Detection and exclusion of alcoholism in men on the basis of clinical laboratory findings

Alcoholism is a common disease; it is found in 10% to 15% of all patients admitted to general hospitals. There is no single characteristic finding, but on the other hand, changes as compared with normal values have been reported in the literature for more than 30 frequently assayed clinical chemical and haematological parameters. In the project reported here all 24 clinical chemical parameters and all 8 haematological parameters frequently assayed were studied in each of 82 hospitalized men with a confirmed diagnosis of alcoholism. The diagnosis of alcoholism was made on the basis of the Munich Alcoholism Test (MALT) together with the following standardized assessments and examinations: past history, an alcohol questionnaire, general physical examination and neurological examination. All forms were filled in completely. All steps in the clinical laboratory investigations were standardized, and all were subject to ongoing reliability control. The clinical problem is usually not to differentiate alcohol abusers or alcoholics from healthy persons but rather to identify the alcoholics among a population of patients with a variety of illnesses. For this reason 70 patients from two hospitals who were clearly neither alcohol abusers nor alcoholics were studied in exactly the same manner as the alcoholics. In this combined group of 152 hospitalized patients significant differences were found in the distribution of the values for the alcoholics and the non-alcoholics for the following clinical chemical and haematological parameters: at the 0.1% level gamma-glutamyltransferase, aspartate aminotransferase, urea, creatinine and mean corpuscular volume (MCV), and at the 1% level glutamate dehydrogenase, alanine aminotransferase and alkaline phosphatase. From these eight parameters those combinations of between two and six parameters were selected that discriminated best between the alcoholics and the non-alcoholics. Using conventional decision limits the following was found: For the alcoholics two or more of the results for the following five parameters were outside the decision limits given in parentheses: gamma-glutamyltransferase (greater than or equal to 28 U/l), aspartate aminotransferase (greater than or equal to 18 U/l), alanine aminotransferase (greater than or equal to 22 U/l), MCV (greater than or equal to 96 fl), creatinine (less than or equal to 66.3 mumol/l). The diagnostic sensitivity (alcoholics) is 85%, the diagnostic specificity (non-alcoholics) is 64%.(ABSTRACT TRUNCATED AT 400 WORDS)     

Alcoholism in elderly persons: a study of the psychiatric and psychosocial features of 216 inpatients

The medical records of 216 elderly persons, admitted to the hospital for treatment of alcoholism, were reviewed. Concern of family and friends was the most common factor motivating patients for admission. Patients with late-onset alcoholism reported an association between a life event and problem drinking more frequently than did the early-onset alcoholics. The most common associated psychiatric disorders were tobacco dependence (67%), organic brain syndrome (25%), atypical or mixed organic brain syndrome (19%), and affective disorder (12%). Fourteen percent of patients also had a drug abuse or dependence problem, all using legally prescribed drugs. Psychiatric diagnoses and results of psychologic testing did not differ between early-onset and late-onset alcoholism groups. In a 60-patient cohort studied for correlation of outcome of treatment for alcoholism with major psychiatric diagnoses, no associations were found.     

The effect of alcoholism treatment on medical care use

OBJECTIVE: The objective of this study was to assess changes in outpatient and inpatient medical care utilization associated with outpatient and inpatient treatment of alcohol abuse by comparing alcoholics who engaged in treatment to alcoholics who presented for, but did not engage in, treatment. RESEARCH DESIGN: Claims and encounter data of 29,122 adults receiving benefits from both a behavioral managed care company and its parent medical care insurance company who had a diagnosis of alcoholism were analyzed. The nontreated alcoholics in this sample (n = 13,133) were used for comparison and to control for historical time trend in medical utilization across the study years 1993-1999. A longitudinal over-dispersed Poisson regression model was fit by the generalized estimating equation method to compare differences in medical utilization before and after outpatient and inpatient alcoholism treatment. RESULTS: The pattern of medical utilization before and after alcoholism treatment appears basically symmetric. There is a gradual increase, which accelerates in the year before treatment and then falls off rapidly for the first year after treatment and then falls more gradually. Such a pattern does not suggest any net savings over time. The area under the curve before treatment is basically equivalent to that after treatment. Slopes of medical utilization for both treatment groups before 1 year before treatment were statistically similar to the control groups, but during 1 year before treatment, both treatment groups' outpatient utilization increased 1.25% and inpatient utilization increased 1.8% relative to the nontreated group. The slopes posttreatment showed differential effects over time of inpatient versus outpatient alcoholism treatment on inpatient and outpatient medical utilization. CONCLUSIONS: Although a clear increase in medical utilization before treatment and a decrease in utilization after treatment was found, it is not clear if the change is linked to changes in the status of the individuals as they prepare to enter alcoholism treatment or if there is a real causal effect of the alcoholism treatment.     

Postinfectious glomerulonephritis--is there a link to alcoholism?

From January 1984 to May 1993, we observed 30 cases of postinfectiousglomerulonephritis (GN)- endocapillary, exudative GN with humps(23 males, 7 females; median age 49 years; range 17–77).They represented 4.5% of all renal biopsies. Crescents werepresent in 9/26 who had renal biopsies (35%) and there was amesangioproliferative pattern in 14 (54%). Seventeen of the30 patients (57%) were alcoholics by history and biochemistry.Cirrhosis was present in 8/17 (47%), but alcoholic hepatitisin none. Nine of the 17 alcoholic (53%) but none of the non-alcoholicpatients developed chronic renal failure. Adverse renal prognosiswas significantly correlated to alcoholism. We conclude that(i) alcoholism is common in patients with postinfectious GN,and, (ii) alcoholism adversely affects renal prognosis in patientswith postinfectious GN.     

Alcoholism and homelessness

A prospective study was carried out over a three-year period to assess the incidence of alcoholism and its effect on the homeless. Of 423 homeless people interviewed, 48.7 per cent were found to be alcoholics. Alcoholism was common in Celts and Roman Catholics but showed no correlation with educational achievement or school-leaving age. It was strongly associated with the use of casualty departments and criminal activity.     

Vitamin D deficiency and muscle strength in male alcoholics

1. Chronic alcoholism may be complicated by proximal muscle weakness associated with a selective atrophy of type II skeletal muscle fibres. The histopathological findings are non-specific as identical changes are seen in proximal muscle weakness associated with various metabolic myopathies, including osteomalacia. 2. The maximum voluntary contraction (MVC) of the dominant quadriceps and plasma 25-hydroxycholecalciferol [25-(OH)D] were measured in male alcoholics and control subjects to determine whether vitamin D deficiency contributed to proximal muscle weakness. 3. In both groups MVC declined with age and was related to body build. The distribution of plasma 25-(OH)D was skewed in alcoholics, with the mean significantly lower than in control subjects. Seventeen per cent of patients (but none of the control subjects) had pronounced biochemical deficiency [plasma 25-(OH)D less than 10 nmol/l]. 4. Alcoholics were significantly weaker than control subjects, even after correcting for the effects of age, height and weight. The severity of associated liver disease (cirrhosis vs no cirrhosis) did not influence muscle strength. Variation in plasma 25-(OH)D and albumin made an insignificant contribution to the difference in MVC observed between patients and control subjects. 5. We conclude that proximal muscle strength is reduced in chronic alcoholism but that this is not due to associated vitamin D [25-(OH)D] deficiency or alcoholic cirrhosis.     

The frequency of alcoholism among patients with pain due to terminal cancer

The purpose of this retrospective study was to determine the prevalence of alcoholism among terminally ill cancer patients when assessed by multidisciplinary interviews and by the CAGE Questionnaire. We reviewed the charts of 100 consecutive patients assessed by a multidisciplinary team for the presence of alcoholism during 1989, and 100 consecutive patients assessed by the CAGE Questionnaire during 1992. Alcoholism was diagnosed in 28/100 patients during 1989 (28%) and 18/66 patients during 1992 (27%). Thirty-four patients were unable to complete the CAGE Questionnaire in 1992 because of sedation or cognitive impairment; six of these patients (17%) were found to be alcoholics after multidisciplinary assessment. Only 9/28 (32%) and 8/24 (33%) patients diagnosed as alcoholics during 1989 and 1992, respectively, had been previously diagnosed as alcoholics according to the medical charts. The mean equivalent daily dose of morphine during admission and on Day 2 during 1992 were 1.53±193 mg and 183±198 for alcoholic patients, versus 58±80 and 70±79 mg for nonalcoholics (P = 0.06 and 0.03, respectively). The maximal dose of opioid and the pain intensity during admission, however, were not significantly different between alcoholics and nonalcoholics. Our results suggest that alcoholism is highly prevalent and underdiagnosed among symptomatic terminally ill cancer patients. The CAGE Questionnaire should be used for screening for alcoholism in this population. When multidimensional assessment and management of pain is applied, the outcome of alcoholic patients appears to be similar to that of nonalcoholics.     

Serotonin in early onset, male alcoholics with violent behaviour

Several lines of evidence suggest that abnormal brain serotonin metabolism may occur in early onset, type 2 alcoholism in men. Low cerebrospinal fluid 5-hydroxy-indoleacetic acid concentration has been found to be associated with a history of paternal alcoholism, and abnormal oral glucose tolerance tests (tendency to low blood glucose nadir) in subjects who are prone to exhibit impulsive, aggressive behaviour under the influence of alcohol. Moreover, a low ratio of the concentrations of tryptophan and other large neutral amino acids in plasma seems to correlate with early onset alcohol abuse and violent tendencies. More knowledge is required about neurochemical changes in homogenous subgroups of alcoholics such as the putative type 2 so as to understand which of the relationships are causative and to provide treatment strategies for alcoholism and its complications.     

Alcoholism in elderly persons: medical aspects and prognosis of 216 inpatients

We describe 216 elderly patients (65 years of age or older) who were treated for alcoholism in an inpatient treatment program. Emphasis is placed on the demographics, medical characteristics, results of laboratory tests, outcome of treatment, and various comparisons of early- and late-onset alcoholism. The frequency of serious medical disorders among these patients was higher than would be expected for the overall population of a similar age. Elderly alcoholics have more abnormal results of commonly used laboratory tests than do younger alcoholics. Our data show that the elderly alcoholic can be successfully treated in a medically oriented inpatient treatment program. The concept of less-intensive treatment for the elderly alcoholic is generally not supported. More-intensive treatment may be necessary for some of these patients because of the high frequency of accompanying major medical and psychiatric problems. Early-onset alcoholism predominated, but we found no major differences between the two groups.     

Identifying and helping children of alcoholics

Though alcoholism is generally recognized as a disease, it is not widely recognized as a family disease reaching far beyond the alcoholic to affect the spouse, children and others with devastating consequences. It is estimated that 28 million Americans are children of alcoholics; 7 million are under age 18. These individuals are at high risk for developing alcohol-related physical and emotional problems. Current literature on children of alcoholics is relatively sparse, reflecting the limited amount of research and professional attention that has been given to this group. The treatment of alcoholism has focused primarily upon the alcoholic, while the children of alcoholics have been virtually ignored. This article describes the characteristics and roles of children of alcoholics in order to assist the health care provider in the identification of these individuals. A management approach is provided that can be used within a primary care setting for children of alcoholics.     

Behavioral complications of alcoholism

Behavioral complications of alcoholism are frequently found in young alcoholics before medical complications develop. The antisocial alcoholic is at high risk of behavioral complications, including aggressive, violent behavior and accidental injury. Because of the markedly increased risk of trauma in alcoholism, the family physician should investigate the possible role of alcohol or other drug use in any patient with an injury.     

Alcoholism: the missed diagnosis

Physicians fail to recognize the early signs and symptoms of alcoholism in their patients. This results in delays in the proper diagnosis and treatment for alcoholism, the underlying cause for many common complaints. Reasons for missing the diagnosis include inadequate education opportunities for physicians in the field of chemical dependency, the physician's attitude toward alcoholics, and the alcoholic's own denial of his addiction. There are steps that physicians can take to increase their ability to identify alcoholism as the underlying cause of the patient's complaint.     

Morphodensitometric evaluation of lymphocytes enzymatic status in pathogenesis of chronic alcoholism

Activities of succinate dehydrogenase (SDH), alpha-glycerophosphate dehydrogenase (alpha-GPDH), and nonspecific esterase (NE) were studied in blood lymphocytes of healthy men and chronic alcoholics. SDH activity was notably decreased, while the levels of alpha-GPDH and NE were increased in alcoholics. The detected metabolic changes suggest lymphocyte dysfunction and hence, impairment of neuroimmune relationships, which may be the central component in the pathogenesis of chronic alcoholism.     

Alcohol and the liver.

This paper discusses briefly the definition of alcoholism, the extent of the problem in Britain, the roles of ethanol toxicity and malnutrition in causing liver damage, and the types of liver damage seen in alcoholics.     

Nervous and mental disorders in patients with chronic alcoholic pancreatitis

Presented are the results of comprehensive CNS examinations in 53 alcoholics with chronic pancreatitis. Related psychopathological and neurological syndromes are specified. Hepatopancreatoduodenal and CNS abnormalities were found directly correlated. The addition of pancreatitis to alcoholism leads to development of encephalomyelopolyradiculoneurotic syndrome.     

Alcohol-induced pathology

The classical symptom formation of alcoholism is identified along with the main causes of death in a representative cohort of U.S. alcoholics. New findings in alcoholism studies pertaining to allergenic and hypoglycemic pathways are discussed. The failure of current treatment modes based on a behavioral disease model of alcoholism is noted. The evidence for a new model of alcoholism as an inherited predisposition for metabolic/enzymatic dysfunction is presented, along with the potential for a new treatment protocol based on that model.     

The febrile alcoholic in the emergency department

The authors retrospectively reviewed the charts of 31 alcoholic patients admitted with fever without a defined source. In our population 58% of patients were subsequently found to have an infectious cause for their fever. Pneumonia was the most common infection, but occult urinary tract infections were seen surprisingly often. Noninfectious but serious disorders, such as delirium tremens, prolonged postictal state, and subarachnoid hemorrhage, were also common. Infectious and noninfectious causes commonly coexisted. The most common noninfectious cause was alcohol withdrawal, with or without seizures. The authors believe that indigent, malnourished, chronic alcoholics with fever for which a source cannot be readily identified, should usually be admitted to the hospital for observation and to await culture results.     

Dopamine receptors and transporters in the brain reward circuits of type 1 and 2 alcoholics measured with human whole hemisphere autoradiography

The role of the dopamine system in brain reward mechanisms and development of substance abuse is well-established with nucleus accumbens as a key structure in mediating these effects. Several studies on alcoholism have indicated defects in dopaminergic neurotransmission and alterations in dopamine receptor densities. However, it has remained unclear if the substance abuse-related dopaminergic defect is specifically associated with a certain receptor subtype. The aim of this study was to compare putative alterations of dopamine D(1,) D(2), and D(3) receptors in nucleus accumbens, amygdala, and substantia nigra among alcoholics and controls. We studied the densities of dopamine D(1) and D(3) receptors in brains of 9 type 1 alcoholics, 8 type 2 alcoholics, and 10 healthy controls by using postmortem human whole hemisphere autoradiography. The mean densities of dopamine D(1) and D(3) receptors were at the same level in all study groups. Combining these with our previous results, our data suggest that among type 1 alcoholics dopamine transporters are lower in nucleus accumbens and dopamine D(2), but not D(1) or D(3) receptors in nucleus accumbens and amygdala. Further, the densities of all these dopamine-binding sites among type 2 alcoholics are at the level of healthy controls. The results suggest that lower dopamine receptor density is specific for D(2) receptor and for type 1 alcoholism, which supports Cloninger's neurogenetic model of two alcoholic subtypes, and indicates the importance of classifying these subgroups separately when issues related to dopaminergic activity are studied.     

Immunologic indices for the diagnosis of the initial stages of chronic alcoholism]

Immunologic examinations of 60 patients suffering from common hard drinking and of 24 chronic alcoholics, stage I, has revealed a clear-cut difference in the levels of circulating immune complexes and theophylline-sensitive lymphocytes in these populations. These data are recommended as additional tests for the differential diagnosis of the initial forms of alcoholism.     

Central sleep apnea

Central sleep apnea is a disorder characterized by apneic episodes during sleep with no associated ventilatory effort. More commonly than not these apneas are seen in patients who also have obstructive and mixed events. Although patients with this disorder frequently complain of insomnia and depression, frank hypersomnolence is rarely encountered. As these complaints are common ones seen in numerous clinical situations, and since sleep studies are rarely conducted to investigate their etiology, the true incidence of central sleep apnea has not been determined. The etiology of central apnea remains unknown, although the association between these breathing events and a number of other disease processes has increased our understanding of the disorder. Central apneas during sleep commonly occur after hyperventilation with the associated hypocapnic alkalosis. This occurs at high altitude when hyperventilation is induced by hypoxia and at sea level when spontaneous nocturnal hyperventilation occurs. This suggests that PCO2 is the primary stimulus to ventilation during sleep and that loss of this drive, as occurs with hypocapnia, may produce dysrhythmic breathing. Patients with complete absence of ventilatory chemosensitivity such as occurs with Ondine's curse (central alveolar hypoventilation) or the obesity-hypoventilation syndrome may also have central apneas. For reasons that remain unexplained, central sleep apnea is commonly seen in patients with congestive heart failure, nasal obstruction, and certain neurologic disorders. However, in most patients with central sleep apnea no obvious cause or association can be found. The treatment of this disorder is not entirely satisfactory. If it is severe, mechanical ventilation during sleep can be provided by any one of a number of techniques. However, for the patient who simply complains of insomnia and is found to have a moderate number of central apneas, the treatment choices are limited. Acetazolamide has been shown to decrease central apneas during short-term use, but results have been variable with prolonged administration. Other ventilatory stimulants seem to have little efficacy. Interestingly, oxygen administration has been shown to reduce central apneas considerably in a number of studies, although the explanation for its success is unknown. Central sleep apnea therefore remains a relatively rare disorder whose etiology is not fully understood and whose treatment is not completely satisfactory.