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Ratner JA, Blaney H, Rastegar DA. Management of alcohol withdrawal syndrome in patients with alcohol-associated liver disease. Hepatol Commun 2024; 8:e0372. [PMID: 38251886 PMCID: PMC10805424 DOI: 10.1097/hc9.0000000000000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024] Open
Abstract
Alcohol-associated liver disease is a common and severe sequela of excessive alcohol use; effective treatment requires attention to both liver disease and underlying alcohol use disorder (AUD). Alcohol withdrawal syndrome (AWS) can be dangerous, is a common barrier to AUD recovery, and may complicate inpatient admissions for liver-related complications. Hepatologists can address these comorbid conditions by learning to accurately stage alcohol-associated liver disease, identify AUD using standardized screening tools (eg, Alcohol Use Disorder Identification Test), and assess risk for and symptoms of AWS. Depending on the severity, alcohol withdrawal often merits admission to a monitored setting, where symptom-triggered administration of benzodiazepines based on standardized scoring protocols is often the most effective approach to management. For patients with severe liver disease, selection of benzodiazepines with less dependence on hepatic metabolism (eg, lorazepam) is advisable. Severe alcohol withdrawal often requires a "front-loaded" approach with higher dosing, as well as intensive monitoring. Distinguishing between alcohol withdrawal delirium and HE is important, though it can be difficult, and can be guided by differentiating clinical characteristics, including time to onset and activity level. There is little data on the use of adjuvant medications, including anticonvulsants, dexmedetomidine, or propofol, in this patient population. Beyond the treatment of AWS, inpatient admission and outpatient hepatology visits offer opportunities to engage in planning for ongoing management of AUD, including initiation of medications for AUD and referral to additional recovery supports. Hepatologists trained to identify AUD, alcohol-associated liver disease, and risk for AWS can proactively address these issues, ensuring that patients' AWS is managed safely and effectively and supporting planning for long-term recovery.
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Affiliation(s)
- Jessica A. Ratner
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Hanna Blaney
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Darius A. Rastegar
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Hernández-Évole H, Jiménez-Esquivel N, Pose E, Bataller R. Alcohol-associated liver disease: Epidemiology and management. Ann Hepatol 2024; 29:101162. [PMID: 37832648 DOI: 10.1016/j.aohep.2023.101162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023]
Abstract
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.
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Affiliation(s)
- Helena Hernández-Évole
- Liver Unit, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Natalia Jiménez-Esquivel
- Liver Unit, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Elisa Pose
- Liver Unit, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ramón Bataller
- Liver Unit, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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Kuronen JO, Winell K, Hartsenko J, Räsänen KP. Occupational health care personnel tackling alcohol overuse - an observational study of work processes and patient characteristics. BMC Public Health 2022; 22:67. [PMID: 35012504 PMCID: PMC8751364 DOI: 10.1186/s12889-021-12473-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background Overuse of alcohol is a significant risk factor for early retirement. This observational study investigated patient characteristics and work processes in occupational health care (OHC) affecting practices in tackling alcohol overuse. Methods The data were from 3089 patient contacts gathered for quality improvement purposes in fifteen OHC units during the years 2013–2019 in Finland. A two-proportion z-test was performed to find associations between reason for contact, and 17 other factors, and the probability of alcohol use being checked and overuse tackled. Results OHC personnel checked alcohol use twice as often with male patients as with female patients. Employees at risk of needing sick leave were checked for alcohol use more often (55.4, 95% confidence interval 49.2–61.6%) than those on > 30-day sick leave or working with permanent work disability (p < 0.01). Alcohol use was checked in 64.1% (59.5–68.7%) of patients while making an individual health promotion plan compared to 36.9% of those without a plan (33.1–40.6%, p < 0.0001). Patients with depression were actively checked for alcohol use, especially in cases of major depression (72.7%, 64.0–81.0%). Work processes in which OHC should have been more active in checking and tackling alcohol use included assessing the need for rehabilitation (36.5%, 32.0–41.0%) and health check-ups (HCUs) for mental reasons (43.8%, 38.1–49.4%). HCUs where alcohol overuse was detected led to brief interventions to tackle the overuse in 58.1% (43.4–72.9%) of cases. Conclusions The study showed factors that increased OHC personnel’s practices in checking and tackling alcohol use and work processes where the activity should be improved. Discussions about alcohol use took place more often with working-aged men than women, the younger the more. OHC personnel checked actively alcohol use with patients in danger of sick leave, patients treated for depression, while making an individual health promotion plan, and in planned HCUs with a confirmed protocol. More improvement is needed to conduct brief interventions in disability prevention processes, and especially when overuse is detected. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-12473-2.
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Affiliation(s)
- Jarmo O Kuronen
- Etelä-Savon Työterveys Oy, Maaherrankatu 13, 50100, Mikkeli, Finland.
| | - Klas Winell
- Conmedic Oy, Antaksenkuja 3, 02330, Espoo, Finland
| | - Jelena Hartsenko
- Conmedic Oy, Antaksenkuja 3, 02330, Espoo, Finland.,Department of Business Administration, Tallinn University of Technology, Ehitajate tee 5, 12616, Tallinn, Estonia
| | - Kimmo P Räsänen
- University of Eastern Finland, Faculty of Health Sciences, School of Medicine, Institute of Public Health and Clinical Nutrition, Box 1627, 70211, Kuopio, Finland
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Rittenberg A, Hines AL, Alvanzo AA, Chander G. Correlates of alcohol use disorder pharmacotherapy receipt in medically insured patients. Drug Alcohol Depend 2020; 214:108174. [PMID: 32721788 PMCID: PMC8011546 DOI: 10.1016/j.drugalcdep.2020.108174] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Alcohol use disorder is a highly prevalent disease with multiple medications available for treatment. The overall prevalence of patients receiving pharmacotherapy is believed to be low and the characteristics and comorbidities that affect receipt are not well-established. METHODS We created a dataset from Truven Health Analytics MarketScan Commercial Claims and Encounters Database of patients with an outpatient encounter for alcohol abuse or dependence in 2014. We subsequently identified patient characteristics, comorbid medical, psychiatric, or substance use disorders, as well as encounter provider specialties and, using multivariable logistic regression, assessed which variables correlated with increased or decreased receipt of pharmacotherapy for alcohol use disorder for this population. RESULTS In our dataset of 123,355 patients, patient receipt of pharmacotherapy for alcohol use disorder was 3.3 %, and 9.3 % when restricted to the former diagnosis of alcohol dependence only. Male sex, younger age, alcohol-related liver disease, and cannabis use disorders correlated with decreased receipt whereas comorbid major depressive disorders and anxiety disorders correlated with increased receipt. Compared to patients seen by psychiatrists, those seen by primary medical doctors had a lower odds of receiving pharmacotherapy. CONCLUSIONS Pharmacotherapy for alcohol use disorder is an underutilized treatment modality with a low prevalence of prescription in insured individuals. Patients with specific characteristics and comorbidities are less likely to receive this treatment and greater focus on these patients and in the primary care setting can allow for increased prescribing of these medications.
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Affiliation(s)
- Alexander Rittenberg
- Johns Hopkins University School of Medicine, 1830 E Monument Street, Baltimore, MD, 21287, United States.
| | - Anika L. Hines
- Johns Hopkins University School of Medicine, 1830 E Monument Street, Baltimore, MD, 21287, United States
| | - Anika A. Alvanzo
- Johns Hopkins University School of Medicine, 1830 E Monument Street, Baltimore, MD, 21287, United States
| | - Geetanjali Chander
- Johns Hopkins University School of Medicine, 1830 E Monument Street, Baltimore, MD, 21287, United States.
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6
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Peng JL, Patel MP, McGee B, Liang T, Chandler K, Tayarachakul S, O'Connor S, Liangpunsakul S. Management of alcohol misuse in patients with liver diseases. J Investig Med 2016; 65:673-680. [PMID: 27940551 DOI: 10.1136/jim-2016-000254] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2016] [Indexed: 12/20/2022]
Abstract
Excessive alcohol use not only causes alcoholic liver disease (ALD) but also increases the risk of liver-related mortality in patients who already have other chronic liver diseases. Screening for alcohol misuse or alcohol use disorder (AUD) among patients with underlying liver disease is essential. This clinical review covers what is known about ALD, the impact of alcohol in patients with underlying liver diseases, current management of alcohol misuse and AUD, and the management of alcohol misuse and AUD specifically in patients with liver diseases. Several treatment options for alcohol misuse and AUD exist such as psychosocial intervention and behavioral and pharmacological therapies. The strategies used in the treatment of alcohol misuse and AUD are still applicable in those who consume alcohol and have underlying liver disease. However, certain medications still need to be carefully used due to potentially worsening already compromised liver function. Screening of ongoing alcohol use in subjects with liver disease is important, and prompt intervention is needed to prevent the associated morbidity and mortality from the detrimental effects of continued alcohol use on underlying liver disease. Considering alcoholism is a complex disease, probably a multidisciplinary approach combining psychotherapy and comprehensive medical care will be the most effective. Future research could focus on identifying additional treatment options for addressing the psychotherapy component since the self-determination and will to quit drinking alcohol can play such a crucial role in promoting abstinence.
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Affiliation(s)
- Jennifer L Peng
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Milan Prakash Patel
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Breann McGee
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Tiebing Liang
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Kristina Chandler
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Sucharat Tayarachakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University Medical Center, Indianapolis, Indiana, USA.,Southern Plains Tribal Health Board, Oklahoma Area Tribal Epidemiology Center, Oklahoma City, Oklahoma, USA
| | - Sean O'Connor
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Roudebush Veterans Administration Medical Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Suthat Liangpunsakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University Medical Center, Indianapolis, Indiana, USA.,Roudebush Veterans Administration Medical Center, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Depertment of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Abstract
This issue provides a clinical overview of alcohol use, focusing on health benefits, harms, prevention, screening, diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.
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Goulding E. Alcohol Use and Management. LIFESTYLE MEDICINE 2016. [DOI: 10.1007/978-3-319-24687-1_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Costa MDA, Salum Junior GA, Isolan LR, Acosta JR, Jarros RB, Blaya C, Diemen LV, Manfro GG. Association between anxiety symptoms and problematic alcohol use in adolescents. TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2015; 35:106-10. [PMID: 25923300 DOI: 10.1590/s2237-60892013000200003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 08/16/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND Anxiety disorders are highly prevalent, affecting approximately 10% of individuals throughout life; its onset can be detected since early childhood or adolescence. Studies in adults have shown that anxiety disorders are associated with alcohol abuse, but few studies have investigated the association between anxiety symptoms and problematic alcohol use in early ages. OBJECTIVE To evaluate if anxiety symptoms are associated with problematic alcohol use in young subjects. METHODS A total of 239 individuals aged 10-17 years were randomly selected from schools located in the catchment area of Hospital de Clínicas de Porto Alegre. The Screen for Child Anxiety-Related Emotional Disorders (SCARED) was used to evaluate the presence of anxiety symptoms, and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), to evaluate alcohol use. RESULTS One hundred twenty-seven individuals (53.1% ) reported having already used alcohol. Of these, 14 individuals showed problematic alcohol use (5.8% ). There was no association between lifetime use of alcohol and anxiety symptoms, but mean SCARED scores in individuals with problematic alcohol use was higher if compared to those without problematic use, even after adjustment for age and gender (29.9±8.5 vs. 23.7±11.8, p < 0.001). CONCLUSIONS Despite the limitation of a cross-sectional design, our study suggests that anxiety symptoms are associated with problematic alcohol use early in life.
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Affiliation(s)
- Marianna de Abreu Costa
- Anxiety Disorders Program for Child and Adolescent Psychiatry, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | | | - Jandira Rahmeier Acosta
- Anxiety Disorders Program for Child and Adolescent Psychiatry, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | | | - Lísia Von Diemen
- Center for Drug and Alcohol Research, HCPA, UFRGS, Porto Alegre, RS, Brazil
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At-Risk Drinking Is Independently Associated With ICU and One-Year Mortality in Critically Ill Nontrauma Patients*. Crit Care Med 2014; 42:860-7. [DOI: 10.1097/ccm.0000000000000041] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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11
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Sanvisens A, Vallecillo G, Bolao F, Rivas I, Fonseca F, Fuster D, Torrens M, Pérez-Hoyos S, Pujol R, Tor J, Muga R. Temporal trends in the survival of drug and alcohol abusers according to the primary drug of admission to treatment in Spain. Drug Alcohol Depend 2014; 136:115-20. [PMID: 24485061 DOI: 10.1016/j.drugalcdep.2013.12.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 12/27/2013] [Accepted: 12/27/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Mortality of alcohol and drug abusers is much higher than the general population. We aimed to characterize the role of the primary substance of abuse on the survival of patients admitted to treatment and to analyze changes in mortality over time. METHODS Longitudinal study analyzing demographic, drug use, and biological data of 5023 patients admitted to three hospital-based treatment units in Barcelona, Spain, between 1985 and 2006. Vital status and causes of death were ascertained from clinical charts and the mortality register. Piecewise regression models were used to analyze changes in mortality. RESULTS The primary substances of dependence were heroin, cocaine, and alcohol in 3388 (67.5%), 945 (18.8%), and 690 patients (13.7%), respectively. The median follow-up after admission to treatment was 11.6 years (IQR: 6.6-16.1), 6.5 years (IQR: 3.9-10.6), and 4.8 years (IQR: 3.1-7.8) for the heroin-, cocaine-, and alcohol-dependent patients, respectively. For heroin-dependent patients, mortality rate decreased from 7.3×100person-years (p-y) in 1985 to 1.8×100p-y in 2008. For cocaine-dependent patients, mortality rate decreased from 10.7×100p-y in 1985 to <2.5×100p-y after 2004. The annual average decrease was 2% for alcohol-dependent patients, with the lowest mortality rate (3.3×100p-y) in 2008. CONCLUSIONS Significant reductions in mortality of alcohol and drug dependent patients are observed in recent years in Spain. Preventive interventions, treatment of substance dependence and antiretroviral therapy may have contributed to improve survival in this population.
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Affiliation(s)
- Arantza Sanvisens
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Gabriel Vallecillo
- Institute of Neuropsychiatry & Addictions, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ferran Bolao
- Department of Internal Medicine, Hospital Universitari de Bellvitge, Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Inmaculada Rivas
- Municipal Centre for Substance Abuse Treatment (Centro Delta), IMSP Badalona, Badalona, Spain
| | - Francina Fonseca
- Institute of Neuropsychiatry & Addictions, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Daniel Fuster
- Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Marta Torrens
- Institute of Neuropsychiatry & Addictions, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Santiago Pérez-Hoyos
- Department of Preventive Medicine and Public Health, Vall d'Hebrón Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ramon Pujol
- Department of Internal Medicine, Hospital Universitari de Bellvitge, Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Jordi Tor
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Roberto Muga
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain.
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Lee SH, Lee BC, Kim JW, Yi JS, Choi IG. Association between Alcoholism Family History and Alcohol Screening Scores among Alcohol-dependent Patients. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2013; 11:89-95. [PMID: 24023553 PMCID: PMC3766760 DOI: 10.9758/cpn.2013.11.2.89] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 06/19/2013] [Accepted: 07/01/2013] [Indexed: 11/30/2022]
Abstract
Objective Several tests can be used to screen for alcohol dependence (AD), a prevalent disease with a heterogeneous etiology. As some patients with AD have a strong familial tendency in this regard, a family history of alcohol use disorders can affect the outcomes of screening tests and diagnostic evaluations for AD. In this study, we evaluated associations between a family history of alcohol use disorders and evaluations using the Cut down, Annoyed, Guilty, Eye-opener (CAGE) test, Alcohol Use Disorder Identification Test (AUDIT), and Diagnostic and Statistical Manual of Mental Disorders-fourth edition (DSM-IV) diagnostic criteria among patients with AD. Methods We recruited 487 male patients with AD from eight hospitals in Korea. Patients were evaluated using the CAGE, AUDIT, and DSM-IV diagnostic criteria. Patients with and without family histories were compared in terms of these assessment tools. Results Drinking initiation, uncontrollable drinking, and problem drinking occurred earlier and CAGE "annoyed" scores were higher in patients with a family history. Alcohol problems before the age of 25 years, frequency of spontaneous or compulsive alcohol-seeking behavior, and frequencies of psychological dependence and guilt related to alcohol use were also higher. Conclusion Earlier drinking problems, higher scores on specific items of the CAGE, and AUDIT, and meeting more diagnostic criteria indicate more dependent, harmful drinking by patients with AD who have a family history of this condition. Clinicians should consider patients' family history of alcohol use disorders when screening for AD to identify the correct diagnosis and develop appropriate treatment plans for these patients.
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Affiliation(s)
- So-Hyun Lee
- Department of Psychiatry, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
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13
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Gacouin A, Roussel M, Gros A, Sauvadet E, Uhel F, Chimot L, Marque S, Camus C, Fest T, Le Tulzo Y. Chronic alcohol exposure, infection, extended circulating white blood cells differentiated by flow cytometry and neutrophil CD64 expression: a prospective, descriptive study of critically ill medical patients. Ann Intensive Care 2012; 2:50. [PMID: 23272900 PMCID: PMC3539872 DOI: 10.1186/2110-5820-2-50] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 11/14/2012] [Indexed: 11/29/2022] Open
Abstract
Background A history of prolonged and excessive consumption of alcohol increases the risk for infections. The goal of this study was to investigate circulating white blood cells (WBC) differentiated by flow cytometry and neutrophil CD64 expression in excessive alcohol drinkers versus abstinent or moderate drinkers, and in those with or without infection, in medical patients admitted to the intensive care unit (ICU). Methods All patients admitted between September 2009 and March 2010 with an ICU-stay of 3 days or more were eligible for inclusion. Upon admission, hematological exams were conducted by flow cytometry. Results Overall, 281 adult were included, with 37% identified as at-risk drinkers. The only significant difference found in circulating WBC between at-risk and not-at-risk drinkers was a lower number of B lymphocytes in at-risk drinkers (P = 0.002). Four groups of patients were defined: not-at-risk drinkers with no infection (n = 66); not-at-risk drinkers with infection (n = 112); at-risk drinkers with no infection (n = 53); and at-risk drinkers with infection (n = 50). Whilst the presence of infection significantly reduced levels of noncytotoxic and cytotoxic T lymphocytes and significantly increased levels of CD16– monocytes in not-at-risk drinkers, with variation related to infection severity, infection had no effect on any of the variables assessed in at-risk drinkers. Post-hoc comparisons showed that B-lymphocyte, noncytotoxic, and cytotoxic T lymphocyte and CD16– counts in at-risk drinkers were similar to those in not-at-risk drinkers with infection and significantly lower than those in not-at-risk drinkers without infection. Neutrophil CD64 index varied significantly between groups, with variations related to infection, not previous alcohol consumption. Conclusions These results show that chronic alcohol exposure has an impact on the immune response to infection in critically ill medical patients. The absence of significant variations in circulating WBC seen in at-risk drinkers according to the severity of infection is suggestive of altered immune response.
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Affiliation(s)
- Arnaud Gacouin
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, Rennes, F-35033, France.
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Abstract
This article reviews the spectrum of alcohol use disorders. The pharmacologic properties of ethanol and its metabolism, and the historical, physical, and laboratory elements that may help diagnose an alcohol use disorder are examined. The concepts of motivational interviewing and stages of change are mentioned, along with the American Society of Addiction Medicine patient placement criteria, to determine the best level of treatment for alcoholism. Various therapeutic management options are reviewed, including psychological, pharmacologic, and complementary/alternative choices. This article provides a basic understanding of available tools to diagnose and treat this cunning and baffling brain and multisystem disease.
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Affiliation(s)
- Anthony P Albanese
- Hepatology and Chemical Dependency, VA Northern California Healthcare System, University of California Davis School of Medicine, Sacramento, CA, USA.
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15
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Cheng WJ, Cheng Y, Huang MC, Chen CJ. Alcohol dependence, consumption of alcoholic energy drinks and associated work characteristics in the Taiwan working population. Alcohol Alcohol 2012; 47:372-9. [PMID: 22493045 DOI: 10.1093/alcalc/ags034] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
AIMS To examine the association between work characteristics and the risk of alcohol dependence across different employment types and occupations, including the pattern of alcohol consumption in the form of energy drinks and its association with alcohol dependence. METHODS A total of 13,501 men and 8584 women participated in a national survey in Taiwan. Alcohol dependence was defined as ≥2 points in the CAGE questionnaire. A self-administered questionnaire recorded drinking behaviors, consumption of alcoholic energy drinks, employment type, occupation and a number of psychosocial work stressors, namely job demands, job control, employment security and workplace justice. RESULTS Of the total, 9.4% of men and 0.8% of women were CAGE-positive, and 6.0% of men and 0.7% of women regularly consumed alcoholic energy drinks. In male and female regular consumers of alcoholic energy drinks, 38.7 and 23.3%, respectively, were alcohol-dependent. Multivariate regression analyses showed that male employees in manual skilled occupations, with lower workplace justice, having weekly working hours <40 h and on piece-rated or time-based pay systems were at higher risks of alcohol dependence. CONCLUSION Certain occupational groups and workers with adverse psychosocial work characteristics should be targets for prevention of alcohol dependence. Alcoholic energy drink consumption should be taken into consideration while studying alcohol dependence in the work population in Taiwan.
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Affiliation(s)
- Wan-Ju Cheng
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, 17 Xu-Zhou Rd., Taipei, Taiwan
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16
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Kartha A, Anthony D, Manasseh CS, Greenwald JL, Chetty VK, Burgess JF, Culpepper L, Jack BW. Depression is a risk factor for rehospitalization in medical inpatients. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2011; 9:256-62. [PMID: 17934548 DOI: 10.4088/pcc.v09n0401] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2006] [Accepted: 03/09/2007] [Indexed: 10/20/2022]
Abstract
BACKGROUND Rehospitalization occurs in approximately 20% of medical inpatients within 90 days of discharge. Rehospitalization accounts for considerable morbidity, mortality, and costs. Identification of risk factors could lead to interventions to reduce rehospitalization. The objective of the study was to determine if physical and mental health, substance abuse, and social support are risk factors for rehospitalization. METHOD This was a prospective cohort study in an innercity population conducted from September 2002 to September 2004. Participants included 144 adult inpatients with at least 1 hospital admission in the past 6 months. Measurements included age, length of stay, number of admissions in the past year, and medical comorbidity as well as measures of depression, alcohol and drug abuse, social support, and health-related quality of life. The outcome studied was the rehospitalization status of participants within 90 days of the index hospitalization. RESULTS The mean age of the subjects was 54.8 years; 48% were black and 78% spoke English as a primary language. Subjects were admitted a mean of 2.5 times in the year before the index admission. Sixty-four patients (44%) were subsequently rehospitalized within 90 days after the index admission. In bivariate analysis, rehospitalized patients had more prior admissions (median of 3.0 vs. 2.0 admissions, p = .002), greater medical comorbidity (mean Charlson Comorbidity Index score of 2.6 vs. 2.0, p = .04), and poorer physical functional status (mean SF-12 physical component score of 31.5 vs. 36.2, p = .03). A logistic regression model, including prior admissions in the last year, comorbidity, physical functional status, and depression, showed that depression tripled the odds of rehospitalization (odds ratio = 3.3, 95% CI = 1.2 to 9.3). This model had fair accuracy in identifying patients at greatest risk for rehospitalization (c statistic = 0.72). CONCLUSIONS Hospitalized patients with a history of prior hospitalization within 6 months who screen positive for depression are 3 times more likely to be rehospitalized within 90 days in this relatively high-risk population. Screening during hospitalization for depressive symptoms may identify those at risk for rehospitalization.
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Affiliation(s)
- Anand Kartha
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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Geirsson M, Hensing G, Spak F. Does gender matter? A vignette study of general practitioners' management skills in handling patients with alcohol-related problems. Alcohol Alcohol 2010; 44:620-5. [PMID: 19846585 DOI: 10.1093/alcalc/agp071] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS The aims of this study were to analyse the perceptions of female and male primary care physicians (PCPs) of alcohol problems in male and female patients, their recommendations to reduce or abstain from alcohol, their referrals to treatment and their views of safe levels of drinking for male and female patients. These factors were related to the physicians' own alcohol consumption. METHODS A slightly adjusted version of the WHO Collaborative Study Questionnaire for General Practitioners was posted to all PCPs (n = 132) in the district of Skaraborg, Sweden, of whom 68 PCPs responded. In the questionnaire, the PCPs' perceptions of two patient vignettes were analysed. RESULTS Both the gender of the patients in the vignettes and of the PCPs influenced the advice and the referrals that the patients received: 83% of male excessive drinkers and 47% of female excessive drinkers were recommended to cut down on drinking. In 50% of cases, the male excessive drinker was not referred, compared with 25% for the female excessive drinker. This was statistically significant only for excessive drinkers. The odds ratio for referral to any treatment was 0.33 (CI = 0.12-0.93) for the male excessive drinker compared with the female excessive drinker. The male PCP referred the excessive drinker less often to any treatment than did the female PCP, odds ratio 0.26 (CI = 0.08-0.90). The upper limit of alcohol consumption before the PCPs would advise the patient to cut down was significantly higher for PCPs with the AUDIT-C score >or= 3. The limit was 146 g/week for male patients and 103 g/week for female patients. Corresponding figures for PCP with the AUDIT-C score <or= 2 were 89 and 68 g/week. CONCLUSION Male patients were less likely to be advised to stop drinking altogether than female patients and were less likely to be referred, according to this vignette study. Taking into account that male patients have a higher prevalence of alcohol problems, this may be of considerable importance for men's health outcomes. Implications of these findings are the need to increase awareness of male excessive drinking and that gendered perceptions might bias alcohol management recommendations.
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Asada T, Takaya S, Takayama Y, Yamauchi H, Hashikawa K, Fukuyama H. Reversible alcohol-related dementia: a five-year follow-up study using FDG-PET and neuropsychological tests. Intern Med 2010; 49:283-7. [PMID: 20154432 DOI: 10.2169/internalmedicine.49.2662] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE As the pathophysiology of alcohol-related dementia (ARD) is unclear, we examined a patient with reversible ARD using neuropsychological tests and (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET). DESIGN A five-year follow-up case study with neuropsychological tests and FDG-PET. SETTING Kyoto University Hospital. Patients A 42-year-old patient who was unable to perform his office duties because of slowly progressive amnesia with executive dysfunction. RESULTS The initial evaluation with neuropsychological tests showed severe verbal memory disturbance. The patient did not discuss his excessive alcohol consumption in the initial history-taking session and thiamine deficiency was absent; therefore, early-stage Alzheimer's disease was suspected. Later, the patient revealed prior excessive alcohol intake and his cognitive function improved markedly after a period of abstinence. Retrospective analysis of initial FDG-PET images using a voxel-wise statistical method revealed glucose hypometabolism in the diencephalon and basal forebrain. Follow-up for 5 years after the initial evaluation showed improved cognitive function and recovery of glucose metabolism in the two brain regions. CONCLUSION Hypofunction in the diencephalon and basal forebrain was associated with cognitive decline in our patient. This case may provide evidence for the etiopathic brain regions in reversible type ARD.
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Affiliation(s)
- Tomohiko Asada
- Human Brain Research Center, Kyoto University Graduate School of Medicine, Kyoto
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Sannibale C, Fucito L, O'Connor D, Curry K. Process evaluation of an out-patient detoxification service. Drug Alcohol Rev 2009; 24:475-81. [PMID: 16361203 DOI: 10.1080/09595230500292912] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This paper describes the process evaluation of an out-patient detoxification service (ODS) established by Drug Health Services (DHS) to increase the supervised withdrawal options for substance users in a Sydney metropolitan Area Health Service. The ODS aimed to provide a safe and effective supervised withdrawal to substance users who were at low risk of severe withdrawal, engage those with severe dependence in further treatment and increase the involvement of general practitioners (GPs) in the medical care of ODS clients. During its first 10 months of operation, the ODS received 199 inquiries, assessed 82 individuals and admitted 76 clients for detoxification. Withdrawal treatment proceeded without complications and within the expected time frames. Fifty-four clients completed withdrawal, 10 ceased treatment, 10 remained in treatment without completing withdrawal and two were transferred elsewhere. Clients who injected substances (mainly heroin) daily at admission, compared to others, were less likely to complete withdrawal and more likely to use a range of non-prescribed substances during withdrawal. One-fifth of clients went on to further treatment with DHS, attending at least once. Overall, the ODS met its goals, providing a safe and effective supervised withdrawal to local residents, especially women, young people and those withdrawing from benzodiazepines who had significant substance dependence, impairment and previous alcohol and other drug (AOD) treatment. Non-injecting substance users benefited most from the ODS in terms of withdrawal completion and ongoing treatment. The level of GP involvement in the conjoint care of ODS clients remained constant over time. The development and expansion of the ODS are discussed.
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Affiliation(s)
- Claudia Sannibale
- Drug Health Services, Central Sydney Area Health Service, Sydney, New South Wales, Australia
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Ekstedt M, Franzén LE, Holmqvist M, Bendtsen P, Mathiesen UL, Bodemar G, Kechagias S, Franzén LE, Holmqvist M, Bendtsen P, Mathiesen UL, Bodemar G, Kechagias S. Alcohol consumption is associated with progression of hepatic fibrosis in non-alcoholic fatty liver disease. Scand J Gastroenterol 2009; 44:366-74. [PMID: 19016382 DOI: 10.1080/00365520802555991] [Citation(s) in RCA: 142] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Moderate alcohol consumption has been reported to be inversely associated with cardiovascular disease and total mortality. The importance of non-alcoholic fatty liver disease (NAFLD) is increasing and many NAFLD patients suffer from cardiovascular disease. In these patients, moderate alcohol consumption could be beneficial. The aim of this study was to investigate whether low alcohol intake, consistent with the diagnosis of NAFLD, is associated with fibrosis progression in established NAFLD. MATERIAL AND METHODS Seventy-one patients originally referred because of chronically elevated liver enzymes and diagnosed with biopsy-proven NAFLD were re-evaluated. A validated questionnaire combined with an oral interview was used to assess weekly alcohol consumption and the frequency of episodic drinking. Significant fibrosis progression in NAFLD was defined as progression of more than one fibrosis stage or development of endstage liver disease during follow-up. RESULTS Mean follow-up (SD) was 13.8 (1.2) years between liver biopsies. At follow-up, 17 patients (24%) fulfilled the criteria for significant fibrosis progression. The proportion of patients reporting heavy episodic drinking at least once a month was higher among those with significant fibrosis progression (p=0.003) and a trend towards higher weekly alcohol consumption was also seen (p=0.061). In a multivariate binary logistic regression analysis, heavy episodic drinking (p<0.001) and insulin resistance (p<0.01) were independently associated with significant fibrosis progression. CONCLUSIONS Moderate alcohol consumption, consistent with the diagnosis of NAFLD to be set, is associated with fibrosis progression in NAFLD. These patients should be advised to refrain from heavy episodic drinking.
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Affiliation(s)
- Mattias Ekstedt
- Division of Gastroenterology and Hepatology, Department of Clinical and Experimental Medicine, University Hospital, Linköping, Sweden.
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Fung CH, Setodji CM, Kung FY, Keesey J, Asch SM, Adams J, McGlynn EA. The relationship between multimorbidity and patients' ratings of communication. J Gen Intern Med 2008; 23:788-93. [PMID: 18427902 PMCID: PMC2517863 DOI: 10.1007/s11606-008-0602-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2007] [Revised: 02/27/2008] [Accepted: 03/12/2008] [Indexed: 12/01/2022]
Abstract
BACKGROUND The growing interest in pay-for-performance and other quality improvement programs has generated concerns about potential performance measurement penalties for providers who care for more complex patients, such as patients with more chronic conditions. Few data are available on how multimorbidity affects common performance metrics. OBJECTIVE To examine the relationship between multimorbidity and patients' ratings of communication, a common performance metric. DESIGN Cross-sectional study SETTING Nationally representative sample of U.S. residents PARTICIPANTS A total of 15,709 noninstitutionalized adults living in the United States participated in a telephone interview. MEASUREMENTS We used 2 different measures of multimorbidity: 1) "individual conditions" approach disregards similarities/concordance among chronic conditions and 2) "condition-groups" approach considers similarities/concordance among conditions. We used a composite measure of patients' ratings of patient-physician communication. RESULTS A higher number of individual conditions is associated with lower ratings of communication, although the magnitude of the relationship is small (adjusted average communication scores: 0 conditions, 12.20; 1-2 conditions, 12.06; 3+ conditions, 11.90; scale range 5 = worst, 15 = best). This relationship remains statistically significant when concordant relationships among conditions are considered (0 condition groups 12.19; 1-2 condition groups 12.03; 3+ condition groups 11.94). CONCLUSIONS In our nationally representative sample, patients with more chronic conditions gave their doctors modestly lower patient-doctor communication scores than their healthier counterparts. Accounting for concordance among conditions does not widen the difference in communication scores. Concerns about performance measurement penalty related to patient complexity cannot be entirely addressed by adjusting for multimorbidity. Future studies should focus on other aspects of clinical complexity (e.g., severity, specific combinations of conditions).
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At-risk drinkers are at higher risk to acquire a bacterial infection during an intensive care unit stay than abstinent or moderate drinkers*. Crit Care Med 2008; 36:1735-41. [DOI: 10.1097/ccm.0b013e318174dd75] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Janicik R, Kalet AL, Schwartz MD, Zabar S, Lipkin M. Using Bedside Rounds to Teach Communication Skills in the Internal Medicine Clerkship. MEDICAL EDUCATION ONLINE 2007; 12:4458. [PMID: 28253095 DOI: 10.3402/meo.v12i.4458] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Physicians' communication skills, which are linked to important patient outcomes, are rarely explicitly taught during the clinical years of medical school. This paper describes the development, implementation, and evaluation of a communication skills curriculum during the third-year Internal Medicine Clerkship. METHODS In four two-hour structured bedside rounds with trained Internal Medicine faculty facilitators, students learned core communication skills in the context of common challenging clinical situations. In an end-of-clerkship survey students evaluated the curriculum's educational effectiveness. RESULTS Over the course of a year, 160 third-year students and 15 faculty participated. Of the 75/160 (47%) of students who completed the post-clerkship survey, almost all reported improvement in their communication skills and their ability to deal with specific communication challenges. CONCLUSIONS The curriculum appears to be a successful way to reinforce core communication skills and practice common challenging situations students encounter during the Internal Medicine Clerkship.
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Abstract
PURPOSES To test the effectiveness of motivational interviewing in a population of hazardous drinkers utilizing community health care centers in rural southeastern Idaho. DATA SOURCES This study targeted rural people at risk for alcohol dependence utilizing low-income community health care centers in rural southeastern Idaho. The Alcohol Use Disorders Identification Test (AUDIT) was used to screen interested clients' alcohol use. Clients achieving an AUDIT score indicating hazardous alcohol use were recruited into the study and randomized into a control or treatment group. Twenty-six hazardous drinkers attending five low-income community health centers participated in the study. The experimental group participated in one motivational interviewing session with the investigator, a family nurse practitioner (NP). The comparison group received no treatment. Alcohol use was tracked for 6 weeks after successful recruitment into the program. CONCLUSIONS Participants in the study significantly decreased their average number of drinks per day. At time 1 (pretreatment), the control group drank 4.37 drinks per day and the treatment group drank 4.65 drinks per day. At time 2 (posttest), the control group drank 3.77 drinks per day and the treatment group drank 1.95 drinks per day. The effects of the motivational interviewing treatment on hazardous drinking also were measured by serum gamma-glutamyltransferase (GGT), a liver function test. There was also a significant decrease in the GGT from pretest to posttest in the treatment group. IMPLICATIONS FOR PRACTICE The results of this investigation found that motivational interviewing shows promise as an effective intervention for hazardous drinkers attending low-income community clinics. Although other possible explanations could be postulated for the positive changes in sample participants, the data indicate that the motivational interviewing approach was responsible for a significant portion of the positive changes within the current sample. The information collected from the study adds to the literature on hazardous drinking, research, and treatment of this significant problem. Negotiating change in behavior is part of the practice of NPs. People struggling with alcohol use are more likely to encounter NPs, family doctors, or social workers than counselors specializing in alcohol treatment. Motivational interviewing is specifically designed for preparing people for change. Because most people resist being told what to do, that is, "you have to stop drinking," use of motivational interviewing principles can decrease resistance and optimize change. Additionally, identifying and intervening with hazardous drinking in a primary care setting can reduce healthcare costs and reduce the stigma of specialist care. Adding this valuable communication skill to the competencies of NPs is important to both clients and NPs.
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Affiliation(s)
- Nancy Beckham
- Department of Nursing, Gonzaga University, Spokane, Washington 99258-0038, USA.
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Conigliaro J, Justice AC, Gordon AJ, Bryant K. Role of alcohol in determining human immunodeficiency virus (HIV)-relevant outcomes: A conceptual model to guide the implementation of evidence-based interventions into practice. Med Care 2006; 44:S1-6. [PMID: 16849963 DOI: 10.1097/01.mlr.0000223659.36369.cf] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Joseph Conigliaro
- Program for Quality, Safety and Patient Rights, Department of Medicine, University of Kentucky, Lexington, Kentucky 40536, USA.
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Abstract
BACKGROUND Both inpatient and outpatient treatment centers that focus solely on psychosocial therapies for the treatment of alcohol dependence have high relapse rates. Thus, extensive research has focused on the development of pharmacologic moieties to attenuate the craving for alcohol after acute alcohol detoxification. Three drug therapies are currently approved by the US Food and Drug Administration (FDA) for this purpose: disulfiram, naltrexone, and acamprosate. The latter was approved by the FDA in 2004. OBJECTIVE This article describes the pharmacologic properties and clinical usefulness of acamprosate for the treatment of alcohol dependence. METHODS Relevant information was identified through searches of MEDLINE (1966 to March 2005), International Pharmaceutical Abstracts (1970-2005), Current Contents (1996-2005), and Cumulative Index to Nursing and Allied Health Literature (1982-Week 2, 2004) using the key words acamprosate, alcohol dependence, and alcoholism (MeSH). RESULTS Acamprosate limited to randomized, controlled clinical trials yielded 33 hits in MEDLINE. Twenty-two articles were reviewed for efficacy end points, and 10 were reviewed for pharmacology and pharmacokinetics data. Acamprosate plus pharmacokinetics and pharmacodynamics yielded 19 hits, some of which were duplicates from the previously described search. Acamprosate plus meta-analysis (MeSH) yielded 5 hits, naltrexone plus meta-analysis (MeSH) yielded 9 hits, and disulfiram plus meta-analysis yielded 3 hits. The most recent review articles and their reference lists were assessed to ensure completeness of literature searches. Based on these searches, acamprosate is known to be an analogue of taurine and gamma-aminobutyric acid (GABA), 2 central nervous system neuromodulators. Acamprosate is thought to share some of the cellular actions of taurine affecting GABA and glutaminergic receptors in the nucleus accumbens, a brain region that may be responsible for the reinforcing effects received after alcohol consumption. Acamprosate is thought to also suppress excitation-induced calcium entry that results from chronic alcohol exposure, thereby altering the conformation of the N-methyl-d-aspartate receptors. The percentage of patients taking acamprosate who were completely abstinent throughout the different durations of the studies varied from approximately 18% to 61%, compared with 4% to 45% with placebo. Diarrhea was the most common adverse effect accompanying acamprosate therapy, and this was generally described as dose related and transient. CONCLUSIONS Acamprosate is associated with modest treatment effects. Its efficacy is similar to naltrexone, and the combination of acamprosate and naltrexone appears to be more efficacious than acamprosate alone, when combined with psychosocial interventions.
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Affiliation(s)
- Lisa A Boothby
- Harrison School of Pharmacy, Auburn University, Alabama, USA.
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Fiellin DA, O'Connor PG, Wang Y, Radford MJ, Krumholz HM. Quality of care for acute myocardial infarction in elderly patients with alcohol-related diagnoses. Alcohol Clin Exp Res 2006; 30:70-5. [PMID: 16433733 DOI: 10.1111/j.1530-0277.2006.00001.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Elderly adults with alcohol-related diagnoses represent a vulnerable population that may receive lower quality of treatment during hospitalization for acute myocardial infarction. We sought to determine whether elderly patients with alcohol-related diagnoses are less likely to receive standard indicators of quality care for acute myocardial infarction. METHODS We conducted a retrospective cohort analysis using administrative and medical record data from the Cooperative Cardiovascular Project. Subjects were Medicare beneficiaries with a confirmed principal discharge diagnosis of acute myocardial infarction from all acute care hospitals in the United States over an 8-month period. Our primary outcome was the receipt of 7 guideline-recommended care measures among all eligible patients and patients who were ideal candidates for a given measure. RESULTS In all, 1,284 (1%) of the 155,026 eligible patients met criteria for an alcohol-related diagnosis. Among the alcohol-related diagnoses, 1,077/1,284 (84%) were for the diagnoses of alcohol dependence or alcohol abuse. Patients with alcohol-related diagnoses were less likely than those without alcohol-related diagnoses to receive beta-blockers at the time of discharge (55% vs. 60%, p = 0.02). We found no other significant differences in performance of the quality indicators after stratifying by indication and adjustment for baseline characteristics. CONCLUSIONS Alcohol-related diagnoses are not a barrier to receiving most quality of care measures in elderly patients hospitalized for acute myocardial infarction.
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Affiliation(s)
- David A Fiellin
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8088, USA
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Bush KR, Kivlahan DR, Davis TM, Dobie DJ, Sporleder JL, Epler AJ, Bradley KA. The TWEAK is weak for alcohol screening among female Veterans Affairs outpatients. Alcohol Clin Exp Res 2004; 27:1971-8. [PMID: 14691385 DOI: 10.1097/01.alc.0000099262.50094.98] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal brief questionnaire for alcohol screening among female patients has not yet been identified. This study compared the performance of the TWEAK (tolerance, worried, eye-opener, amnesia, cutdown), the Alcohol Use Disorders Identification Test (AUDIT), and the AUDIT Consumption (AUDIT-C) as self-administered screening tests for hazardous drinking and/or active alcohol abuse or dependence among female Veterans Affairs (VA) outpatients. METHODS Women were included in the study if they received care at VA Puget Sound and completed both a self-administered survey containing the AUDIT and TWEAK screening questionnaires and subsequent in-person interviews with the Alcohol Use Disorders and Associated Disabilities Interview Schedule. Sensitivities, specificities, positive and negative likelihood ratios, and areas under Receiver Operating Characteristic curves were computed for each screening questionnaire compared with two interview-based comparison standards: (1) active DSM-IV alcohol abuse or dependence and (2) hazardous drinking and/or active DSM-IV alcohol abuse or dependence, the more appropriate target for primary care screening. RESULTS Of 393 women who completed screening questionnaires and interviews, 39 (9.9%) met diagnostic criteria for alcohol abuse or dependence, and 89 (22.7%) met criteria for hazardous drinking or alcohol abuse or dependence. The TWEAK had relatively low sensitivities (0.62 and 0.44) but adequate specificities (0.86 and 0.89) for both interview-based comparison standards, even at its lowest cut-point (>/=1). The AUDIT and AUDIT-C were superior, with the following areas under the receiver operating characteristic curve for active alcohol abuse or dependence and hazardous drinking and/or active alcohol abuse or dependence, respectively: AUDIT, 0.90 [95% confidence interval (CI), 0.85-0.95] and 0.87 (95% CI, 0.84-0.91); AUDIT-C, 0.91 (95% CI, 0.88-0.95) and 0.91 (95% CI, 0.88-0.94); and TWEAK, 0.76 (95% CI, 0.66-0.86) and 0.67 (95% CI, 0.60-0.74). CONCLUSIONS The TWEAK has low sensitivity as an alcohol-screening questionnaire among female VA outpatients and should be evaluated further before being used in other female primary care populations. The three-item AUDIT-C was the optimal brief alcohol-screening questionnaire in this study.
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Affiliation(s)
- Kristen R Bush
- Department of Veterans Affairs, Veterans Health Administration, Veterans Affairs Puget Sound Health Care System, Center of Excellence in Substance Abuse Treatment and Education, Seattle, WA 98108, USA.
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Conigliaro J, Madenwald T, Bryant K, Braithwaite S, Gordon A, Fultz SL, Maisto S, Samet J, Kraemer K, Cook R, Day N, Roach D, Richey S, Justice A. The Veterans Aging Cohort Study: observational studies of alcohol use, abuse, and outcomes among human immunodeficiency virus-infected veterans. Alcohol Clin Exp Res 2004; 28:313-21. [PMID: 15112939 DOI: 10.1097/01.alc.0000113414.73220.21] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article represents the proceedings of a symposium at the 2003 annual meeting of the Research Society on Alcoholism in Fort Lauderdale, FL. The organizers/chairs were Joseph Conigliaro and Amy Justice. The presentations were (1) Introduction, by Joseph Conigliaro and Tamra Madenwald; (2) Alcohol and HIV/AIDS: the importance of integrative and translational research, by Kendall Bryant; (3) Alcohol use and abuse among patients with HIV infection, by Joseph Conigliaro and Stephan Maisto; (4) Severity of comorbid alcohol use/abuse in HIV infection, by Amy Justice and Jeffrey Samet; (5) Estimating the impact of alcohol use on long-term HIV outcomes, by Scott Braithwaite and Amy Justice; (6) Homelessness, drug & alcohol use among HIV+ veterans, by Adam Gordon and Robert Cook; and (7) Hepatitis C & alcohol in the VACS 3 study, by Shawn Fultz and Kevin Kraemer. The symposium concluded with a discussion led and facilitated by Diedra Roach.
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Affiliation(s)
- Joseph Conigliaro
- Center for Health Equity Research and Promotion (CHERP), Pittsburgh, PA, USA.
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Abstract
BACKGROUND Biomedical markers may provide additive objective information in screening and confirmation of acute or recent consumption, intoxication, relapse, heavy drinking, hazardous/harmful use/abuse and dependence and alcohol use related organ dysfunction (alcohol use-related disorders: AUDs). AIMS To review the use of biomarkers in clinical practice to detect AUDs. FINDINGS About one-fifth of the patients seen in clinical practice have AUDs, which offer a variety of treatment options if diagnosed. The diagnosis of AUDs relies on clinical and alcohol-related history, physical examination, questionnaires and laboratory values. No clinical available laboratory test [e.g. for acute abuse: alcohol in blood or breath; for chronic alcohol abuse: gamma-glutamyl transferase (GGT), mean corpuscular volume (MCV), carbohydrate-deficient transferrin (CDT)] is reliable enough on its own to support a diagnosis of alcohol dependence, harmful use or abuse. Sensitivities, specificities and the predictive values may vary considerably according to patient and control group characteristics (e.g. gender, age or related comorbidity). In patient groups with limited cooperation markers may be helpful when considering treatment options. CONCLUSIONS More research is needed to determine the value of markers (single or combined, with questionnaires) in the context of clinical decision-making algorithms in defined settings and with defined dichotomous outcome variables.
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Affiliation(s)
- Tim Neumann
- Department of Anesthesiology and Intensive Care Medicine, Universitaetsmedizin-Berlin Charité, Charité Campus Mitte Berlin, Germany
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Conigliaro J, Gordon AJ, McGinnis KA, Rabeneck L, Justice AC. How harmful is hazardous alcohol use and abuse in HIV infection: do health care providers know who is at risk? J Acquir Immune Defic Syndr 2003; 33:521-5. [PMID: 12869842 DOI: 10.1097/00126334-200308010-00014] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We conducted a prospective cohort study to describe the association between alcohol use, HIV disease progression, and drug toxicity and to determine health care provider awareness of excessive alcohol use by recruiting 881 HIV-infected veterans (median age, 49 years; 99% male; 54% African American) from 3 VA HIV clinics. Twenty percent of patients were hazardous drinkers by the Alcohol Use Disorders Identification Test, 33% were binge drinkers, 32% had a chart ICD-9 alcohol diagnosis, and 12.5% and 66.7%, respectively, were described by their health care providers as currently and ever drinking "too much." Hazardous/binge drinkers more often had detectable viral loads (P < 0.001). Patients with alcohol diagnoses more often had elevated alanine transaminase or aspartate transaminase levels (P </= 0.02), anemia (P < 0.001), and elevated mean corpuscular volume (P < 0.001). Health care providers missed hazardous drinking in patients with undetectable viral loads (P = 0.01), patients without hepatitis C (P = 0.09), and patients with normal aspartate transaminase levels (P = 0.07) and missed alcohol diagnoses in patients without hepatitis and those with CD4 cell counts of >200/mL. We conclude that in HIV-positive veterans, hazardous drinking and alcohol diagnoses were common and associated with HIV disease progression and/or hepatic comorbidity and anemia. Health care providers more often missed alcohol problems in patients with less severe HIV infection and those without evidence of liver disease. Health care providers should routinely screen and counsel patients regarding alcohol problems as part of standard of care to minimize disease progression and bone marrow and hepatic toxicity.
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Affiliation(s)
- Joseph Conigliaro
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, Pennsylvania 15240, USA
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Abstract
The purpose of this article is to provide an overview of empirically supported, primarily self-report methods of screening and diagnosis related to alcohol use disorders (AUDs). The discussion of screening instruments focuses on the primary care setting, and the diagnosis instruments discussion centers on the alcohol (and other drug) treatment setting. The literature shows that the AUDIT and the CAGE are the most widely validated methods of screening for AUDs in primary care and may be applied readily in that context. Similarly, a number of instruments designed to derive DSM-IV (and ICD-10) AUD diagnoses, as well as constructs related to how AUDs are defined, are available and can meet a variety of clinical needs. Future research priorities include further development of brief methods to identify hazardous drinkers or individuals who have an AUD, as well as refinement of diagnosis instruments to increase their application across treatment settings and subpopulations.
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Affiliation(s)
- Stephen A Maisto
- Department of Psychology, Syracuse University, Syracuse, NY 13244, USA.
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Sekula LK, DeSantis J, Gianetti V. Considerations in the management of the patient with comorbid depression and anxiety. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 2003; 15:23-33. [PMID: 12613410 DOI: 10.1111/j.1745-7599.2003.tb00251.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE To provide clinicians with guidelines for the assessment, evaluation, diagnosis, and management of comorbid depression and anxiety in the primary care setting. DATA SOURCES Research-based articles in the medical and psychiatric literature, literature reviews by experts in the field, and DSM-IV-TR. CONCLUSIONS Comorbid anxiety and depression occurs at a high rate in primary care, and is costly to both the individual and to society. These patients most often present in primary care settings, have more severe symptoms, and require more health care resources. The presentation of depression and anxiety together pose complicated diagnostic and treatment challenges, leading to inadequate diagnosis and treatment resulting in unnecessary patient distress and increased utilization of health care services. IMPLICATIONS FOR PRACTICE This article is a review of comorbid depression and anxiety with a focus upon societal and patient significance and impact, under recognition and under treatment, diagnostic challenges, medical comorbidity, treatment considerations, and educational strategies. Effective assessment, evaluation, diagnosis and treatment can lead to better treatment outcomes and improved quality of life in primary care patients.
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Turner BJ, Fleishman JA, Wenger N, London AS, Burnam MA, Shapiro MF, Bing EG, Stein MD, Longshore D, Bozzette SA. Effects of drug abuse and mental disorders on use and type of antiretroviral therapy in HIV-infected persons. J Gen Intern Med 2001; 16:625-33. [PMID: 11556944 PMCID: PMC1495260 DOI: 10.1046/j.1525-1497.2001.016009625.x] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To distinguish the effects of drug abuse, mental disorders, and problem drinking on antiretroviral therapy (ART) and highly active ART (HAART) use. DESIGN Prospective population-based probability sample of 2,267 (representing 213,308) HIV-infected persons in care in the United States in early 1996. MEASUREMENTS Self-reported ART from first (January 1997-July 1997) to second (August 1997-January 1998) follow-up interviews. Drug abuse/dependence, severity of abuse, alcohol use, and probable mental disorders assessed in the first follow-up interview. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) estimated from weighted models for 1) receipt of any ART, and 2) receipt of HAART among those on ART. RESULTS Of our study population, ART was reported by 90% and HAART by 61%. Over one third had a probable mental disorder and nearly half had abused any drugs, but drug dependence (9%) or severe abuse (10%) was infrequent. Any ART was less likely for persons with dysthymia (AOR, 0.74; CI, 0.58 to 0.95) but only before adjustment for drug abuse. After full adjustment with mental health and drug abuse variables, any ART was less likely for drug dependence (AOR, 0.58; CI, 0.34 to 0.97), severe drug abuse (AOR, 0.52; CI, 0.32 to 0.87), and HIV risk from injection drug use (AOR, 0.55; CI, 0.39 to 0.79). Among drug users on ART, only mental health treatment was associated with HAART (AOR, 1.57; CI, 1.11 to 2.08). CONCLUSIONS Drug abuse-related factors were greater barriers to ART use in this national sample than mental disorders but once on ART, these factors were unrelated to type of therapy.
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Affiliation(s)
- B J Turner
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pa 19104, USA.
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