DOVER and QUVER-new marker combinations to detect and monitor at-risk drinking

Levels and types of alcohol biomarkers in DUI and clinic samples for estimating workplace alcohol problems

Widespread concern about illicit drugs as an aspect of workplace performance potentially diminishes attention on employee alcohol use. Alcohol is the dominant drug contributing to poor job performance; it also accounts for a third of the worldwide public health burden. Evidence from public roadways--a workplace for many--provides an example of work-related risk exposure and performance lapses. In most developed countries, alcohol is involved in 20-35% of fatal crashes; drugs other than alcohol are less prominently involved in fatalities. Alcohol biomarkers can improve detection by extending the timeframe for estimating problematic exposure levels and thereby provide better information for managers. But what levels and which markers are right for the workplace? In this paper, an established high-sensitivity proxy for alcohol-driving risk proclivity is used: an average eight months of failed blood alcohol concentration (BAC) breath tests from alcohol ignition interlock devices. Higher BAC test fail rates are known to presage higher rates of future impaired-driving convictions (driving under the influence; DUI). Drivers in alcohol interlock programmes log 5-7 daily BAC tests; in 12 months, this yields thousands of samples. Also, higher programme entry levels of alcohol biomarkers predict a higher likelihood of failed interlock BAC tests during subsequent months. This paper summarizes the potential of selected biomarkers for workplace screening. Markers include phosphatidylethanol (PEth), percent carbohydrate deficient transferrin (%CDT), gammaglutamyltransferase (GGT), gamma %CDT (γ%CDT), and ethylglucuronide (EtG) in hair. Clinical cut-off levels and median/mean levels of these markers in abstinent people, the general population, DUI drivers, and rehabilitation clinics are summarized for context.

Predicting DUI recidivism of male drunken driving: a prospective study of the impact of alcohol markers and previous drunken driving

The aim of the present study was to determine whether the alcohol biomarkers CDT, GGT, the biomarker gamma-CDT index and previous drunken driving contributed significantly to the prediction of DUI recidivism. The subjects consisted of two different samples of drivers, viz. drivers who were found to have a positive breath alcohol concentration during random breath testing surveys (n=237), and drunken drivers who were apprehended during ordinary police work (n=193). The drunken driving events were monitored using a data-base both retrospectively and prospectively. It was found that the biomarker index, gamma-CDT, emerged as a notable predictor of recidivism in the group of random breath tested drivers. Measurement of gamma-CDT and its impact on DUI recidivism has not to our knowledge been applied to random breath tested drivers before. The apprehended drunken drivers, on the other hand, did not show a significant relationship between gamma-CDT and DUI recidivism. However, in both groups of drivers it was found that a previous conviction for drunken driving strongly predicted DUI recidivism. More attention should be paid by both physicians and the police to the high risk of recidivism among those convicted of drunken driving.

Circulating cytokines as biomarkers of alcohol abuse and alcoholism

There are currently no consistent objective biochemical markers of alcohol abuse and alcoholism. Development of reliable diagnostic biomarkers that permit accurate assessment of alcohol intake and patterns of drinking is of prime importance to treatment and research fields. Diagnostic biomarker development in other diseases has demonstrated the utility of both open, systems biology, screening for biomarkers and more rational focused efforts on specific biomolecules or families of biomolecules. Long-term alcohol consumption leads to altered inflammatory cell and adaptive immune responses with associated pathologies and increased incidence of infections. This has led researchers to focus attention on identifying cytokine biomarkers in models of alcohol abuse. Alcohol is known to alter cytokine levels in plasma and a variety of tissues including lung, liver, and very importantly brain. A number of cytokine biomarker candidates have been identified, including: tumor necrosis factor-alpha, interleukin (IL)-1-alpha, IL-1-beta, IL-6, IL-8, IL-12, and monocyte chemoattractant protein-1. This is an emerging and potentially exciting avenue of research in that circulating cytokines may contribute to diagnostic biomarker panels, and a combination of multiple biomarkers may significantly increase the sensitivity and specificity of the biochemical tests aiding reliable and accurate detection of excessive alcohol intake.

Cluster-randomized controlled trial of dissemination strategies of an online quality improvement programme for alcohol-related disorders

AIMS

This project investigated different dissemination strategies of an online quality improvement programme for alcohol-related disorders into routine care in South Baden and South Württemberg in Germany.

METHODS

In a cluster-randomized controlled trial, 112 general practices were randomized into three groups. The first group (n = 43) received access to the online system and a training programme for the general practitioners (GPs). The second group (n = 42) additionally received education for the whole practice team. The third group (n = 27) acted as control and received only access to the online system.

RESULTS

Two thousand six hundred and forty-seven practitioners were asked to take part in the study, and it was possible to randomize 112 (4%) practices. There were no significant differences concerning the use of the system between the groups: 41.9% of the GPs in the first group, 42.9% in the second group and 44.4% in the control group used the system. In terms of only the system users, 55.6% of the GPs in the first group, 33.3% in the second group and 8.3% in the control group used the system six times or more (P = 0.019). Diagnostic assessments made by the GPs in the groups differed substantially: 72.2% of diagnoses in the first group were correct, while this figure lay at 69.7% in the second group and 36.4% in the control group (P = 0.034).

CONCLUSIONS

No effect of the additional training on the primary outcome (acceptance) was identified, but on two of the secondary outcomes. Further cost-effectiveness studies should investigate whether the effort involved in providing training additionally to the system is justifiable. The study is registered at ClinicalTrials.gov: NCT00314067. This article conforms to the guidelines in the Consolidated Standards of Reporting Trials (CONSORT) statement (Moher et al., 2001; Campbell et al., 2004).

Cost-effectiveness of screening for unhealthy alcohol use with % carbohydrate deficient transferrin: results from a literature-based decision analytic computer model

BACKGROUND

The %carbohydrate deficient transferrin (%CDT) test offers objective evidence of unhealthy alcohol use but its cost-effectiveness in primary care conditions is unknown.

METHODS

Using a decision tree and Markov model, we performed a literature-based cost-effectiveness analysis of 4 strategies for detecting unhealthy alcohol use in adult primary care patients: (i) Questionnaire Only, using a validated 3-item alcohol questionnaire; (ii) %CDT Only; (iii) Questionnaire followed by %CDT (Questionnaire-%CDT) if the questionnaire is negative; and (iv) No Screening. For those patients screening positive, clinicians performed more detailed assessment to characterize unhealthy use and determine therapy. We estimated costs using Medicare reimbursement and the Medical Expenditure Panel Survey. We determined sensitivity, specificity, prevalence of disease, and mortality from the medical literature. In the base case, we calculated the incremental cost-effectiveness ratio (ICER) in 2006 dollars per quality-adjusted life year ($/QALY) for a 50-year-old cohort.

RESULTS

In the base case, the ICER for the Questionnaire-%CDT strategy was $15,500/QALY compared with the Questionnaire Only strategy. Other strategies were dominated. When the prevalence of unhealthy alcohol use exceeded 15% and screening age was <60 years, the Questionnaire-%CDT strategy costs less than $50,000/QALY compared to the Questionnaire Only strategy.

CONCLUSIONS

Adding %CDT to questionnaire-based screening for unhealthy alcohol use was cost-effective in our literature-based decision analytic model set in typical primary care conditions. Screening with %CDT should be considered for adults up to the age of 60 when the prevalence of unhealthy alcohol use is 15% or more and screening questionnaires are negative.

The validity of the laboratory marker combinations DOVER and QUVER to detect physician's diagnosis of at-risk drinking

Especially in situations where it might be favorable for the patient to dissimulate the existing alcohol problem, 'objective' laboratory tests can be helpful. In this study we report validation of the two combinations DOVER (DOctor VERified) and QUVER (QUestionnarie VERified) of the biological markers percent carbohydrate-deficient transferrin (%CDT) and gamma-glutamyl-transferase (gamma-GT) to detect patients that have been identified by their physicians with at-risk drinking behavior. Fifty-eight general practitioners (GPs) participated at two study sites in South-West Germany. Patients filled in a questionnaire that included the alcohol use disorders identification test (AUDIT) and gave a blood sample. The GP recorded his/her assessment about the presence of an alcohol-related disorder in the patient. Receiver operating characteristics (ROC) analyses of the marker combinations DOVER and QUVER were performed. A total of 2940 patients participated in the study, of which 2496 completed data sets that could be used for further analysis. The area under the curve (AUC) of 79.5% for DOVER and 77.2% (QUVER) are in a higher range than the values for gamma%CDT (75.7%) or gamma-GT (72.5%) and %CDT (64.5%) and suggest superiority of the proposed marker combinations. Cross-validation results were almost identical with 76.6% and 73.3% for DOVER and QUVER, respectively. Our analysis demonstrated that the combination of the markers gamma-GT and %CDT with the physician's judgement of the condition as reference was superior to the use of single markers.