Chronic colonization with Pandoraea apista in cystic fibrosis patients determined by repetitive-element-sequence PCR.

Pandoraea apista is recovered with increasing frequency from the lungs of patients with cystic fibrosis (CF) and may represent an emerging pathogen (I. M. Jorgensen et al., Pediatr. Pulmonol. 36:439-446, 2003). We identified two CF patients from our hospital whose sputum specimens were culture positive for P. apista over the course of several years. Repetitive-element-sequence PCR was employed to determine whether sequential isolates that were recovered from these patients represented a single clone and whether each patient had been chronically colonized with the same strain. Banding patterns generated with ERIC primers, REP primers, and BOX primers showed that individual patient isolates had a high degree of similarity (>97%) and were considered identical. However, only the banding patterns from the ERIC primers and BOX primers were able to show that the strains from patients I and II were unique (similarity indices of 79.8% and 70.0%, respectively). We concluded that all strains of P. apista from patient I were identical, as were all strains from patient II, establishing chronic colonization. Only two of the three methods employed indicate that the strains from the two patients are distinct. This implied that the organism was not transferred from one patient to the other, suggesting that the choice of methodology could generate misleading results when examining person-to-person transmission regarding this organism.

Variation among aging alcoholic patients in treatment.

The authors compared demographic and clinical features of two groups of older patients with alcohol use disorders (n=205 and 124) selected before and after major program changes took place at a clinic designed specifically to treat aging alcoholic patients. Program changes (admission criteria, case-finding practices, treatments offered), significantly altered case-mix and treatment adherence. Results demonstrate variability among older alcoholic patients as well as the impact of program policies and practices on patient profiles and treatment responses.

Alcohol related dementia: proposed clinical criteria.

Current diagnostic criteria for Alcohol Related Dementia (ARD) are based almost exclusively on clinical judgment. Moreover, there are no guidelines available to assist the clinician or the researcher in distinguishing Alcohol Related Dementia from other causes of dementia such as Alzheimer's Disease (AD). However, this distinction may have implications for the prognosis and treatment of patients. In this article, provisional diagnostic criteria for establishing a diagnosis of Alcohol Related Dementia are proposed for further study. The criteria are based on the available literature on the relationship between alcohol consumption and dementia and were modeled after existing diagnostic criteria for AD and Vascular Dementia. Validity of these criteria for distinguishing AD from ARD will require further study.

Outcome of nursing home care for residents with alcohol use disorders.

OBJECTIVES: To describe the outcome of nursing home (NH) care for a previously established cohort of residents with active, inactive or no alcohol use disorder (AUD), and to examine demographic variables, health services utilization, mortality and drinking behaviors in this group. DESIGN: Retrospective cohort study with participant interviews at NH admission and 3 years later. SETTING: Urban Veterans Affairs (VA) Medical Center and Nursing Home Care Unit (NHCU). PARTICIPANTS: Patients older than age 50 admitted consecutively to a VA NHCU between July 1991 and February 1993 who completed a structured interview, N = 117. MAIN OUTCOME MEASURES: AUD as determined by DSM-III-R criteria. Demographics, health services utilization and mortality as abstracted from the VA medical record. RESULTS: Health service utilization as measured by care episodes was not significantly different in the three groups (active, inactive and no AUD), but subjects with AUD had documented health services use related to alcoholism, including hospitalizations for alcohol-related illness, placements in long-term care facilities to control drinking and death from alcohol-related causes. The mean age at death was significantly younger for study participants with active or inactive AUD compared to those with no AUD: 67.7, 70.4 and 77.9 years, respectively (p < 0.004). Of the 21 participants with active AUD at NHCU entry, 11 resumed drinking after discharge and six still met criteria for active AUD 3 years later. CONCLUSIONS: The subset of NHCU patients with active AUD continued to incur alcohol-related hospitalizations and institutionalizations following NHCU discharge and suffered early mortality relative to their peers. Effective models of care for this subset of patients should be sought.

Alcoholism and dementia.

This article reviews epidemiological, neurological, cognitive, and imaging data on alcohol-induced dementia. Recent studies indicate that "heavy alcohol use" (variously defined) is a contributing factor in 21-24% of cases of dementia. Research difficulties include lack of positive diagnostic criteria, few post-mortem studies, and no accepted pathological mechanism. Sulcal widening and ventricular enlargement (occasionally reversible) are the strongest findings in patients with alcohol-induced dementia. There is evidence for peripheral neuropathy, ataxia, sparing of language, and improved prognosis when patients with alcohol-induced dementia are compared to other dements. Case examples, etiologic theories, and recommendations for research, training, and clinical practice are included.

Screening for alcohol use disorders in the nursing home.

OBJECTIVES: To determine the prevalence of Alcohol Use Disorders (AUDs) among residents of a Veterans Affairs (VA) nursing home (NH) using DSM-III-R criteria for alcohol abuse and dependence, and to examine the demographic variables associated with AUDs among NH residents. A third objective was to assess the sensitivity, compared with DSM-III-R criteria, of three screening tests for AUDs in the NH: the CAGE, the MAST-G, and the two-question instrument developed by Cyr and Wartman. DESIGN: A cross-sectional design, with DSM-III-R criteria determined by the alcohol module of the Diagnostic Interview Schedule (DIS) as the criterion standard. PATIENTS: Patients older than age 50 admitted consecutively to a VA NH, n = 117. MAIN OUTCOME MEASURES: Sensitivities, specificities, positive predictive values for the CAGE, MAST-G, and Cyr and Wartman Screening questionnaires; receiver operating characteristic (ROC) curves for the CAGE and MAST-G. MAIN RESULTS: Forty-nine percent of study participants met DSM-III-R criteria for lifetime alcohol abuse or dependence (18% active, 31% inactive). The sensitivities and specificities of the three screening questionnaires were as follows: CAGE-82% and 90%; MAST-G-93% and 65%; Cyr and Wartman-70% and 92% respectively. The area under the ROC curve was 0.94 for the CAGE and 0.90 for the MAST-G. CONCLUSIONS: The prevalence of lifetime alcohol abuse and dependence was high in this VA NH population. Both the CAGE and MAST-G are sensitive to AUDs in this setting. The areas under the ROC curves were not significantly different and indicate both tests discriminated well between NH residents with and without AUDs.

Principles of clinical medicine: an interdisciplinary integrated 2-year longitudinal course.

In keeping with the Report of the Panel on the General Professional Education of the Physician (Association of American Medical Colleges 1984), Oregon Health Sciences University (OHSU) School of Medicine is in the midst of revising its curriculum. After a 4-year process, the Curriculum Committee mandated development of the Principles of Clinical Medicine course, a 2-year longitudinal course integrating input from both basic and clinical science departments. We describe the steps leading to the course's implementation, its administrative and organizational structure, the evaluation of student performance, teacher training, course curriculum, and the use of interdisciplinary teaching. This course embodies many of the changes called for in the AAMC Report and serves as a model for interdisciplinary education.

Factors affecting outpatient treatment compliance of older male problem drinkers.

This study sought to identify predictors of outpatient treatment compliance in a cohort of 205 male problem drinkers, age 55 to 79 years. Patients agreed to attend a weekly outpatient therapy group designed for older persons and abstain from using alcohol for one year. Patients who were drinking-driving offenders, who had later onset of alcohol-related problems and/or whose spouses also participated in counseling were more likely than others to comply with outpatient requirements.

Late versus early onset problem drinking in older men.

Age at onset of problem drinking was studied in 132 older men (age 60 years and older) admitted to a VA geriatric alcoholism outpatient treatment program. Demographics, alcohol history, self reported psychological status, special treatment, and treatment compliance variables were tested for association with onset age. Late onset (defined as onset of the first alcohol problem at or after age 60) was not uncommon, occurring in 15% of the sample (29% of patients age 65 or older). Compared to earlier onset cases, late onset alcohol problems were milder and more circumscribed, and were associated with less family alcoholism and greater psychological stability. Late onset patients were also more compliant with outpatient treatment requirements; however, treatment program variables were better predictors of compliance than onset age.

Aging and alcohol use disorders: diagnostic issues in the elderly.

Alcohol use and use disorders in older people tend to be hidden and ignored by clinicians and scholars. Resulting misinformation about elderly alcohol problems can be found in such fundamental works as the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Yet, an extensive literature about the nature of geriatric alcohol problems has developed recently. This article reviews that literature, comments on current research at several North American centers, and offers some new information from the author's study of more than 300 older male alcoholics. Many findings remain to be replicated and further verified. Nonetheless, several coherent strands of information seem to be well substantiated: (a) problem drinking in the elderly constitutes a public health problem of moderate proportion, especially in men; (b) most signs predict increasing problem drinking in coming generations of elderly women and men; (c) many cases of geriatric alcoholism have late onset; (d) many geriatric cases are not properly identified; and (e) present screening and diagnostic methods for alcohol use disorders lack adequate validation for older persons.

Treatment compliance of older alcoholics: an elder-specific approach is superior to "mainstreaming".

A sample of 24 alcoholics (mean age, 58.8 years) treated in typical mixed-age outpatient groups, is compared to a sample of 25 alcoholics (mean age, 60.2 years) treated in special elderly peer groups. Patients treated in the special peer group program remained in treatment significantly longer and were more likely to complete treatment than those treated in mixed-age groups. These findings support the continued development and evaluation of elder-specific treatment approaches for older alcoholics.

Military combat, posttraumatic stress disorder, and criminal behavior in Vietnam veterans.

Although data are inconclusive, popular perception has linked military combat, posttraumatic stress disorder (PTSD), and criminal behavior. This paper discusses the multifactorial elements of this association that include both conscious and unconscious parameters of psychologic functioning. Testimony on combat-related PTSD has been presented in the courtroom to support veterans' claims of not guilty by reason of insanity (NGRI) and diminished capacity and for consideration during judicial sentencing. Because there is a known connection between the degree of combat involvement and PTSD, verification through collateral sources of the veteran's report of combat experiences is an important component of forensic assessment. The DSM-III-defined diagnosis of PTSD and the presence of a dissociative state have particular relevance in NGRI determinations. In other aspects of the judicial process demonstration of the absolute presence or absence of PTSD is often irrelevant and should be replaced by efforts to establish plausible links between provable combat experiences and the circumstances of the crime.

Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders.

Thirty-two patients with coexisting substance abuse and other psychiatric disorders were treated in a unique outpatient pilot program that used techniques drawn from both psychiatric and substance abuse treatment. Eleven patients remained in treatment for 3 or more months, and seven completed a year or more of treatment. Severity of associated psychiatric illness did not affect retention in treatment. Drug-abusing patients and those with personality disorders dropped out quickly; patients with a history of reliable outpatient treatment involvement tended to remain in treatment. Treatment retention was associated with reduced hospital utilization. The authors suggest guidelines for management of patients with coexisting substance abuse and other psychiatric disorders.

Posttraumatic stress disorder as an insanity defense: medicolegal quicksand.

A growing awareness of posttraumatic stress disorder has led to recent use of the disorder as a legal defense against criminal responsibility for both violent and nonviolent crimes. Diagnosis of posttraumatic stress disorder is difficult because the symptoms are mostly subjective, often nonspecific, usually well publicized, and, therefore, relatively easy to imitate. Accurate psychiatric testimony in such cases requires diligent searching for collateral sources of information. The authors argue that the insanity defense is appropriate only in the rare instance that a dissociative episode related to posttraumatic stress disorder directly leads to criminal activity.

Early versus late onset alcoholism in older persons: preliminary findings.

Systematic data comparing early onset (EO) versus late onset (LO) subgroups of older alcoholics is presented in this preliminary clinical report. Thirty-six older active problem drinkers, ages 53 to 76 years at the time of entry into a special outpatient treatment program, were assessed on selected demographic, psychological, alcohol history, and alcohol treatment compliance variables. There were 14 EOs (first alcohol problem prior to age 40 years) and 22 LOs (first problem after age 40). Compared to EOs, LOs reported less family alcoholism and greater current psychological stability. Treatment compliance in both groups was similarly high, compared to overall clinic norms.

The VA psychiatry service as a setting for residency education.

The authors report data from a survey of chairmen of academic departments of psychiatry and chiefs of Veterans Administration (VA) psychiatry services concerning administrative relationships between academic psychiatry departments and VA psychiatry services and the education of psychiatry residents in VA settings. The extent and quality of relationships, the interdependence of academic departments and VA psychiatry services, factors important for good VA training, and advantages and disadvantages of using the VA for residency education are documented. The authors present their conclusions and recommendations for improving the quality of relationships between academic departments and VA psychiatry services and for strengthening psychiatric education in the VA setting.

Diagnosis of posttraumatic stress disorder in Viet Nam veterans: preliminary findings.

Sixty-six Viet Nam veterans were evaluated for posttraumatic stress disorder. Several of the DSM-III criteria for the disorder, but no other clinical features, distinguished patients diagnosed as having the disorder from others. The findings tend to validate the DSM-III construct for this disorder.