Biochemical and haematological indicators of excessive alcohol consumption

Constitutive androstane receptor activation promotes bilirubin clearance in a murine model of alcoholic liver disease

Increased plasma levels of bilirubin have been reported in rat models and patients with alcoholic liver disease (ALD). The constitutive androstane receptor (CAR) is a known xenobiotic receptor, which induces the detoxification and transport of bilirubin. In the present study, the bilirubin transport regulatory mechanisms, and the role of CAR activation in hepatic and extrahepatic bilirubin clearance were investigated in a murine model of ALD. The mice were fed a Lieber-DeCarli ethanol diet or an isocaloric control diet for 4 weeks, followed by the administration of CAR agonists, 1,4-bis-[2-(3,5-dichlorpyridyloxy)]benzene (TCPOBOP) and phenobarbital (PB), and their vehicles to examine the effect of the pharmacological activation of CAR on serum levels of bilirubin and on the bilirubin clearance pathway in ALD by serological survey, western blotting and reverse transcription-quantitative polymerase chain reaction. The results showed that chronic ethanol ingestion impaired the nuclear translocation of CAR, which was accompanied by elevated serum levels of bilirubin, suppression of the expression of hepatic and renal organic anion transporting polypeptide (OATP) 1A1 and hepatic multidrug resistance-associated protein 2 (MRP2), and induction of the expression of UDP-glucuronosyltransferase (UGT) 1A1. The activation of CAR by TCPOBOP and PB resulted in downregulation of the serum levels of bilirubin followed by selective upregulation of the expression levels of OATP1A1, OATP1A4, UGT1A1 and MRP2 in ALD. These results revealed the bilirubin transport regulatory mechanisms and highlighted the importance of CAR in modulating the bilirubin clearance pathway in the ALD mouse model.

Altered oxidative stress/antioxidant status in blood of alcoholic subjects is associated with alcoholic liver disease

BACKGROUND

Oxidative stress is implicated in pathogenesis of alcoholic liver disease (ALD). This study investigated the possible correlation among the erythrocyte indices of oxidative stress, the leukocyte panels of antioxidant proteins (metallothioneins), the serum biochemical parameters and the liver steatosis grade.

METHODS

A total of 118 cases including 60 alcoholic subjects and 58 controls were enrolled. All the alcoholic subjects were screened for body mass index (BMI), liver steatosis, and blood chemistry and serology. The level of oxidative stress and oxidative stress-related parameters were measured in the blood and correlated with clinical findings.

RESULTS

Alcoholic subjects showed higher BMI, moderate/severe hepatic steatosis, increase in the levels of triglycerides, cholesterol, glucose, γ-glutamyl-transpeptidase (GGT), alanine aminotransferase (ALT), bilirubin, alpha 1 and beta 2 globulins, iron and a decrease in the levels of aspartate aminotransferase (AST) and beta 1 globulin with respect to the reference values. Moreover, alcoholic subjects showed: (i) an increase in Thiobarbituric Acid Reactive Substance (TBARS) content representing a good estimation of global oxidative stress; (ii) a stimulation of the activities of the antioxidant enzymes catalase and SOD; (iii) a modulation of expression of metallothioneins, with a down-regulation of MT-1A and an up-regulation of MT-1E isoforms.

CONCLUSIONS

Our data suggest that alcoholism is strongly associated with altered pattern of blood metallothioneins; this parameter combined with the score calculated by an ad hoc implemented algorithm (HePaTest) could offer a non-invasive alternative approach for evaluating alcohol-related damages and could be used in follow-up of alcoholic patients.

Biochemical diagnosis of alcoholism

Medically diagnosed alcoholics can be differentiated reliably from non-alcoholics using clinically laboratory tests. In the present study, patients with liver diseases either due to alcohol or without alcohol compared with a group of normal healthy persons. Heavy drinkers showed significantly lower body weight and percent body fat, and low BMI compared with other groups. The percentage of hemoglobin and total number of RBC were found to be significantly decreased, whereas mean corpuscular volume (MCV) significantly increased in alcoholic liver disease (ALD). Hyperbilirubinemia, hyperuricemia and hypoalbuminemia correlate with alcohol intake. Albumin/globulin ratio significantly decreased in ALD. In acute liver injury AST/ALT ratio is ≤1.0, whereas in alcoholic hepatitis it is always >1.0. Moderately elevated level of ALP and high GGT values are good discriminator of alcoholic patients. Alcohol-induced liver injury is linked to oxidative stress as observed by decreased level of reduced glutathione and ascorbic acid, and increased level of thiobarbituric acid reactive substances.

Biochemical markers for alcohol consumption

A variety of laboratory tests are available to assist in the diagnosis of alcohol consumption and related disorders. The levels of intake at which laboratory results become abnormal vary from person to person. Laboratory tests are particularly useful in settings where cooperativeness is suspected or when a history is not available. Several biochemical and hematological tests, such as γ-glutamyltransferase (GGT) activity, aspartate aminotransferase (AST) activity, high-density lipoprotein cholesterol (HDL-C) content of serum, and erythrocyte mean corpuscular volume (MCV) are established markers of alcohol intake. Their validity as markers is based largely on correlations with recent intake at a single time point and on decreases in elevated values when heavy drinkers abstain from alcohol. These readily available laboratory tests provide important prognostic information and should be integral part of the assessment of persons with hazardous alcohol consumption. There are several other markers with considerable potential for more accurate reflection of recent alcohol intake. These include carbohydrate deficient transferrin, β-hexosaminidase, acetaldehyde adducts and the urinary ratio of serotonin metabolites, 5-hydroxytryptophol and 5-hydroxyindoleacetic acid. These markers provide hope for more sensitive and specific aids to diagnosis and improved monitoring for intake.

Identification of heavy drinkers using a combination of laboratory tests

OBJECTIVE

This study derived and evaluated a model that used results of commonly performed laboratory tests to identify men who are heavy drinkers.

METHOD

The results of 40 commonly available laboratory tests were obtained on a diverse sample of 426 heavy drinkers and 188 light drinkers. A logistic regression equation for identifying heavy drinkers was derived in a training data set of 411 subjects and tested in a validation data set of 203 subjects.

RESULTS

Ten laboratory measurements were included in the final regression equation: chloride, sodium, ratio of direct to total bilirubin level, blood urea nitrogen, high density lipoproteins, monocyte count, phosphorus, platelets, aspartate aminotransferase, and mean corpuscular hemoglobin. In the validation data this model correctly identified 98% of the 161 heavy drinkers and 95% of the 42 light drinkers. Other models reported in previous literature were applied to these subjects and did not perform as well. The model performed better for subjects of lower socioeconomic status.

CONCLUSIONS

The laboratory tests in our model may help identify heavy drinkers. The performance of models to identify heavy drinkers depends on the demographic characteristics of the subjects.

Factors affecting the discriminant function analysis of blood chemistry profiles

The discriminant function analysis (DFA) of a battery of blood chemistry tests is generally more sensitive and specific than single biochemical test in detecting alcoholism or hazardous drinking. This study examined factors affecting the DFA of blood chemistry profiles (BCP) from alcoholics (ALC) in treatment, primary care outpatients (PC), and the general population (GP). Our data indicate that of the 32 variables in the BCP, 14 are not correlated with alcohol intake or consequences and can be deleted from the set considered for use in the DFA. Confounding medical conditions in the data set used in the DFA did not adversely affect the correct classification of ALC or heavy drinkers. It was not necessary to use only extreme groups (e.g., alcoholics vs. light drinkers/abstainers) to develop the discriminant function. Transformation of some blood variables greatly improved the selection of key variables in the DFA. Another finding was that there was little benefit from fitting the DFA to the demographics of subjects. When the BCP was combined with the results of a brief questionnaire, the TWEAK, it only improved slightly the classification power of the DFA based only on the TWEAK questions.

Biological State Markers of Alcohol Abuse

Certain changes in blood chemistry may serve as markers of alcohol consumption. These markers can be useful in the early diagnosis, prevention, and treatment of alchol-related problems.

Clinical features of alcoholic liver disease

The severity and range of histological liver lesions caused by alcohol abuse varies considerably; these lesions are not specific for alcoholic damage, and diagnosis of alcoholic liver disease depends on obtaining an adequate history of prolonged alcohol abuse and on excluding other known causes of liver disease. The clinical features of alcoholic liver disease vary greatly and they have been classified into various syndromes. However, the syndromes overlap, the histological features underlying them also overlap and they represent part of a wide clinical spectrum. Alcoholic fatty liver occurs more in younger patients and has a much better prognosis than alcoholic hepatitis or alcoholic cirrhosis, but the previous view that alcoholic fatty liver is an innocuous lesion can no longer be maintained. Alcoholic hepatitis and alcoholic cirrhosis cause more severe syndromes and more florid clinical features, and mortality is related to features of liver failure and variceal bleeding. Abstinence is the only means of ensuring the best possible survival.

Liver giant mitochondria revisited

AIMS

To examine the correlation between the severity of alcohol induced liver damage and the presence of intracytoplasmic red bodies (defined as periodic acid-Schiff diastase negative, globular, hyaline cytoplasmic inclusions larger in size than the hepatocyte nucleolus). To investigate the incidence of intracytoplasmic red bodies (ICRBs) in non-alcoholic liver disease.

METHODS

Liver biopsy specimens from 53 patients with alcoholic liver disease and 50 patients with a variety of nonalcohol related liver diseases were examined by light microscopy for the presence of ICRBs. For the 53 patients with alcoholic liver disease an assessment of recent alcohol consumption was made indirectly from measurements of red cell volume (MCV) and plasma gamma-glutamyl transferase (GGT). In addition, 10 liver biopsies with alcohol induced changes and ICRBs were examined by electron microscopy for the presence of mitochondrial aberrations including enlargement.

RESULTS

ICRBs were detected in 18 of the 53 liver biopsy specimens showing alcohol induced changes, and were more abundant in those showing more advanced changes. Those patients whose liver specimens contained ICRBs were found to have a significantly higher mean plasma GGT activity and mean MCV than those individuals whose liver biopsy specimens did not contain ICRBs. Two of the 50 liver biopsy specimens showing non-alcohol induced changes contained ICRBs. Giant mitochondria were not detected by electron microscopy, but this may reflect sampling.

CONCLUSIONS

The results of this study indicate that ICRBs are definitely associated with alcoholic liver disease and are more likely to be found in liver biopsy specimens showing more advanced alcohol induced damage, and when recent alcohol consumption has been high.

Laboratory markers of ethanol intake and abuse: a critical appraisal

Laboratory markers for ethanol intake and abuse and chronic alcoholism currently in use have been critically reviewed. The merits and pitfalls of each test have been evaluated. The clinical use of the new test of carbohydrate-deficient transferrin has been particularly emphasized. Carbohydrate-deficient transferrin currently provides the highest specificity and sensitivity of all commonly used markers of alcoholism.

Biological markers of alcoholism

The roles of two categories of biological markers--those relating to alcohol consumption and those relating to the risk of developing alcohol related problems--are reviewed. Platelet Mono-amino oxidase levels are low in individuals with a strong inheritance of their drinking problem (Cloninger Type II alcoholics). Elevated gamma-glutamyl transpeptidase (GGT) levels identify regular heavy drinkers with a sensitivity between 40-60%. Mean corpuscular volume (MCV) has a high specificity (95%) and is useful in detecting regular heavy drinkers in the ambulatory care population if other causes of an elevated MCV can be included.

High performance liquid chromatographic studies of erythrocytes haem biosynthetic enzyme activities in alcoholic macrocytosis

The activities of 5-aminolaevulinate dehydrase (ALA-D), hydroxymethylbilane synthase (HMB-S), uroporphyrinogen III synthase (URO-S) and uroporphyrinogen decarboxylase (URO-D) in the erythrocytes of alcoholics were assayed and compared with those in controls and abstaining alcoholics. The HMB-S and URO-S activities in alcoholics were significantly higher than the controls and there were significant correlations between enzyme activities and mean corpuscular volume (MCV). Alcoholics abstaining from alcohol over a nine-month period showed a return to normal enzyme activities in parallel with the normalization of their MCV. Abstaining alcoholics thus all had normal HMB-S and URO-S activities. The ALA-D and URO-D activities of alcoholics were not significantly different from controls or from abstaining alcoholics. Alcohol appears to have a selective effect on the haem biosynthetic enzymes in the erythron.

Carbohydrate deficient transferrin: a marker for alcohol abuse

OBJECTIVE

To assess the value of serum carbohydrate deficient transferrin as detected by isoelectric focusing on agarose as an indicator of alcohol abuse.

DESIGN

Coded analysis of serum samples taken from patients with carefully defined alcohol intake both with and without liver disease. Comparison of carbohydrate deficient transferrin with standard laboratory tests for alcohol abuse.

SETTING

A teaching hospital unit with an interest in general medicine and liver disease.

PATIENTS

22 "Self confessed" alcoholics admitting to a daily alcohol intake of at least 80 g for a minimum of three weeks; 15 of the 22 self confessed alcoholics admitted to hospital for alcohol withdrawal; 68 patients with alcoholic liver disease confirmed by biopsy attending outpatient clinics and claiming to be drinking less than 50 g alcohol daily; 47 patients with non-alcoholic liver disorders confirmed by biopsy; and 38 patients with disorders other than of the liver and no evidence of excessive alcohol consumption.

INTERVENTION

Serial studies performed on the 15 patients undergoing alcohol withdrawal in hospital. MAIN OUTCOME measure--Determination of relative value of techniques for detecting alcohol abuse.

RESULTS

Carbohydrate deficient transferrin was detected in 19 of the 22 (86%) self confessed alcohol abusers, none of the 47 patients with non-alcoholic liver disease, and one of the 38 (3%) controls. Withdrawal of alcohol led to the disappearance of carbohydrate deficient transferrin at a variable rate, though in some subjects it remained detectable for up to 15 days. Carbohydrate deficient transferrin was considerably superior to the currently available conventional markers for alcohol abuse.

CONCLUSION

As the technique is fairly simple, sensitive, and inexpensive we suggest that it may be valuable in detecting alcohol abuse.

Ethanol-induced increase in cytosolic estrogen receptors in human male liver: a possible explanation for biochemical feminization in chronic liver disease due to alcohol

The hepatic cytosolic estrogen receptor content was measured in liver samples from patients with normal livers and from patients with nonalcoholic cirrhosis, alcoholic cirrhosis and alcoholic hepatitis. The estrogen receptor content of normal liver was 5.2 +/- 3.5 fmoles per mg of cytosolic protein. Levels which were not significantly different from this were found in the samples from patients with nonalcoholic cirrhosis (2.1 +/- 2.0 fmoles per mg of cytosolic protein). The cytosolic estrogen receptor content in the livers of patients with alcoholic cirrhosis who were abstaining was 4.2 +/- 3.6 fmoles per mg of cytosolic protein, but it increased to 10.4 +/- 4.9 fmoles per mg of protein in the livers of patients with alcoholic cirrhosis who were drinking, to 17.3 +/- 8.7 fmoles per mg of protein in the livers of patients with alcoholic hepatitis with cirrhosis and to 22.7 +/- 15.7 fmoles per mg of protein in the livers of patients with alcoholic hepatitis without cirrhosis. Alcohol abuse appeared, therefore, to induce an increase in the estrogen receptor content of human liver, especially in patients who were drinking and had histological evidence of acute liver damage (alcoholic hepatitis). The increase in hepatic estrogen receptor which we have observed may be involved in the molecular mechanisms underlying the feminization of the liver in alcoholic males.

Diagnosis of alcoholism

Alcoholism is among the most prevalent of the difficult diseases to establish diagnoses in medicine. This article outlines a number of steps to help in identifying the alcoholic patient. These include: a careful history, several laboratory blood tests, simple paper-and-pencil tests, and recognition of alcohol-related medical disorders.

Immunoglobulin A in the diagnosis of alcoholic liver disease

The diagnostic relevance of the serum immunoglobulin A (IgA) concentration and liver deposition of IgA for chronic excessive alcohol consumption was evaluated in 164 patients with biochemical liver abnormalities. A relationship was demonstrated between the amount of daily alcohol consumption and the two IgA parameters and serum gamma-glutamyl transpeptidase. A continuous pattern of IgA deposition along hepatic sinusoids proved to be the best diagnostic feature, combining a specificity of 0.91 with a sensitivity of 0.75. Although serum IgA has a specificity of 0.78, its diagnostic value is restricted by a sensitivity of 0.50, making it not superior to serum gamma-glutamyl transpeptidase. Furthermore, serum IgA proved to be related to liver histopathology. High levels of serum IgA are found in hepatitis and cirrhosis, without significant differences between alcoholic and nonalcoholic patients. However, in the case of mild histopathologic changes in the liver, such as steatosis and fibrosis, significantly higher serum IgA concentrations are found in alcoholic than in nonalcoholic liver disease.

Discriminant function analysis of clinical laboratory data. Use in alcohol research

There has been a growing interest in the use of discriminant function analysis of routinely collected laboratory data to differentiate between alcoholic and nonalcoholic individuals. However, no consensus has been reached concerning the validity and reliability of this form of analysis regarding the diagnosis of, or screening for, alcoholism. In addition, this technique may provide important information concerning the multivariate nature of the pathophysiological effects of alcohol. However, this issue is seldom discussed. Because of differences in methodology across studies and the growing confusion regarding conceptual issues associated with this statistical technique, there have been few critical reviews. This chapter is directed at critically evaluating the current literature, particularly with respect to the methodological and conceptual issues associated with the use of discriminant function analysis in alcohol research. As part of this approach we suggest guidelines for future research in this area.

Desialylated transferrin as a serological marker of chronic excessive alcohol ingestion

Partly desialylated transferrin was measured in the serum of subjects with chronic alcoholism, of patients with non-alcoholic-related steatohepatitis, diabetes, and other non-alcoholic liver diseases, and of healthy controls. In non-alcoholic patients and controls the maximum desialylated transferrin expressed in relation to total transferrin was 1.5%. This value was exceeded in 18 (90%) of the 20 alcoholics. By contrast, gamma-glutamyl transferase was within the reference range in 9 of the alcoholics.

Identification of alcoholism in young adults by blood chemistries

A stepwise linear discriminant analysis was conducted between young adult alcoholics in an alcoholism treatment center and non-alcoholic college students. Analysis of 31 commonly ordered clinical laboratory tests yielded three significant variables (urea nitrogen, potassium and MCV) which correctly classify 89% of alcoholics and 92% of non-alcoholics.

Methods of intervention to modify drinking patterns in heavy drinkers

More than 30,000 individuals have been investigated in the continuous screening and intervention study in Malmö. Large subsamples of individuals with different levels of serum gamma-glutamyltransferase (GGT) have been characterized and followed up; GGT has proved to be a useful and simple tool in identifying and treating heavy drinkers and monitoring their outcome. In the intervention study, counseling and repeated feedback of GGT results in a group of middle-aged heavy drinkers led to a significant reduction in sick absence, hospitalization, and mortality compared with those in a control group over a period of 6 to 8 years. At follow-up, about 15% of middle-aged men in the general population had serious alcohol problems. Assessment and treatment of heavy drinkers within general medicine would provide a very considerable impact on the total problem of alcohol-related disease.

Monitoring alcoholism treatment: the appropriateness of choice between gamma GT or MCV evaluation after a short time of abstinence

Gamma glutamyl transferase (gamma GT) and mean corpuscular volume (MCV) were evaluated in 58 alcoholics entering alcoholism treatment. The same patients were reassessed after one month of abstinence. Group results revealed a significant reduction of gamma GT from 80.2 to 43.1 IU/l while no alteration was detected for MCV (from 97.1 to 96.7 mu 3). However, individual analysis showed that the average MCV results obtained from the 2nd evaluation masked important within-individual differences. Thus, although a considerable percentage of alcoholics with initial high values showed an improvement, 44% of those with initial normal results had abnormally high reevaluation values. Limitations of serial MCV measurement during alcoholism treatment follow-up are discussed in light of these data.

Agreement between laboratory tests and self-reports of alcohol, tobacco, caffeine, marijuana and other drug use in post-partum women

The agreement between self-reported consumption of several drugs and laboratory tests used to detect their use is examined. Post-partum women (N = 108) enrolled in a research study participated in a detailed interview covering alcohol and caffeine ingestion, tobacco smoking and use of marijuana and other psychoactive drugs. They also kept a 4-day record of their use of these substances. Blood and urine samples were taken and a physical exam done at the close of the record period. Laboratory tests to detect use of alcohol, tobacco, caffeine, marijuana and other drugs were carried out and the results compared to self-reported drug use in the interview and the record. The degree of agreement depended on the drug taken, the test used and the pattern of drug use in the sample. Sporadic or infrequent consumption related poorly to laboratory tests, especially those that were designed as screening tools. Regular consumption could be identified with greater accuracy. However, the group associations evident between self-reports of drug use and laboratory results were not sufficient to guarantee that subjects were correctly classified. Error in both self-report and the decision made from laboratory values must be taken into account in determining the confidence that should be placed in the data and the conclusions drawn from it.

Diagnostic of alcoholism: how useful is the combination of gamma glutamyl transferase with different biochemical markers?

The present paper analyses the alterations in sensitivity, specificity and in the positive predictive value (PPV) of GGT as a state marker of alcohol abuse when used either alone or in combination with glutamate pyruvate transaminases (SGPT), glutamate oxalacetate (SGOT) and mean corpuscular volume (MCV). The results obtained with an alcoholic (n = 70) and non-alcoholic sample (n = 63) showed that the best combination considering sensitivity was obtained when GGT was combined with MCV (80%). However, this combination produced the largest decrease in PPV. The relevance of taking into account not only sensitivity but also PPV when the markers are to be used as screening tests in unselected populations is discussed.

Relationship between gamma-glutamyl transpeptidase and mean urinary alcohol levels in alcoholics while drinking and after alcohol withdrawal

In 42 patients with alcoholic liver disease in whom daily urinary ethanol concentrations were measured for 3 months, after an abstinence of at least 1 month, serum gamma-glutamyl transpeptidase (GGT) activity was found to correlate (r = 0.69; p less than 0.0001) with mean urinary alcohol levels. The half-life of serum GGT decay in 32 patients who remained abstinent for an 8-week period was calculated to be 26 days. This prolonged half-life can result in high serum GGT levels in patients abstinent for prolonged periods, in whom serum GGT baselines before abstinence were very high. Individual variations in serum GGT levels should be interpreted in relation to continued alcohol consumption, keeping in mind the long half-life for this enzyme in these patients.

Biochemical and haematological response to alcohol intake

In a clinical survey of 7735 middle-aged men, alcohol consumption has been related to 25 biochemical and haematological measurements obtained from a single blood sample. Most measurements showed some association with alcohol consumption, gamma-glutamyl transferase (GGT) being the most strongly associated. Lead, mean corpuscular haemoglobin (MCH), mean corpuscular volume, high-density lipoprotein-cholesterol (HDL-C), urate and aspartate transaminase also showed substantial associations with alcohol intake. Using a discriminant analysis technique, a simple score based on five variables (GGT, HDL-C, urate, MCH and lead) provided the best discrimination between heavy drinkers (e.g. more than three pints of beer daily) and occasional drinkers, but still failed to identify more than half of the heavy drinkers. This combined score may prove a useful measure of an individual's biochemical/haematological response to alcohol consumption for use in epidemiological and clinical studies of alcohol related disorders. The use of such indices should complement but not replace measures of alcohol intake derived from questionnaires.

Biochemical markers for alcoholism: sensitivity problems

A panel of blood tests, purportedly markers for alcohol abuse, were examined in 543 relatively healthy alcoholics entering ambulatory rehabilitation treatment. Individual tests were too low in sensitivity: gamma-glutamyl transpeptidase was abnormally high in only 49%, then mean corpuscular volume (45%), high density lipoprotein cholesterol (HDLC) (25%), serum glutamic oxaloacetic transaminase (SGOT) (28%), and blood alcohol (21%). HDLC was of low sensitivity, generally unaffected by liver disease, and related to quantitation of recent alcohol consumed. Combining seven markers, 82% of males and 71% females had at least one abnormally high value. Histories of heavy recent drinking, positive blood alcohol levels on admission, and manifest liver disease on physical examination or by hyperbilirubinemia were associated with high sensitivities of individual and pooled markers. The biochemical markers studied can be useful to suggest alcohol abuse, especially in some populations of drivers. In other populations of alcoholics, especially with intermittent alcohol or recent abstinence, their sensitivities were so low as to discourage extensive reliance on their use. The diagnosis of alcoholism continues to depend on clinical history of alcohol-related problems, including social, familial, legal, medical, psychological, and economic.

Early intervention for alcohol problems

Despite awareness of the wide variety of clinical and laboratory abnormalities associated with alcohol abuse, drinking problems often remain undetected in clinical practice. There is increasing evidence that problem drinking can be successfully treated by brief intervention. The general practitioner is in a good position to identify patients who drink excessively, and to intervene with brief counselling at an early stage when prognosis is more favourable. A practical strategy is described for diagnosis and intervention that could be readily implemented in clinical practice.

Clinical pathology of alcohol

There is good though not conclusive evidence that a small to modest average daily intake of alcohol--that is, 20-30 g/day is associated with increased longevity due mainly to a reduction in death from cardiovascular disease. Larger average daily alcohol intakes--especially those in excess of 60 g/day for men and 40 g/day for women--are associated with gradually increasing morbidity and mortality rates from a variety of diseases. Alcohol may be unrecognised as the cause of somatic disease, which can occur without overt psychosocial evidence of alcohol abuse, unless the index of suspicion is high and a thorough drink history obtained. Laboratory tests for the detection and/or confirmation of alcohol abuse are useful but subject to serious limitations being neither as sensitive nor specific as sometimes believed. The value of random blood and/or breath alcohol measurements, in outpatients, as an aid to diagnosis of alcohol-induced organic disease is probably not sufficiently appreciated and, though relatively insensitive, is highly specific.