Does psychosocial treatment enhance the efficacy of acamprosate in patients with alcohol problems?

AIMS: Acamprosate in combination with psychosocial treatment has been shown to be effective for the treatment of alcohol dependence. The goal of the present study was to determine whether the addition of psychosocial intervention to the medical prescription of acamprosate contributes to treatment outcome. METHODS: Patients (n = 248) meeting DSM-IV criteria for alcohol dependence or abuse were recruited in 14 outpatient treatment centres and randomized into one of three treatment conditions: acamprosate; acamprosate plus minimal intervention aimed at motivational enhancement (3-weekly sessions of 20 min); and acamprosate plus brief cognitive behavioural therapy (7-weekly sessions of 60 min). Acamprosate was prescribed for 28 weeks, medically monitored by a physician on six occasions lasting 10 min. Drinking behaviour, medication compliance and psychological distress were assessed throughout the treatment period. Follow-up assessment was undertaken 6 months after termination of pharmacological treatment. RESULTS: Of 241 patients with intention to treat (ITT), 114 (47.3%) remained in treatment for the full 28 weeks; 169 of the ITT population (70.1%) were seen for follow-up. No statistically significant differences were found between treatment groups for any of the drinking outcomes either at the end of the 28 weeks of treatment or at 6-month follow-up. There were no statistically significant differences in medication compliance, drop-out rates, or psychological distress. However, a significant interaction effect was observed between treatment centre and treatment group, indicating that brief interventions were differentially effective in different treatment centres. CONCLUSIONS: A clear supplemental value of minimal and brief psychosocial interventions to the prescription of acamprosate was not demonstrated. The widely held belief that pharmacotherapy for alcohol dependence should always be combined with psychosocial intervention is debatable and merits further research.

Ectopic pregnancy within a rudimentary horn in a case of unicornuate uterus.

We report the MRI features of two cases of unicornuate uterus and occluded rudimentary horn. In one patient pregnancy had occurred in the occluded horn, prompting to urgent resection. The second patient illustrates more conventional findings in occluded rudimentary horn. In both cases MRI was able to correctly characterise the nature of the developmental anomaly. Furthermore, on the basis of signal intensities, differentiation between distended lumen due to blood accumulation and amniotic sac in the case of pregnancy could be made. Because of its high accuracy in determining the type of anomaly present, the lack of ionizing radiation, and the ability to evaluate, with the exception of the fallopian tubes, the entire genitourinary tract, MR imaging is essential and plays a key role in the evaluation of women who are consulting for infertility.

An open study with acamprosate in Belgium and Luxemburg: results on sociodemographics, supportive treatment and outcome.

This open study on 614 alcohol-dependent patients from 51 centres in Belgium over 24 weeks collected data on the sociodemographic, medical and drug safety profiles and the type of psychosocial support most commonly associated with acamprosate. Psychiatric problems (34%) and gastro-intestinal ulcers (15%) were the most frequent other medical diagnoses. As supportive treatment, 48% of patients received individual psychotherapy, 25% group therapy, 16% relapse prevention and coping skills, 9% brief intervention and 2% family therapy. Fifteen (29%) centres used only 1 form of supportive treatment, 14 (27%) used 2 forms of support, 16 (31%) used 3 forms, 4 (8%) used 4 and only 2 centres (4%) used all 5 supportive treatment options. Three hundred and fifty-nine patients dropped out of the study. At any moment during the treatment period, up to 11% relapsed, 9% had binge drinking and 9% had drinking lapses. The quantity of alcohol consumption during relapse, lapse or binge drinking showed a considerable drop in the mean number of drinks per day, from 19.53 before treatment to 4.23-7.83 drinks for lapse drinking, 9.27-14.62 drinks for binge drinking and 4.96-10.29 drinks per day for relapse. All 8 dimensions of the SF36 quality of life questionnaire improved over the treatment period. Acamprosate was well tolerated by all patients.

Hepatic lesion detection and characterization: value of nonenhanced MR imaging, superparamagnetic iron oxide-enhanced MR imaging, and spiral CT-ROC analysis.

PURPOSE: To determine the accuracy for detection and characterization of focal hepatic lesions of nonenhanced, superparamagnetic iron oxide (SPIO)-enhanced, or a combination of nonenhanced and SPIO-enhanced MR imaging and contrast-enhanced spiral computed tomography (CT). MATERIALS AND METHODS: Spiral CT and T2-weighted SPIO-enhanced (ferucarbotran-enhanced) MR imaging were performed in 35 patients within 2 weeks before surgery for malignant hepatic lesions. Only malignant lesions with histopathologic proof were considered. A total of 875 images with and 800 images without focal lesions were presented to five readers, who were asked to assess the presence and characterization of lesions by using a five-point confidence scale. Receiver operating characteristic analysis was performed. RESULTS: Nonenhanced and SPIO-enhanced images together and SPIO-enhanced images alone yielded the best performance for lesion detection. No differences were found among all imaging techniques with regard to lesion characterization (benign vs malignant). The combined approach resulted in larger area under the ROC curve (A(z) = 0.9062) and accuracy (85.3%) (P < 0.02), as compared with SPIO-enhanced MR imaging (A(z) = 0.8667; accuracy, 73.1%). CONCLUSION: SPIO-enhanced T2-weighted MR imaging was more accurate than nonenhanced T1-weighted and T2-weighted MR imaging and contrast-enhanced spiral CT for the detection of focal hepatic lesions. The combined analysis of nonenhanced and SPIO-enhanced images was more accurate in the characterization of focal hepatic lesions than was review of SPIO-enhanced images alone.

A French translation of the obsessive-compulsive drinking scale for craving in alcohol-dependent patients: a validation study in Belgium, France, and Switzerland.

The Obsessive-Compulsive Drinking Scale (OCDS) is an instrument developed to measure cognitive aspects of alcohol craving. The aim of this study was to validate the French translation of the OCDS according to the international methodology as published by Hunt and coworkers (see text), including forward-backward translations, patient interviews (9 patients), patient's perception of acceptability (15 patients), and final validation within a treatment program (50 patients). All 74 patients were native French-speaking alcohol-dependent patients from Belgium, France, and Switzerland. The derived aggregated total (TOT) score and both subscores corresponding to the obsessive (OB) and compulsive (CP) dimensions were shown to be asymptomatically normal. Good internal consistencies were found, with Cronbach alpha: TOT = 0.88; OB = 0. 82; CP = 0.79. The test-retest procedure was used to examine intrarater reliability (r = 0.81). The construct validity was examined with linear correlation of the two main components: r(OB, CP) = 0.62; r(OB, TOT) = 0.86; r(CP, TOT) = 0.92. Principal-components analysis revealed two main factors: the first factor representing the total scale score, while the obsessive and compulsive subscale scores were distributed along factor two. The translated scale seems to be psychometrically as valid as the original English scale and confirms the psychometric properties of the OCDS.

Craving and relapse measurement in alcoholism.

This paper attempts to summarize the measurement of craving with four different craving instruments and to relate this to definitions and measurement of relapse. The definitions of relapse may vary between studies and researchers, but are usually well defined. Five commonly used methods to measure relapse are: (1) quantity/frequency of drinking; (2) cumulative duration of abstinence (CDA); (3) post-withdrawal abstinent period; (4) stable recovery period; (5) the time line follow-back method. The definition of craving is much less clear and is mostly described as an emotional-motivational state or as obsessive-compulsive behaviour. Four self-rating instruments are briefly discussed and compared: the Obsessive-Compulsive Drinking Scale, OCDS, the Lübeck Craving Scale, LCRR, the Alcohol Craving Questionnaire, ACQ-Now-SF-R, and ordinal scales (e.g. visual analogue, Likert, or verbal descriptive scales). These instruments measure different aspects or dimensions of craving over different periods. The different dimensions measured suggest that there is still a need to conceptualize a standard interpretation of the word craving. There is a need also to measure an emotional-motivational dimension, a cognitive-behavioural dimension, expectancies, and effects on positive and negative reinforcement with different instruments or with one multidimensional instrument. It is suggested that different patients are expected to have different craving profiles.

Insulinoma associated with liver lesions: value of MR imaging.

We report on a middle-aged woman who presented with clinical and biochemical findings of insulinoma. Preoperative evaluation by ultrasound, CT, and angiography located the pancreatic lesion but also revealed two focal liver lesions. The latter were interpreted as metastases. MR imaging with injection of superparamagnetic iron oxide particles not only localized the insulinoma but proved to be the only noninvasive technique capable to exclude presence of liver metastases preoperatively. This reversed management to minimal laparoscopic surgery. Recent literature of preoperative imaging evaluation of insulinoma and focal liver lesions is discussed.

Transient uterine contraction mimicking adenomyosis on MRI.

Transient myometrial contraction as a physiological phenomenon may simulate pathological conditions, such as a focal or diffuse adenomyosis. Clinicians should be aware of the potential presence of this phenomenon and imaging should be repeated after a suitable interval when the nature of a bulge or a region of low intensity in the myometrium is in doubt. In this paper, we report a transient myometrial contraction that mimics an adenomyosis, but disappears in repeated series.

The influence of MR field strength on the detection of focal liver lesions with superparamagnetic iron oxide.

The purpose of this study was to compare the value of low- vs high-field MR systems in the detection of focal liver lesions after IV administration of iron oxide particles. A prospective study was undertaken which included 20 patients with focal liver lesions on CT or US, or strong clinical suspicion of focal liver disease. Iron oxide particles were administered in an IV drip infusion over 30 min. Magnetic resonance imaging was subsequently performed on a 0.2 and a 1.5-T system. Both examinations were performed in one session. Turbo spin-echo T2-weighted sequences were used for further analysis (at 0.2 T: TR 4050 ms, TE 96 ms; 1.5 T: TR 3000 ms, TE 103 ms). After randomisation, images were analysed by two blinded readers. The evaluation included lesion counts, determination of lesion conspicuity and overall image quality (both graded on a scale 1-5). Quantitative analysis was performed on 29 lesions. Lesion-to-liver signal intensity and contrast-to-noise ratios (CNRs) were calculated. The total lesion count (cumulative counts for two observers) was 59 on the high-field system and 63 on the low-field system. Statistical analysis showed no significant difference. On both systems median value for lesion conspicuity was 3. No statistically significant difference was found. Global image quality was rated higher on the high-field system: 3 vs 2 for the low-field system (p = 0.0017). Quantitative analysis showed no significant difference for lesion-to-liver signal intensity ratios or CNRs. Although subjective image quality is significantly better on the high-field system, this does not result in better lesion detection or better lesion conspicuity. No significant difference in objective quantitative parameters was found in our series.

Is it a haemangioma?

A retrospective study of 92 cases of proven haemangiomas is presented. In this study, we evaluated the degree of confidence of the radiologist in differentiating haemangioma by ultrasound (US), computed tomography (CT), angiography (AR), and magnetic resonance imaging (MRI) in an incidental and an oncologic (high risk) population. The diagnosis of haemangioma was confirmed by surgery, by fine needle aspiration biopsy (FNAB) and by long follow-up. Maximum lesions were diagnosed with high confidence by MRI (88-93%) and by angiography (85-91%) in both incidental and oncologic group. 44% of the lesions were confidently diagnosed in incidental group as compared to the 11% of the lesions in oncologic group by ultrasound. Similarly, lesions were diagnosed with maximum confidence in 76% in incidental group as compared to 48% in oncologic group by dynamic contrast bolus CT. Confidence was also evaluated according to the size of the lesions but due to the low number of lesions in < 1.5 cm category, the difference in the confidence levels was not apparent. We conclude that in high risk group, MRI, if available, should be directly performed after US. In the incidental finding group, if the lesion has typical features, US follow-up every 6 months is sufficient.

Unusual cystic liver lesions: a pictorial essay.

Cystic liver lesions are being increasingly detected by ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI). These lesions produce a wide spectrum of radiological features. Unfortunately their appearance is not always specific and they may resemble and be mistaken for other lesions. Cystic lesions can be classified into congenital, inflammatory, neoplastic and miscellaneous groups. In this pictorial essay a number of unusual cystic lesions are illustrated with a brief analysis of morphological features of the individual lesion and a diagnostic approach for cystic liver lesions is suggested.

Mucinous cystadenocarcinoma of the pancreas with liver metastases. An unusual presentation of a rare tumor.

We present a case of mucinous cystadenocarcinoma of the pancreas with liver metastases. Initially, the patient presented as pancreatitis and pseudocyst which was marsupialised into the stomach in 1983. Eight years later, a tumor with liver metastases was detected. The liver metastases mimicked multiple abscesses. Over a period of forty-four days, CT features changed considerably and there was explosive enlargement of the lesions in the postoperative period. The reason for this dramatic increase in size was the anaplastic component of the tumor. To our knowledge, no such case has been reported in literature.

Focal nodular hyperplasia of the liver: radiologic findings.

A retrospective analysis of the results of ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) of 24 cases (28 lesions) of proven focal nodular hyperplasia (FNH) is presented. While US exhibited nonspecific features, CT frequently showed characteristic features: hypodensity on precontrast scans (69%), transient immediate enhancement after bolus injection (96%), and homogeneity (85%). A scar was noted in 31% of the cases. The typical MR triad of isointensity on T1- and/or T2-weighted (T2-WI), homogeneity, and a scar which shows hyperintensity on T2-WI was seen in only 12% of our cases. The most common finding was homogeneity (94%). In two cases the scar was hypointense on T2-WI. To our knowledge, this finding has not been described before. We conclude that the features of FNH, although fairly constant, are at times indistinguishable from those of other hepatic tumors, such as hepatic adenoma (HA), fibrolamellar hepatocellular carcinoma (FLHCC), small hepatocellular carcinoma, and a hyperplastic nodule. Therefore, a multimodality approach is essential for the correct diagnosis in order to prevent unnecessary surgery.

Recombinant human erythropoietin for the treatment of anemia in the myelodysplastic syndromes: a clinical and erythrokinetic assessment.

The clinical and ferrokinetic effects of escalating doses of subcutaneously administered recombinant human erythropoietin (rh-EPO) were studied in ten patients with myelodysplastic syndromes and severe transfusion-dependent anemia. Red blood cell transfusion requirements diminished in four patients, and one of the patients eventually became transfusion independent with an EPO-induced rise of Hb from 7.7 g/dl to 12.3 g/dl. Endogenous serum levels of EPO were significantly increased in all patients (100-5700 mU/ml), but three of four responders had a relatively low baseline level. The effective red cell iron turnover (RCIT) improved in two responding patients and even normalized in one patient. This increase in RCIT was accompanied with a decline in the ineffective red cell iron turnover (IIT). The other responding patients had a relatively preserved RCIT before EPO treatment. EPO therapy further increased the fraction of IIT in the latter patients. Red cell survival time did not increase during EPO therapy, even in the responding patients. One transient and one maintained increase in platelet count were observed. Disease progression with a sustained increase in blast cells in one patient and a transient elevation of blasts in another patient was seen. No other side effects of EPO therapy were observed. These results suggest that anemic MDS patients with low serum EPO levels and relatively spared effective erythropoiesis as measured by ferrokinetic studies may be the best candidates for treatment with recombinant human EPO.