Validation of a screening test for alcohol use,the Russian Federation

ObjectiveTo validate a Russian-language version of the World Health Organization’s Alcohol Use Disorders Identification Test (AUDIT).MethodsWe invited 2173 patients from 21 rural and urban primary health-care centres in nine Russian regions to participate in the study (143 declined and eight were excluded). In a standardized interview, patients who had consumed alcohol in the past 12 months provided information on their sociodemographic characteristics and completed the Russian AUDIT, the Kessler Psychological Distress Scale and the Composite International Diagnostic Interview to identify problem drinking and alcohol use disorders. We assessed the feasibility of administering the test, its internal consistency and its ability to predict hazardous drinking and alcohol use disorders in primary health care in the Russian Federation.FindingsOf the 2022 patients included in the study, 1497 were current drinkers with Russian AUDIT scores. The test was internally consistent with good psychometric properties (Cronbach’s α : 0.842) and accurately predicted alcohol use disorders and other outcomes (area under the curve > 75%). A three-item short form of the test correlated well with the full instrument and had similar predictive power (area under the curve > 80%). We determined sex-specific thresholds for all outcomes, as non-specific thresholds resulted in few women being identified.ConclusionWith the validated Russian AUDIT, there is no longer a barrier to introducing screening and brief interventions into primary health care in the Russian Federation to supplement successful alcohol control policies.     

Beta-blocker therapy and symptoms of depression,fatigue, and sexual dysfunction

Context  -Blocker therapy remains substantially underused in cardiac patientsdespite its proven mortality benefits. Reluctance to prescribe these agentsmay derive from concerns about their association with symptoms of depression,fatigue, and sexual dysfunction. Objective  To determine the association of -blockers with depressive symptoms,fatigue, and sexual dysfunction by performing a quantitative review of randomizedtrials that tested -blockers in myocardial infarction, heart failure,and hypertension. Data Sources  Randomized trials of -blockers used in the treatment of myocardialinfarction, heart failure, or hypertension were identified by searching theMEDLINE database for English-language articles (1966-2001). In addition, wesearched the reference lists of previously published trials and reviews of -blockersfor additional studies. Study Selection  Criteria for inclusion of trials in the review were: random allocationof study treatments, placebo control, noncrossover design, enrollment of atleast 100 patients, and a minimum of 6 months of follow-up. The initial searchproduced 475 articles, 42 of which met these criteria. Fifteen of these trialsreported on depressive symptoms, fatigue, or sexual dysfunction and were selectedfor inclusion. Data Extraction  For each trial, 1 author abstracted the frequency of adverse eventsin the -blocker and placebo groups and the numbers of patients randomizedto the treatment groups. Two other authors verified the counts of events,and all authors adjudicated any discrepancies. Two different types of informationon adverse events were abstracted: patient-reported symptoms and withdrawalof therapy due to a specified symptom. We categorized the tested -blockersby generation (early vs late) and lipid solubility (high vs low to moderate). Data Synthesis  The 15 trials involved more than 35 000 subjects. -Blockertherapy was not associated with a significant absolute annual increase inrisk of reported depressive symptoms (6 per 1000 patients; 95% confidenceinterval [CI], –7 to 19). -Blockers were associated with a smallsignificant annual increase in risk of reported fatigue (18 per 1000 patients;95% CI, 5-30), equivalent to 1 additional report of fatigue for every 57 patientstreated per year with -blockers. -Blockers were also associatedwith a small, significant annual increase in risk of reported sexual dysfunction(5 per 1000 patients; 95% CI, 2-8), equivalent to one additional report forevery 199 patients treated per year. None of the risks of adverse effectsdiffered significantly by degree of -blocker lipid solubility. The riskassociated with reported fatigue was significantly higher for early-generationthan for late-generation -blockers (P = .04). Conclusion  The conventional wisdom that -blocker therapy is associated withsubstantial risks of depressive symptoms, fatigue, and sexual dysfunctionis not supported by data from clinical trials. There is no significant increasedrisk of depressive symptoms and only small increased risks of fatigue andsexual dysfunction. The risks of these adverse effects should be put in thecontext of the documented benefits of these medications.      

Pleural mesothelioma: little evidence, still time to do trials

CONTEXT: The incidence of malignant pleural mesothelioma is increasing throughout most of the world. This cancer is uniformly fatal, and characterised by progressive breathlessness and unremitting pain in the chest wall. From the onset of symptoms, survival is from a few weeks to a few years. Desperation by patients and doctors has driven a search for effective treatments. Clinical benefits are marginal and evidence of a good quality is lamentably lacking. STARTING POINT: David Sugarbaker is the world's leading proponent of extrapleural pneumonectomy (EPP), an operation in which all the pleura is removed with the lung, pericardium, and diaphragm. He has recently reported the complications of this radical surgery in a series of 496 operations (J Thorac Cardiovasc Surg 2004; 128: 138-46). Although EPP as part of trimodality therapy (preoperative chemotherapy and postoperative radiation) is thought to be the best that can be offered and is regarded as the standard of care for selected patients given the morbidity associated with it, evidence for benefit is needed to justify its wider use. WHERE NEXT? With the increase in the number of cases there is increasing awareness of the disease, leading to earlier diagnosis, and an expectation that something must be done. Survival is short and the treatments on offer are onerous. The only responsible approach from a scientific, compassionate, or economic view (and why not combine all three?) is to find evidence of effectiveness to avoid futile and distressing treatment when possible.     

The Tooth,the Whole Tooth,and Nothing But the Tooth: Can Dental Pain Ever Be the Sole Presenting Symptom of a Myocardial Infarction? A Systematic Review

Background

Pain symptoms related to cardiac ischemia can vary greatly from patient to patient. However, should emergency physicians consider the possibility of myocardial infarction in patients who present solely with dental pain?

Objective

This is a systematic review of the literature investigating the incidence of jaw, tooth, or facial pain as the sole symptom of cardiac ischemia.

Methods

Studies investigating jaw, tooth, or facial pain of cardiac origin were identified using the PubMed database. All English studies in which cardiac pain originated in the face, teeth, or jaw were screened for inclusion. Data were abstracted from each study utilizing a structured review process, and rated for methodological quality.

Results

Eighteen studies met study criteria: 16 were case reports, and the remaining 2 were prospective cohort studies. After quality assessment and categorization, nine reports were categorized as weak, eight moderate, and one strong methodological quality.

Conclusion

Cardiac ischemia may present in no anatomic location other than face or jaw. However, despite frequent claims in the literature to the contrary, the lack of methodological quality of the studies investigated impedes a firm conclusion of face, jaw, or tooth pain as the only symptom of cardiac insufficiency.