography (Supersonic Aixplorer), and liver biopsy after an overnight fast.

RESULTS

Transient elastography and 2-dimensional shear wave elastography identified subjects in each group with significant fibrosis (Ishak score ≥3) and cirrhosis (Ishak score ≥5) with high accuracy (area under the curve ≥0.92). There was no difference in diagnostic accuracy between techniques. The cutoff values for optimal identification of significant fibrosis by transient elastography and 2-dimensional shear wave elastography were 9.6 kPa and 10.2 kPa, and for cirrhosis 19.7 kPa and 16.4 kPa. Negative predictive values were high for both groups, but the positive predictive value for cirrhosis was >66% in the high-risk group vs approximately 50% in the low-risk group. Evidence of alcohol-induced damage to cholangiocytes, but not ongoing alcohol abuse, affected liver stiffness. The collagen-proportionate area correlated with Ishak grades and accurately identified individuals with significant fibrosis and cirrhosis.

CONCLUSIONS

In a prospective study of individuals at risk for liver fibrosis due to alcohol consumption, we found elastography to be an excellent tool for diagnosing liver fibrosis and for excluding (ruling out rather than ruling in) cirrhosis.

Biomolecules and Biomarkers Used in Diagnosis of Alcohol Drinking and in Monitoring Therapeutic Interventions

BACKGROUND

The quantitative, measurable detection of drinking is important for the successful treatment of alcohol misuse in transplantation of patients with alcohol disorders, people living with human immunodeficiency virus that need to adhere to medication, and special occupational hazard offenders, many of whom continually deny drinking. Their initial misconduct usually leads to medical problems associated with drinking, impulsive social behavior, and drunk driving. The accurate identification of alcohol consumption via biochemical tests contributes significantly to the monitoring of drinking behavior.

METHODS

A systematic review of the current methods used to measure biomarkers of alcohol consumption was conducted using PubMed and Google Scholar databases (2010-2015). The names of the tests have been identified. The methods and publications that correlate between the social instruments and the biochemical tests were further investigated. There is a clear need for assays standardization to ensure the use of these biochemical tests as routine biomarkers.

FINDINGS

Alcohol ingestion can be measured using a breath test. Because alcohol is rapidly eliminated from the circulation, the time for detection by this analysis is in the range of hours. Alcohol consumption can alternatively be detected by direct measurement of ethanol concentration in blood or urine. Several markers have been proposed to extend the interval and sensitivities of detection, including ethyl glucuronide and ethyl sulfate in urine, phosphatidylethanol in blood, and ethyl glucuronide and fatty acid ethyl esters in hair, among others. Moreover, there is a need to correlate the indirect biomarker carbohydrate deficient transferrin, which reflects longer lasting consumption of higher amounts of alcohol, with serum γ-glutamyl transpeptidase, another long term indirect biomarker that is routinely used and standardized in laboratory medicine.

Diagnosis and Management of Alcoholic Liver Disease

Alcohol is a leading cause of liver disease and is associated with significant morbidity and mortality. Several factors, including the amount and duration of alcohol consumption, affect the development and progression of alcoholic liver disease (ALD). ALD represents a spectrum of liver pathology ranging from fatty change to fibrosis to cirrhosis. Early diagnosis of ALD is important to encourage alcohol abstinence, minimize the progression of liver fibrosis, and manage cirrhosis-related complications including hepatocellular carcinoma. A number of questionnaires and laboratory tests are available to screen for alcohol intake. Liver biopsy remains the gold-standard diagnostic tool for ALD, but noninvasive accurate alternatives, including a number of biochemical tests as well as liver stiffness measurement, are increasingly being utilized in the evaluation of patients with suspected ALD. The management of ALD depends largely on complete abstinence from alcohol. Supportive care should focus on treating alcohol withdrawal and providing enteral nutrition while managing the complications of liver failure. Alcoholic hepatitis (AH) is a devastating acute form of ALD that requires early recognition and specialized tertiary medical care. Assessment of AH severity using defined scoring systems is important to allocate resources and initiate appropriate therapy. Corticosteroids or pentoxifylline are commonly used in treating AH but provide a limited survival benefit. Liver transplantation represents the ultimate therapy for patients with alcoholic cirrhosis, with most transplant centers mandating a 6 month period of abstinence from alcohol before listing. Early liver transplantation is also emerging as a therapeutic measure in specifically selected patients with severe AH. A number of novel targeted therapies for ALD are currently being evaluated in clinical trials.

Patterns of alcohol consumption in the older population of Spain, 2008-2010

BACKGROUND

Older adults are a growing segment of the European population and alcohol is an important cause of disease burden; thus, it is noteworthy that little information is available on alcohol intake among older adults in Europe.

OBJECTIVE

The aim of this study was to examine alcohol consumption patterns and their association with demographic and clinical variables in the older population of Spain.

DESIGN

This was a cross-sectional study.

PARTICIPANTS/SETTING

The sample included 3,058 individuals, representative of the Spanish population aged ≥60 years during 2008-2010.

MAIN OUTCOME MEASURE

Regular alcohol consumption was measured with a validated diet history questionnaire. The threshold between moderate and heavy drinking was ≥40 g alcohol/day in men (≥24 g in women). Binge drinking was defined as intake of ≥80 g alcohol in men (≥60 g in women) during any drinking occasion in the previous month, and problem drinking by a CAGE score ≥2.

STATISTICAL ANALYSIS PERFORMED

The prevalence and 95% CI of the drinking patterns were calculated after accounting for sampling design.

RESULTS

The prevalence of moderate drinking was 44.3% (95% CI 42.0% to 46.6%) and of heavy drinking was 7.8% (95% CI 6.7% to 8.9%). In total, 68.4% (95% CI 65.7% to 71.2%) of individuals obtained >80% of alcohol from wine and 61.8% (95% CI 58.9% to 64.6%) drank only with meals. Furthermore, 1% (95% CI 0.6% to 1.4%) showed binge drinking and 3.1% (95% CI 2.3% to 3.8%) showed problem drinking. Heavy alcohol consumption was significantly more frequent in men. Moderate alcohol consumption was significantly less frequent among women, persons who were not married, living alone, with a diagnosis of diabetes, receiving treatment for diabetes, and with suboptimal self-rated health. About 5% to 10% of individuals with diagnosed hypertension, diabetes, or cardiovascular disease showed heavy drinking. Among those taking sleeping pills or antidiabetes or antithrombotic treatment, 37% to 46% had moderate alcohol intake and 5% to 8% had heavy intake.

CONCLUSIONS

Alcohol consumption among older adults in Spain is frequent and mostly consistent with the traditional Mediterranean drinking pattern. However, a proportion of individuals were heavy drinkers and used medication that may interact with alcohol.

Gene-Lifestyle Interactions in Complex Diseases: Design and Description of the GLACIER and VIKING Studies

Most complex diseases have well-established genetic and non-genetic risk factors. In some instances, these risk factors are likely to interact, whereby their joint effects convey a level of risk that is either significantly more or less than the sum of these risks. Characterizing these gene-environment interactions may help elucidate the biology of complex diseases, as well as to guide strategies for their targeted prevention. In most cases, the detection of gene-environment interactions will require sample sizes in excess of those needed to detect the marginal effects of the genetic and environmental risk factors. Although many consortia have been formed, comprising multiple diverse cohorts to detect gene-environment interactions, few robust examples of such interactions have been discovered. This may be because combining data across studies, usually through meta-analysis of summary data from the contributing cohorts, is often a statistically inefficient approach for the detection of gene-environment interactions. Ideally, single, very large and well-genotyped prospective cohorts, with validated measures of environmental risk factor and disease outcomes should be used to study interactions. The presence of strong founder effects within those cohorts might further strengthen the capacity to detect novel genetic effects and gene-environment interactions. Access to accurate genealogical data would also aid in studying the diploid nature of the human genome, such as genomic imprinting (parent-of-origin effects). Here we describe two studies from northern Sweden (the GLACIER and VIKING studies) that fulfill these characteristics.

Diagnostic challenges in alcohol use disorder and alcoholic liver disease

Alcohol use disorders represent a heterogeneous spectrum of clinical manifestations that have been defined by the Diagnostic and Statistical Manual of Mental Disorders-5. Excessive alcohol intake can lead to damage of various organs, including the liver. Alcoholic liver disease includes different injuries ranging from steatosis to cirrhosis and implicates a diagnostic assessment of the liver disease and of its possible complications. There is growing interest in the possible different tools for assessing previous alcohol consumption and for establishing the severity of liver injury, especially by non-invasive methods.

Stalking experiences and associated factors--a controlled population-based study from Norway

BACKGROUND

Stalking is a considerable health problem. In order to develop interventions for victims, more knowledge is needed concerning prevalence, stress and coping related to stalking as well as associated symptomatology in the victims. This is the first population-based study of stalking in Norway.

AIMS

To examine the prevalence of stalking in relation to gender and time, and the association with indicators of socio-demographic status and mental health.

METHODS

A cross-sectional case-control questionnaire design. The sample, 5000 Norwegians aged 20-59 years, was nationally representative according to gender, 10-year age groups and county of living. A total of 248 (5%) of the mailed envelops were returned due to wrong address, leaving 4752 individuals as possible respondents. Among them 1520 (32%) returned the questionnaire, but 98 of them had to be discarded due to lack of completion, giving a sample of 1422 valid questionnaires (30%).

RESULTS

The total weighted lifetime prevalence of stalking was 8.1% (95% CI 6.6-9.4%), for females 11.8% (95% CI 10.2-13.5%) and for males 4.3% (95% CI 3.2-5.3%) [corrected]. The point prevalence of current stalking was 2.8% (95% CI 2.0-3.7%). The stalked individuals had a significantly poorer social situation and mental health than the controls. Few significant group differences were observed between males and females exposed to stalking.

CONCLUSIONS

The prevalence of stalking was within the range observed by questionnaire studies in other cultures.

Accuracy of one or two simple questions to identify alcohol-use disorder in primary care: a meta-analysis

BACKGROUND

There is much interest in ultra-short alcohol screening in primary care that may support brief alcohol interventions. Brief screening consisting of one or two questions might be used alone or in combination with longer tests as recommended by the Primary Care Service Framework.

AIM

To investigate whether a simple one and two question screening might prove an accurate and acceptable screening method in primary care.

DESIGN AND SETTING

A systematic literature search, critical appraisal and meta-analysis were conducted.

METHOD

A comprehensive search identified 61 analyses of single questions to detect alcohol problems including 17 that took place in primary care, using a robust interview standard. Despite focusing alcohol-use disorder in primary care settings, heterogeneity remained high, therefore random effects and bivariate meta-analyses were used.

RESULTS

After adjustments, diagnostic accuracy of a single-question approach was given by a sensitivity of 54.5% (95% CI = 43.0% to 65.5%) and a specificity of 87.3% (95% CI = 81.5% to 91.5%) using meta-analytic weighting. Two questions had a sensitivity of 87.2% (95% CI = 69.9% to 97.7%) and specificity of 79.8% (95% CI = 75.7% to 83.6%). Looking at each question individually, the most successful single question was a modification of the Single Alcohol Screening Question (SASQ) namely, 'How often do you have six or more drinks on one occasion?'. The optimal approach appears to be two questions followed by the CAGE questionnaire, which achieved an overall accuracy of 90.9% and required only 3.3 questions per attendee.

CONCLUSION

Two brief questions can be used as an initial screen for alcohol problems but only when combined with a second-step screen. A brief alcohol intervention should be considered in those individuals who answer positively on both steps.

Assessing alcohol dependence in hospitalized patients

Alcohol misuse is generally not detected in hospital settings. The goal of this study was to estimate the prevalence of alcohol abuse and dependence in hospitalized patients in a university hospital in Sao Paulo (Brazil). Patients were randomly selected from all hospital admissions. The final sample consisted of 169 adult inpatients. Two screening tools were used: the Short Alcohol Dependence Data (SADD) and the CAGE questionnaires. In this sample, 25.4% of patients could be considered alcohol dependent according to the CAGE questionnaire, whereas 32.9% of patients fulfilled the criteria according to the SADD. The only predictor of alcohol dependence was gender; male inpatients were 3.2 times more prone to alcohol dependence with female inpatients. All inpatients should be systematically screened for alcohol use disorders. The choice of the screening tool will depend on whether the goal is to identify inpatients with hazardous drinking behaviors or with established alcohol-related problems. To maximize proper case identification, the CAGE questionnaire should be used as a first-step screening tool, and patients who screen positive on this scale should be subsequently administered the SADD questionnaire to assess the severity of the condition.

Meta-analysis and meta-modelling for diagnostic problems

BACKGROUND

A proportional hazards measure is suggested in the context of analyzing SROC curves that arise in the meta-analysis of diagnostic studies. The measure can be motivated as a special model: the Lehmann model for ROC curves. The Lehmann model involves study-specific sensitivities and specificities and a diagnostic accuracy parameter which connects the two.

METHODS

A study-specific model is estimated for each study, and the resulting study-specific estimate of diagnostic accuracy is taken as an outcome measure for a mixed model with a random study effect and other study-level covariates as fixed effects. The variance component model becomes estimable by deriving within-study variances, depending on the outcome measure of choice. In contrast to existing approaches - usually of bivariate nature for the outcome measures - the suggested approach is univariate and, hence, allows easily the application of conventional mixed modelling.

RESULTS

Some simple modifications in the SAS procedure proc mixed allow the fitting of mixed models for meta-analytic data from diagnostic studies. The methodology is illustrated with several meta-analytic diagnostic data sets, including a meta-analysis of the Mini-Mental State Examination as a diagnostic device for dementia and mild cognitive impairment.

CONCLUSIONS

The proposed methodology allows us to embed the meta-analysis of diagnostic studies into the well-developed area of mixed modelling. Different outcome measures, specifically from the perspective of whether a local or a global measure of diagnostic accuracy should be applied, are discussed as well. In particular, variation in cut-off value is discussed together with recommendations on choosing the best cut-off value. We also show how this problem can be addressed with the proposed methodology.

Binge drinking in Spain, 2008-2010

BACKGROUND

Most alcohol-related research has focused on northern and eastern Europe and the United States. Data on Mediterranean countries point to drinking patterns approaching the sporadic and excessive patterns found in northern and eastern Europe. This is the first study to estimate the prevalence of binge drinking (BD) and the joint distribution of BD, regular heavy alcohol consumption, and alcohol abuse or dependence (AAD) in a nationally representative sample of the adult population of Spain.

METHODS

Cross-sectional study conducted in 2008 to 2010 with 9,130 persons aged 18 to 64 years. BD was defined as intake of ≥80 g of alcohol in men (≥60 g in women) during any drinking occasion in the previous month, with ≥3 BD episodes discriminating between frequent and sporadic BD. Regular alcohol consumption was measured with a validated diet history, and the threshold between moderate and heavy drinking was ≥40 g of alcohol/d in men (≥24 g in women). AAD was defined by a CAGE score ≥2.

RESULTS

BD prevalence was 10% (95% confidence interval [CI]: 8.8 to 11.2) in men and 4.2% (95% CI: 3.5 to 4.8) in women, and proved highest among 18- to 24-year-olds (19.5% in men and 10.3% in women). During the latest BD episode, men consumed a mean of 114 g of alcohol versus 85.3 g in women; spirits accounted for 65.2 and 66.2% of total intake, respectively. The mean number of monthly BD episodes was 2.3 in men and 2 in women. Among binge drinkers, 61% were 18- to 34-year-olds, over 80% had regular moderate drinking, 25% reported frequent BD, and 22.8% reported AAD. In multivariate analyses, sporadic BD and frequent BD were associated with AAD independently of regular alcohol intake.

CONCLUSIONS

Prevalence of BD in Spain is moderately high. Prevention interventions should consider that the majority of binge drinkers are young men with regular moderate consumption and no AAD traits.

Does social disadvantage over the life-course account for alcohol and tobacco use in Irish people? Birth cohort study

Aims: Few studies have examined how the settlement experiences of migrant parents might impact on the downstream adult health of second-generation minority ethnic children. We used prospective data to establish if childhood adversity relating to the settlement experiences of Irish-born parents might account for downstream adverse health-related behaviours in second-generation Irish respondents in adulthood. Design, setting and participants: Cohort data from the National Child Development Study, comprising 17 000 births from a single week in 1958, from Britain, were analysed. Respondents were followed to mid-life. Dependent variables were alcohol and tobacco use. The contribution of life-course experiences in accounting for health-related behaviours was examined. Findings: Relative to the rest of the cohort, the prevalence of harmful/hazardous alcohol use was elevated in early adulthood for second-generation men and women, although it reduced by age 42. Second-generation Irish men were more likely to report binge alcohol use (odds ratio 1.45; 95% confidence interval 0.99, 2.11; P = 0.05), and second-generation Irish women were more likely to smoke (odds ratio 1.67; 95% confidence interval 1.23, 2.23; P = 0.001), at mid-life. Childhood disadvantage partially mediated associations between second-generation Irish status and mid-life alcohol and tobacco use, although these were modest for associations with smoking in Irish women. Conclusions: The findings suggest mechanisms for the intergenerational ‘transmission’ of health disadvantage in migrant groups, across generations. More attention needs to focus on the public health legacy of inequalities transferring from one migrant generation to the next.

Group interprofessional chronic pain management in the primary care setting: a pilot study of feasibility and effectiveness in a family health team in Ontario

BACKGROUND

Approximately 18.9% of Canadians live with chronic pain. Primary care reform in Ontario presents unique opportunities to assess approaches to help these patients.

OBJECTIVE

To assess the feasibility of an interprofessional primary care-based program for patients living with chronic pain, and to examine the potential impact of such a program on quality of life and health resource utilization.

METHODS

An embedded mixed-methods evaluation (randomized controlled trial with waiting list control and semistructured interviews) of an eight-week series of small group sessions exploring multifactoral aspects of pain management was performed. Participants were randomly assigned to early intervention (EI) or delayed intervention (DI) groups. All participants received the intervention; the DI group served as a control group for comparison with the EI group. Outcomes included the Short Form-36 Health Survey version 2 (SF-36v2), medication use and health care utilization. Qualitative interviews were conducted to identify areas for program improvement.

RESULTS

A total of 240 patients were recruited and 63 agreed to participate. The mean (± SD) age of the participants was 55±14.1 years and 62.3% were female. There was no significant difference in the mean change in SF-36v2 summary scores between the EI and DI groups. However, the SF-36v2 subscale score for bodily pain was significantly improved in the EI group compared with the DI group after six months of observation (mean difference = 13.1 points; P<0.05). There was also significant improvement in this score when both groups were pooled and aggregate preintervention and postintervention scores were compared. There was a significant decrease in the mean number of clinic visits in the six-month period following the intervention compared with the six-month period before the intervention (P=0.043).

CONCLUSION

An interprofessional program in primary care for patients living with chronic pain may lead to improvements in quality of life and health resource utilization. The challenges to the feasibility of the program and its evaluation are recruitment and retention of patients, leading to the conclusion that the program, as it was conducted in the present study, is not appropriate for this setting.

Validation of SURE, a four-item clinical checklist for detecting decisional conflict in patients

BACKGROUND

We sought to determine the psychometric properties of SURE, a 4-item checklist designed to screen for clinically significant decisional conflict in clinical practice.

METHODS

This study was a secondary analysis of a clustered randomized trial assessing the effect of DECISION+2, a 2-hour online tutorial followed by a 2-hour interactive workshop on shared decision making, on decisions to use antibiotics for acute respiratory infections. Patients completed SURE and also the Decisional Conflict Scale (DCS), as the gold standard, after consultation. We evaluated internal consistency of SURE using the Kuder-Richardson 20 coefficient (KR-20). We compared DCS and SURE scores using the Spearman correlation coefficient. We assessed sensitivity and specificity of SURE scores (cut-off score ≤3 out of 4) by identifying patients with and without clinically significant decisional conflict (DCS score >37.5 on a scale of 0-100).

RESULTS

Of the 712 patients recruited during the trial, 654 completed both tools. SURE scores showed adequate internal consistency (KR-20 coefficient of 0.7). There was a significant correlation between DCS and SURE scores (Spearman's ρ = -0.45, P < 0.0001). The prevalence of clinically significant decisional conflict as estimated by the DCS was 5.2% (95% CI 3.7-7.3). Sensitivity and specificity of SURE ≤3 were 94.1% (95% CI 78.9-99.0) and 89.8% (95% CI 87.1-92.0), respectively.

CONCLUSIONS

SURE shows adequate psychometric properties in a primary care population with a low prevalence of clinically significant decisional conflict. SURE has the potential to be a useful screening tool for practitioners, responding to the growing need for detecting clinically significant decisional conflict in patients.

How to apply the results of a research paper on diagnosis to your patient

Interpreting information on diagnostic accuracy is an area that health professionals struggle with. In this paper, we use the example of Mr Samways, a 45-year-old man with joint symptoms, to illustrate how to apply the results of a diagnostic accuracy study in clinical practice. We consider the various measures used to quantify diagnostic accuracy and discuss their clinical utility. We provide an overview of potential biases to consider when evaluating a diagnostic accuracy study and consider how to determine whether the results can be applied to a particular patient.

Alcohol use and hazardous drinking among medical specialists

BACKGROUND

Alcohol use among medical specialists remains a delicate topic. However, the number of prevalence studies remains very limited in Western European countries.

AIMS

To explore alcohol use and hazardous drinking among male and female medical specialists.

METHODS

All medical specialists in Belgium--a typical Western European country regarding alcohol use--were invited to participate. Alcohol use and abuse were measured using the Alcohol Use Disorder Identification Test (AUDIT) and the CAGE screen (acronym based on the four items it contains: 'Cut down drinking', 'Annoyed by criticism', 'Guilty feelings' and 'Eye opener').

RESULTS

A sample of 1,501 specialists completed the survey. The composition of the sample was comparable with that of the overall population of specialists in Belgium regarding gender, age and specialties. A proportion of 18% of the specialists could be classified as hazardous drinkers and 16.8% reported binge drinking at least once a month. Female medical specialists drank less than their male counterparts; however, a substantial proportion of female specialists (14.9%) displayed higher risk levels of hazardous drinking. Significant differences were found between specialties on the CAGE screen. Finally, younger medical specialists tended to display healthier alcohol use patterns compared with their older counterparts.

CONCLUSION

Medical specialists tend to indulge in more hazardous drinking compared with the general population (10%). The alcohol use patterns of female doctors tend to move towards those of males.

[Clinical Practice Guide for Early Detection, Diagnosis and Treatment of the Acute Intoxication Phase in Patients with Alcohol Abuse or Dependence: Part I: Screening, Early Detection and Risk Factors in Patients with Alcohol Abuse or Dependence]

INTRODUCTION

Worldwide, alcohol is the second most-used psychotropic substance and the third risk factor for early death and disability. Its noxious use is a world public health problem given its personal, labor, family, economic and social impact. 70 % of people under risk of having alcohol problems go undetected in medical practice, a fact that underlines the need for specific screening measures allowing early detection leading to timely treatment. This article presents evidence gathered by alcohol abuse and dependence screening as well as by risk factor identification and screening. It also presents evidence concerning withdrawal symptoms, delirium tremens and Wernicke's encephalopathy in order to promote early detection and timely treatment.

METHODOLOGY

Systematic revision of the evidence available together with an evaluation of pertinent guidelines found in literature so as to decide whether to adopt or adapt the existing recommendation for each question or to develop de novo recommendations. For de novo recommendations as well as those adapted, it was carried out an evidence synthesis, together with evidence tables and formulation of recommendations based on the evidence.

RESULTS

Evidence was found and recommendations were made for the pertinent screening and search of risk factors, in order to perform a diagnosis and carry out a timely management of alcohol abuse, dependence and ensuing complications: withdrawal syndrome, delirium tremens and Wernicke's encephalopathy.

Meta-analysis of diagnostic studies based upon SROC-curves: a mixed model approach using the Lehmann family

Meta-analysis of diagnostic studies experiences the common problem that different studies might not be comparable since they have been using a different cut-off value for the continuous or ordered categorical diagnostic test value defining different regions for which the diagnostic test is defined to be positive. Hence specificities and sensitivities arising from different studies might vary just because the underlying cut-off value had been different. To cope with the cut-off value problem, interest is usually directed towards the receiver operating characteristic (ROC) curve which consists of pairs of sensitivities and false positive rate (1–specificity). In the context of meta-analysis, one pair represents one study and the associated diagram is called SROC curve where the S stands for ‘summary’. The paper will consider—as a novel approach—modelling SROC curves with the Lehmann family that assumes log-sensitivity is proportional to the log-false positive rate across studies. The approach allows for study-specific false positive rates which are treated as (infinitely many) nuisance parameters and eliminated by means of the profile likelihood. The adjusted profile likelihood turns out to have a simple univariate Gaussian structure which is ultimately used for building inference for the parameter of the Lehmann family. The Lehmann model is further extended by allowing the constant of proportionality to vary across studies to cope with unobserved heterogeneity. The simple Gaussian form of the adjusted profile likelihood allows this extension easily as a form of a mixed model in which unobserved heterogeneity is incorporated by means of a normal random effect. Some meta-analytic applications on diagnostic studies including brain natriuretic peptides for heart failure, alcohol use disorder identification test (AUDIT) and the consumption part of AUDIT for detection of unhealthy alcohol use as well as the mini-mental state examination for cognitive disorders are discussed to illustrate the methodology.

CAGE, RAPS4, RAPS4-QF and AUDIT screening tests for men and women admitted for acute alcohol intoxication to an emergency department: are standard thresholds appropriate?

AIMS

A number of screening instruments are routinely used in Emergency Department (ED) situations to identify alcohol-use disorders (AUD). We wished to study the psychometric features, particularly concerning optimal thresholds scores (TSs), of four assessment scales frequently used to screen for abuse and/or dependence, the cut-down annoyed guilty eye-opener (CAGE), Rapid Alcohol Problem Screen 4 (RAPS4), RAPS4-quantity-frequency and AUD Identification Test (AUDIT) questionnaires, particularly in the sub-group of people admitted for acute alcohol intoxication (AAI).

METHODS

All included patients [AAI admitted to ED (blood alcohol level ≥0.8 g/l)] were assessed by the four scales, and with a gold standard (alcohol dependence/abuse section of the Mini International Neuropsychiatric Interview), to determine AUD status. To investigate the TSs of the scales, we used Youden's index, efficiency, receiver operating characteristic (ROC) curve techniques and quality ROC curve technique for optimized TS (indices of quality).

RESULTS

A total of 164 persons (122 males, 42 females) were included in the study. Nineteen (11.60%) were identified as alcohol abusers alone and 128 (78.1%) as alcohol dependents (DSM-IV). Results suggest a statistically significant difference between men and women (P < 0.05) in performance of the screening tests RAPS4 (≥1) and CAGE (≥2) for detecting abuse. Also, in this population, we show an increase in TSs of RAPS4 (≥2) and CAGE (≥3) for detecting dependence compared with those typically accepted in non-intoxicated individuals. The AUDIT test demonstrates good performance for detecting alcohol abuse and/or alcohol-dependent patients (≥7 for women and ≥12 for men) and for distinguishing alcohol dependence (≥11 for women and ≥14 for men) from other conditions.

CONCLUSION

Our study underscores for the first time the need to adapt, taking into account gender, the thresholds of tests typically used for detection of abuse and dependence in this population.

Screening for alcohol and drug use disorders among adults in primary care: a review

BACKGROUND: The Patient Protection and Affordable Care Act of 2010 supports integration of substance abuse interventions and treatments into the mainstream health care system. Thus, effective screening and intervention for substance use disorders in health care settings is a priority. OBJECTIVE: This paper reviews the prevalence of alcohol and drug use disorders (abuse or dependence) in primary care settings and emergency departments, as well as current screening tools and brief interventions. METHODS: MEDLINE was searched using the following keywords: alcohol use, alcohol use disorder, drug use, drug use disorder, screening, primary care, and emergency departments. Using the related-articles link, additional articles were screened for inclusion. This review focuses on alcohol and drug use and related disorders among adults in primary care settings. CONCLUSION: Screening, brief intervention, and referral for treatment are feasible and effective in primary care settings, provided that funding for screening is available, along with brief interventions and treatment facilities to which patients can be referred and treated promptly.

[Cannabis cessation interventions offered to young French users: predictors of follow-up]

INTRODUCTION

Cannabis use is very problematic among young French people, because of the young age of first consumption and its health consequences. Indeed, the average age of cannabis experimentation is about 15 in France and 49.5% of 17 year-olds report having used cannabis in their lives. To prevent this problem, tobacco and cannabis cessation services are dedicated to handle patients who want to stop tobacco and/or cannabis. Moreover, in 2004, specific medical outpatient services have been implemented to address the problem of young cannabis users. Since their establishment, some studies have reported demographic and clinical characteristics of the patients attending these services, but we still lack data on their follow-up and their medical and psychological care.

OBJECTIVE

The aim of this study is to describe the clinical and psychiatric characteristics of young patients referred to tobacco/cannabis cessation consultations or specific young cannabis users' consultations and to evaluate their medical care and monitoring.

PATIENTS AND METHODS

We designed a retrospective study in seven cessation clinics in the Paris area between 2005 and 2007. Eligible patients were regular cannabis users aged under 40. An electronic medical database was completed using patients' medical records. Medical files reported demographic and clinical data. Psychiatric disorders were assessed using the HAD and the Beck scores. Nicotine dependence was evaluated by Fagerström's score. The history of addictions, and data about consumption of cannabis, tobacco, alcohol and other drugs were recorded in the medical file. The follow-up of patients was defined by having at least two visits at the medical outpatient services. Tobacco and cannabis cessations were assessed at one-month follow-up. Univariate and multivariate logistic models were used to assess factors associated with patients' follow up and monitoring.

RESULTS

Four cessation clinics accepted to participate in our study. One hundred and eight eligible patients were listed during the study period. One hundred and eleven patients (75%) were males and seventy-nine (53%) were employed. The average age of patients was 26 years old (±6.8). Fifty patients (34%) came to the clinic on their own decision, thirty-three (22%) were referred by a hospital and twenty-eight (19%) came because of their family's advice. The mean age of first cannabis consumption was 16 years old (±7.3) and cannabis consumption was most often associated with tobacco use. Fifty-nine percent of patients had anxiety disorders and 28% had depression according to D-HAD score. The dropout rate after first visit was about 40%. The most frequent therapy proposed to young cannabis users was nicotine replacement therapy. Follow-up data were collected for 135 patients and only 85 (37%) patients made at least two visits at the outpatient services. The average number of consultations was five (±3.8). Multivariate analysis found an association between follow-up and previous cannabis cessation (P=0.04), pharmacological treatment of tobacco withdrawal (P=0.04), and antidepressant treatment (P=0.04). Only one quarter of patients had quit cannabis and/or tobacco at one-month follow-up.

DISCUSSION

This study describes clinical characteristics of patients attending cannabis consultations in France. As reported in other studies, anxiety disorders and depression are important problems in this population and should be considered during their medical care. The efficacy of specific French medical outpatient services is difficult to evaluate because of the high rate of dropout. Some patients' characteristics seem linked to their monitoring but other studies should be assessed to confirm these results. As pharmacological treatments seem associated with patients' follow-up, new research should be implemented to develop therapeutic solutions for cannabis addiction.

Stable genetic effects on symptoms of alcohol abuse and dependence from adolescence into early adulthood

Relatively little is known about how genetic influences on alcohol abuse and dependence (AAD) change with age. We examined the change in influence of genetic and environmental factors which explain symptoms of AAD from adolescence into early adulthood. Symptoms of AAD were assessed using the four AAD screening questions of the CAGE inventory. Data were obtained up to six times by self-report questionnaires for 8,398 twins from the Netherlands Twin Register aged between 15 and 32 years. Longitudinal genetic simplex modeling was performed with Mx. Results showed that shared environmental influences were present for age 15-17 (57%) and age 18-20 (18%). Unique environmental influences gained importance over time, contributing 15% of the variance at age 15-17 and 48% at age 30-32. At younger ages, unique environmental influences were largely age-specific, while at later ages, age-specific influences became less important. Genetic influences on AAD symptoms over age could be accounted for by one factor, with the relative influence of this factor differing across ages. Genetic influences increased from 28% at age 15-17 to 58% at age 21-23 and remained high in magnitude thereafter. These results are in line with a developmentally stable hypothesis that predicts that a single set of genetic risk factors acts on symptoms of AAD from adolescence into young adulthood.

General aspects of the treatment of alcoholic hepatitis

General measures for treating patients with alcoholic hepatitis (AH) are similar irrespective of the disease severity. Alcohol abstinence is the cornerstone of treatment and can be achieved with appropriate social support, Alcoholics Anonymous and sometimes pharmacological therapy. Alcohol withdrawal should be anticipated and treatment initiated to prevent this complication. Treatment for complications of cirrhosis should be as for any other patient with cirrhosis. AH patients are particularly prone to infections and malnutrition. These should be identified and treated appropriately using broad spectrum antibiotics and nutritional support respectively.

Self-reported cognitive problems in testicular cancer patients: relation to neuropsychological performance, fatigue, and psychological distress

OBJECTIVE

There is a concern about negative cognitive effects of systemic chemotherapy. We prospectively explored self-reported cognitive problems in testicular cancer patients (TCPs) treated with and without chemotherapy.

METHODS

One hundred and twenty-two TCPs were interviewed about concentration and memory problems shortly after orchidectomy but before any additional treatment (baseline), and then at a median of 1 year after end of treatment (follow-up). Symptoms of psychological distress, fatigue, and peripheral neurotoxicity were assessed by questionnaires, and patients also underwent neuropsychological testing. Self-reported cognitive problems were compared between three treatments groups: no chemotherapy, one cycle of chemotherapy, and multiple cycles of chemotherapy. Variables associated with an increase of self-reported cognitive problems from baseline to follow-up were explored.

RESULTS

Significantly larger proportions of TCPs in the two chemotherapy groups had an increase of self-reported cognitive problems from baseline to follow-up compared to the no-chemotherapy group. Increase of self-reported cognitive problems was significantly associated with psychological distress, fatigue, lower level of education, and Raynaud-like symptoms, but not with a decline in neuropsychological test performance.

CONCLUSION

In this explorative study of TCPs, an increase of self-reported cognitive problems from baseline to 1-year follow-up was associated with chemotherapy and with symptoms of fatigue and psychological distress at follow-up, while no significant association was found with a decline in neuropsychological test performance.