THE MEDICAL PROFILE OF UNIDENTIFIED PROBLEM DRINKERS IN GENERAL PRACTICE: TEST OF AN HYPOTHESIS

In order to facilitate general practitioner (GP) detection ofproblem drinkers the Dutch College of General Practitionersdeveloped a standard specifying the differences in medical profilebetween problem drinker and non-problem drinkers. The standardmentions 35 Reasons for Encounter (RFEs) and OP Evaluations(Es) that are thought to be specific for problem drinkers. Thestudies referred to in the standard base their conclusions aboutdifferences in medical profile upon a comparison of problemdrinkers already identified by the GP with other patients. Thisstudy tests the hypothesis that the medical profile specifiedby the standard also applies to unidentified problem drinkers.All known problem drinkers in the practices of 16 GPs, as wellas a one in 10 random sample of patients considered to be non-drinkerswere admitted to the study at their first surgery visit duringa 1-year period. Hidden problem drinkers were detected by meansof a screening questionnaire, although the results were notconveyed to the GP until the study was completed. Over the 1-yearstudy period the GPs then registered all RFEs and Es of thestudy population. RFE and E sum scores were then constructedbased on the Alcohol Standard. The estimated population prevalenceof problem drinking, corrected for the one in 10 sample fractionwas 7%. We found 6% problem drinkers (n = 78) in the categoryregarded by the GPs as non-problem drinkers (n = 1254). Differencesin RFEs and Es between hidden problem drinkers and those regardedas non-problem drinkers were significant for irregular heartbeatand psychological problems. Sexual problems were significantat the RFE level, social problems at the E level. When identifiedproblem drinkers are compared with non-problem drinkers moredifferences in the medical profile are found (four times bothRFE and E; twice RFE and once E). We conclude that most of thepublished differences in the medical profile between problemdrinkers and other GP patients are not found for unidentifiedproblem drinkers. The observed differences between unidentifiedproblem drinkers and non-problem drinkers are too small to behelpful to the GP to detect problem drinkers.     

Cholesterol Ascites in Alcoholic Cirrhosis

A 43-year old man with long-standing cirrhosis of the liver and ascites was found to have cholesterol crystals in his ascitic fluid. This unusual finding, not heretofore described in the medical literature, is reported and possible mechanisms for its production are discussed.     

Societal and Individual Determinants of Medical Care Utilization in the United States

A theoretical framework for viewing health services utilization is presented, emphasizing the importance of the (1) characteristics of the health services delivery system, (2) changes in medical technology and social norms relating to the definition and treatment of illness, and (3) individual determinants of utilization. These three factors are specified within the context of their impact on the health care system. Empirical findings are discussed which demonstrate how the framework might be employed to explain some key patterns and trends in utilization. In addition, a method is suggested for evaluating the utility of various individual determinants of health services utilization used in the framework for achieving a situation of equitable distribution of health services in the United States.     

Catheter Ablation of Coexistent Bundle Branch and Interfasdcular Reentrant Ventricular Tachycardias

Bundle Branch and Interfascicular Reentry. Introduction : Bundle branch reentry and interfascicular reentry are potential mechanisms of ventricular tachycardia in the setting of a dilated cardiomyopathy. We report a patient with myotonic dystrophy who presented with near syncope, in whom both of these mechanisms were present, leading to two different wide complex tachycardias.
Methods and Results : Electrophysiologic study demonstrated Infra-Hisian conduction system disease and inducible bundle branch reentrant ventricular tachycardia. Catheter ablation of the right bundle eliminated bundle branch reentry. However, following this, the patient had inducible interfascicular reentry, which subsequently occurred spontaneously while still hospitalized. Catheter ablation of the left posterior fascicle successfully eliminated this second tachycardia, and the patient has had no further arrhythmias.
Conclusions : This report is of an unusual patient with coexistent bundle branch reentry and interfascicular reentry producing two different forms of sustained ventricular tachycardia. This is the first report of catheter ablation of the left posterior fascicle for elimination of conduction system reentry.     

Tissue Magnesium Levels and the Arrhythmic Substrate in Humans

Magnesium and Arrhythmias. Introduction: Magnesium deficiency has been implicated in the pathogenesis of sudden death, but the investigation of arrhythmic mechanisms has been hindered by difficulties in measuring cellular tissue magnesium stores.
Methods and Results: To see if magnesium deficiency is associated with a propensity toward triggered arrhythmias, we measured tissue magnesium levels and QT interval dispersion (as an index of repolarization dispersion) in 40 patients with arrhythmic complaints. Magnesium was measured in sublingual epithelium using X-ray dispersive analysis. QT interval dispersion was assessed on 12-lead surface F-XCs in all patients, and programmed stimulation was performed in 28. The sublingual epithelial magnesium level ([Mg]_i), but the not the serum level, correlated Inversely with QT interval dispersion in 40 patients (r = 0.58, P < 0.0.5); in 12 patients undergoing repeat testing on therapy, the change in magnesium also correlated inversely with the change in QT dispersion (r = 0.61, P < 0.05). Patients with left ventricular ejection fractions > 40% had significantly higher tissue magnesium and lower QT dispersion (34.5 ± 0.5 mEq/L, 81 ± 8 msec) than those with left ventricular ejection fractious < 40% (32.7 ± 0.5 mEq/L, P < 0.01, and 114 ± 9 msec, P < 0.05). There was no difference in either [Mg]_i, or QT dispersion in the 16 patients with inducible monomorphic ventricular tachycardia versus the 12 noninducible patients.
Conclusion: Reduced tissue magnesium stores may represent a significant risk factor for arrhythmias associated with abnormal repolarization, particularly in patients with poor left ventricular systolic function, but may not represent a risk for excitable gap arrhythmias associated with a fixed anatomic substrate (e.g., monomorphic ventricular tachycardia).