Assessment of alcohol histories obtained from patients with liver disease: opportunities to improve early intervention.

BACKGROUND: Alcohol is an important primary and comorbid cause of liver injury in patients referred for investigation and management of liver disease. Early assessment and documentation of alcohol consumption is therefore essential, and recommended in both general practice and hospital settings. AIMS: To determine the extent and accuracy of documentation of alcohol consumption in patients referred for evaluation of liver disease. METHODS: Patients were interviewed using a structured questionnaire. The medical records of all patients interviewed were reviewed to obtain information from the referral letter and the hepatology consultations. RESULTS: Eighty-three patients were surveyed. Only 14 referrals had an informative alcohol history, despite 27 patients admitting risky alcohol consumption at the initial hepatology consultation. Ninety per cent of initial consultations had an informative alcohol history documented, whereas only 56% of patients attending a follow-up appointment had informative documentation. Assessment of alcohol consumption was comparable between the hepatology consultation and the structured questionnaire, but four subjects had substantially different alcohol histories. Alcohol Use Disorders Identification Test identified all patients reporting harmful alcohol consumption on the questionnaire. CONCLUSIONS: Hazardous alcohol use is prevalent in subjects attending hepatology clinics, but informative alcohol histories, which are crucial to patient management, are rarely documented in referrals. Screening tools improve documentation and accuracy of alcohol histories, and their use by general practitioners and hospital clinicians would improve detection rates of hazardous drinking and allow earlier intervention. Systematic use of screening tools in hepatology clinics will provide opportunities for education and reinforce recommendations to reduce hazardous or harmful alcohol consumption.

The application of machine learning techniques as an adjunct to clinical decision making in alcohol dependence treatment.

With few exceptions, research in the addictive sciences has relied on linear statistics and methodologies. Addiction involves a complex array of nonlinear behaviors. This study applies two machine learning techniques, Bayesian and decision tree classifiers, in the assessment of outcome of an alcohol dependence treatment program. These nonlinear approaches are compared to a standard linear analysis. Seventy-three alcohol-dependent subjects undertaking a 12-week cognitive-behavioral therapy (CBT) program and 66 subjects undertaking an identical program but also prescribed the relapse prevention agent Acamprosate were employed in this study. Demographic, alcohol use, dependence severity, craving, health-related quality of life, and psychological measures at baseline were used to predict abstinence at 12 weeks. Decision trees had a 77% predictive accuracy across both data sets, Bayesian networks 73%, and discriminant analysis 42%. Combined with clinical experience, machine learning approaches offer promise in understanding the complex relationships that underlie treatment outcome for abstinence-based alcohol treatment programs.

Improvement in measures of psychological distress amongst amphetamine misusers treated with brief cognitive-behavioural therapy (CBT).

This trial of cognitive-behavioural therapy (CBT) based amphetamine abstinence program (n=507) focused on refusal self-efficacy, improved coping, improved problem solving and planning for relapse prevention. Measures included the Severity of Dependence Scale (SDS), the General Health Questionnaire-28 (GHQ-28) and Amphetamine Refusal Self-Efficacy. Psychiatric case identification (caseness) across the four GHQ-28 sub-scales was compared with Australian normative data. Almost 90% were amphetamine-dependent (SDS 8.15+/-3.17). Pre-treatment, all GHQ-28 sub-scale measures were below reported Australian population values. Caseness was substantially higher than Australian normative values {Somatic Symptoms (52.3%), Anxiety (68%), Social Dysfunction (46.5%) and Depression (33.7%)}. One hundred and sixty-eight subjects (33%) completed and reported program abstinence. Program completers reported improvement across all GHQ-28 sub-scales {Somatic Symptoms (p<0.001), Anxiety (p<0.001), Social Dysfunction (p<0.001) and Depression (p<0.001)}. They also reported improvement in amphetamine refusal self-efficacy (p<0.001). Improvement remained significant following intention-to-treat analyses, imputing baseline data for subjects that withdrew from the program. The GHQ-28 sub-scales, Amphetamine Refusal Self-Efficacy Questionnaire and the SDS successfully predicted treatment compliance through a discriminant analysis function (p<.001).

Cannabis dependence and mental health perception amongst people diverted by police after arrest for cannabis-related offending behaviour in Australia.

BACKGROUND: Use of cannabis and other mind-altering drugs may be associated with violence or other offending behaviours. In many countries mere possession of the drug may be sufficient to lead to a criminal conviction and, therefore, a criminal record. Recent legal and policy reforms in Australia have led to development of cannabis diversion programmes. OBJECTIVE: To describe substance misuse patterns and health perception in a consecutive series of young people in Queensland who were spared a criminal record because of a cannabis diversion scheme. METHOD: Between 9 July 2001 and 24 August 2004, 640 men and 187 women were diverted through the Queensland Illicit Drug Diversion Initiative (QIDDI) for treatment at a hospital alcohol and drug service. In this cross-sectional study of their drug use history, participants also completed the Severity of Dependence Scale (SDS) for cannabis and the General Health Questionnaire-28 (GHQ-28). RESULTS: Almost 60% of participants were cannabis dependent (as determined by the SDS). Polysubstance use was also more prevalent amongst dependent participants. Self-reported health (GHQ-28) was poorer than expected from Australian normative data, and worse if participants were cannabis dependent. Applying the GHQ-28 threshold for psychiatric case identification (caseness), cannabis dependent participants had significantly higher level of caseness across all subscales of somatic concerns, anxiety, social dysfunction and depression. Dependent women registered the highest proportion of psychopathology, particularly anxiety and social dysfunction. CONCLUSIONS: Young cannabis users in Queensland who come into contact with the police are more likely than not to be dependent on the drug. Their high levels of psychopathology suggest that they are better placed in healthcare rather than the criminal justice system, and that appropriately responsive mental healthcare programmes are needed.

Groin tissue necrosis requiring skin graft following parenteral abuse of buprenorphine tablets.

In May 2002 Buprenorphine (Subutex) was listed on the Australian Pharmaceutical Benefits Schedule for treatment in opioid dependence. In addition to broadening treatment options, buprenorphine has the advantage of an improved safety profile. The risk of overdose is lessened but other risks remain due to diversion. French experience reports widespread deviation of buprenorphine sublingual tablets to intravenous injection. We report a case of attempted parenteral administration of buprenorphine tablets. Stringent protocols for dispensing are appropriate.

Randomized controlled trial of two cigarette quit programmes in coronary care patients after acute myocardial infarction.

BACKGROUND: Tobacco cessation after acute myocardial infarction (AMI) substantially improves outcome but how effective individual programmes are needs to be established. To date, few studies have examined this factor. AIMS: To assess the outcome of two smoking cessation programmes after AMI. METHODS: One hundred and ninety-eight current smokers admitted to coronary care with an AMI participated in a randomized controlled study comparing two outpatient tobacco interventions, the Stanford Heart Attack Staying Free (SF) programme and a Usual Care (UC) programme. RESULTS: Log-rank analyses revealed that patients in the SF programme were retained longer (P < 0.001) and had higher cotinine validated abstinence rates (P < 0.001) compared with patients in the UC programme. Twelve months after intervention, 39% of the SF programme compared with 2% of the UC programme demonstrated cotinine validated tobacco cessation, representing a significant reduced relapse rate in the SF programme (chi2, P< 0.001). CONCLUSIONS: The SF smoking cessation programme initiated in hospital can significantly reduce smoking rates at 12 months after myocardial infarction. Although superior to the UC quit programme, Australian outcomes were lower than the American programme originators' published outcomes.

Outpatient cognitive behavioural therapy programme for alcohol dependence: impact of naltrexone use on outcome.

OBJECTIVE: Cognitive-behavioural therapy (CBT) has been effectively used in the treatment of alcohol dependence. Clinical studies report that the anticraving drug naltrexone, is a useful adjunct to treatment. Currently, few data are available on the impact of adding this medication to programmes in more typical, outpatient, and rehabilitation settings. The objective of this study was to examine the impact on outcome of adding naltrexone to an established outpatient alcohol rehabilitation program which employed CBT. METHOD: Fifty patients participated in an established 12-week, outpatient, 'contract'-based alcohol abstinence programme which employed CBT. They also received naltrexone 50 mg orally daily (CBT + naltrexone). Outcomes were compared with 50 historical, matched controls, all of whom participated in the same programme without an anticraving medication (CBT alone). All patients met DSM-IV criteria for alcohol dependence. RESULTS: Programme attendance across the eight treatment sessions was lower in the CBT alone group (p < 0.001). Relapse to alcohol use occurred sooner and more frequently in the CBT alone group (p < 0.001). Rehabilitation programme completion at 12 weeks was 88% (CBT + naltrexone) compared with 36% for (CBT alone) (p < 0.001). Alcohol abstinence at 12 weeks was 76% (CBT + naltrexone) compared with 18% (CBT alone) (p < 0.001). CONCLUSION: When employing the same outpatient rehabilitation programme and comparing outcomes using matched historical controls, the addition of naltrexone substantially improves programme attendance, programme completion and reported alcohol abstinence. In a typical outpatient programme, naltrexone addition was associated with significantly improved programme participation, better outcomes and was well tolerated.

Adherence with naltrexone prescription advice in hospital outpatient alcohol rehabilitation programme.

BACKGROUND: The anti-craving drug, naltrexone, is used as a pharmacotherapeutic adjunct in the treatment of alcohol dependence. In addictive disorders, compliance issues remain central. There are limited data on compliance with naltrexone treatment regimens within formalized rehabilitation programs and even less data that identifies factors that have an impact on this. OBJECTIVE: To study patient adherence to naltrexone medication regimens and examine whether patients' reported pre-treatment alcohol use, dependence severity and measures of psychological health are predictive of medication compliance. METHOD: Fifty outpatients meeting DSM IV criteria for alcohol dependence enrolled in a 12-week rehabilitation programme. This included cognitive behavioural therapy (CBT) and naltrexone, 50 mg orally daily. Measures included: pharmacy prescription pick-up including number of tablets dispensed, programme attendance and patient pre-treatment alcohol use variables. Measures of psychological health included somatic symptoms, anxiety, social dysfunction and depression as measured by the General Health Questionnaire (GHQ-28). RESULTS: Classifying the sample into compliant (> or = 90% medication pick-up) and less compliant groups, 66% of subjects were naltrexone-compliant. Pre-treatment alcohol use variables were not predictive of compliance. Although social dysfunction and depression tended towards poorer prescription filling, measures of psychological distress (GHQ-28) did not identify factors predictive of medication non-compliance. One patient withdrew from treatment because of naltrexone-induced dysphoria. CONCLUSION: Patients with alcohol dependence demonstrated high levels of anti-craving medication compliance, good rehabilitation programme participation and favourable outcomes. Naltrexone was well tolerated. Medication compliance in this study group compared well with those of other hospital populations with chronic disorders. Factors predictive of anti-craving medication compliance in alcohol dependence require further study.

Association of the D2 dopamine receptor A1 allele with alcoholism: medical severity of alcoholism and type of controls.

D2 dopamine receptor (DRD2) A1 allele frequency was determined in alcoholics of varying medical severity from three different inpatient settings and in various controls. A1 frequency was .15 in 68 alcoholics in a detoxification unit (group A), .19 in 90 alcoholics in a rehabilitation unit (group B), and .31 in 43 alcoholics in a gastroenterology unit (group C). Group C had a higher A1 frequency than group B (p = .045) or group A (p = .005) alcoholics. In 46 controls (group D), A1 frequency was .18. In subsets of these controls, A1 frequency was .14 in 39 subjects with a negative family history (FH-) of alcoholism (group E), .06 in 34 subjects without previous hazardous alcohol consumption (group F), and .05 in 30 subjects with FH- and without previous hazardous alcohol consumption (group G). A1 frequency was significantly higher in group C alcoholics than group F (p = .0002) or group G (p = .0002) controls; however, no A1 frequency difference was found among group A alcoholics and any of the control groups. The severity of alcoholism and the type of controls used are important determinants of DRD2 A1 allele association with alcoholism.

Work-place screening of mine employees using the alcohol use disorders identification test (AUDIT) and alcohol breathalyzation.

Although public health campaigns focusing on alcohol in the work-place are receiving increasing attention, there is little empirical evidence regarding the use of screening. In this work-place study, 152 mining personnel (67% of the work-force) completed a self report screen using the Alcohol Use Disorders Identification Test (AUDIT). One hundred and thirty-three of these (58.5% of the work-force) also consented to be breathalysed and one (0.75%) recorded a BAC just over threshold for detection. Forty-eight males (37.7% of the male work-force) recorded AUDIT scores of eight or more consistent with hazardous alcohol use and one female registered a cumulative score above the female cut-off level for hazardous alcohol use. Eighty males (67% of the work-force), recorded binge drinking at least monthly and 81 males recorded a cumulative AUDIT score of less than eight; however, on item analysis, 64 (83%) of these recorded binge drinking at least sometimes. There is substantial hazardous alcohol use in this sample work group and younger males had higher alcohol consumption, more adverse consequences and higher total AUDIT scores identifying them as particularly at risk. The Cronbach & AUDIT was 0.72, confirming adequate internal consistency.

Paroxysmal cerebellar ataxia.

This report describes the clinical features of 13 cases of periodic, paroxysmal cerebellar ataxia. A family history suggestive of an autosomal dominant disorder was present in 10 cases, the first two reported Australian families involved with this disorder. Variation in the age of onset, frequency of attacks and the presence of distinct symptom complexes within one kindred confirm the heterogeneous nature of this disorder. CT head scans were performed on nine cases and were normal in eight. EEG findings were abnormal in six of nine performed. Treatment with acetazolamide resulted in abolition of paroxysms in nine of the 10 treated cases. In addition, two children had dramatic improvement in previously impaired gross and fine motor skills.

Clinical aspects of infection with Yersinia enterocolitica in adults.

Yersinia enterocolitica was isolated from the feces of 29 patients over a three-year period following the introduction of a selective culture medium. Y. enterocolitica was the third most common enteric pathogen after Campylobacter jejuni and Salmonella in this series of 3795 specimens from a predominantly adult population. The isolation rate of Y. enterocolitica was 0.9% and this represented 15.8% of positive cultures. The usual symptoms of Yersinia infection were diarrhea (93%) and abdominal pain (72%), often associated with tenderness in the right iliac fossa and fever. Fourteen patients required admission to hospital and four came to surgery for possible appendicitis. Acute terminal ileitis and mesenteric lymphadenitis were noted in each case. Two patients who were HLA-B27 positive had a reactive arthritis as their dominant complaint. In conclusion, Y. enterocolitica has emerged as a common cause of diarrhea in adults. It is an important cause of symptoms resembling those of acute appendicitis and is occasionally complicated by reactive arthritis.