Optimal Cut-Points for Phosphatidylethanol Vary by Clinical Setting: Response to Nguyen and Seth's (2018) Letter to the Editor

Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement

Background: Severe alcohol withdrawal syndrome (SAWS) is highly morbid, costly, and common among hospitalized patients, yet minimal evidence exists to guide inpatient management. Research needs in this field are broad, spanning the translational science spectrum. Goals: This research statement aims to describe what is known about SAWS, identify knowledge gaps, and offer recommendations for research in each domain of the Institute of Medicine T0-T4 continuum to advance the care of hospitalized patients who experience SAWS. Methods: Clinicians and researchers with unique and complementary expertise in basic, clinical, and implementation research related to unhealthy alcohol consumption and alcohol withdrawal were invited to participate in a workshop at the American Thoracic Society 2019 International Conference. The committee was subdivided into four groups on the basis of interest and expertise: T0-T1 (basic science research with translation to humans), T2 (research translating to patients), T3 (research translating to clinical practice), and T4 (research translating to communities). A medical librarian conducted a pragmatic literature search to facilitate this work, and committee members reviewed and supplemented the resulting evidence, identifying key knowledge gaps. Results: The committee identified several investigative opportunities to advance the care of patients with SAWS in each domain of the translational science spectrum. Major themes included 1) the need to investigate non-γ-aminobutyric acid pathways for alcohol withdrawal syndrome treatment; 2) harnessing retrospective and electronic health record data to identify risk factors and create objective severity scoring systems, particularly for acutely ill patients with SAWS; 3) the need for more robust comparative-effectiveness data to identify optimal SAWS treatment strategies; and 4) recommendations to accelerate implementation of effective treatments into practice. Conclusions: The dearth of evidence supporting management decisions for hospitalized patients with SAWS, many of whom require critical care, represents both a call to action and an opportunity for the American Thoracic Society and larger scientific communities to improve care for a vulnerable patient population. This report highlights basic, clinical, and implementation research that diverse experts agree will have the greatest impact on improving care for hospitalized patients with SAWS.

Blood phosphatidyl ethanol levels as a tool to detect alcohol misuse in trauma patients

INTRODUCTION

There is a strong need for a reliable marker of harmful alcohol consumption to identify injured patients that can benefit from alcohol interventions, and blood phosphatidyl ethanol (PEth) has not previously been tested on this population. This study aims to compare the performance of blood PEth concentration, blood alcohol concentration (BAC) and the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) for the screening of alcohol misuse in trauma patients.

METHODS

Prospective cross-sectional study of 238 adult patients presenting in the emergency department with any type of trauma. PEth concentration was determined in whole blood by high-performance liquid chromatography with tandem mass spectrometry. Consent, AUDIT-C score and demographic data were obtained.

RESULTS

The sample consisted of majority male (67.6%), single (46.2%) and employed (66%) patients. The most common type of trauma was traffic collision (63.9%). The mean age was 41.7 years. We found a significant correlation between PEth levels with AUDIT-C score (Spearman's r = 0.654; p < .0001). PEth had an area under the ROC curve of 0.885 to detect hazardous alcohol consumption (AUDIT-C score ≥ 6) and PEth ≥23.9 ng/mL cutoff point provided 91.2% of sensitivity and 78.4% of specificity. Twelve patients reported alcohol abstinence, but had quantifiable levels of PEth.

CONCLUSIONS

PEth levels and AUDIT-C score had a moderate correlation in our population. PEth was useful to identify 12 cases of underreporting of alcohol consumption habits. PEth shows promising results, but more research is needed to identify the best screening tool for alcohol misuse in trauma patients.