Alprazolam dependence in seven patients.

The authors report on seven patients who met the DSM-III-R criteria for psychoactive substance (alprazolam) dependence. All had withdrawal symptoms, six demonstrated tolerance, and at least four had substantial social or occupational impairment secondary to drug use. All seven patients had begun taking alprazolam as treatment for anxiety or depression. Six patients abused other drugs or alcohol, either in the past or concurrently. Doses of alprazolam ranged from 2 to 12 mg/day, and duration of use was 6 months to 3 years. The potential for dependence should be considered when prescribing alprazolam.

Nutritional status of a group of alcoholics before and after admission to an alcoholism treatment unit.

The nutritional status of the alcoholic has been presumed to be less than adequate because of the large quantity of alcohol ingested. Most reports have focused on the derelict alcoholic. In contrast, the patients in this investigation are more representative of the usual alcoholic population. The pretreatment dietary histories of 58 alcoholics were compared with their actual dietary intake while they were hospitalized for the treatment of alcoholism. Comparisons were also made between dietary intake by history and Recommended Dietary Allowances. The mean calorie, protein, fat, and carbohydrate intake of the patients was adequate and was well within the Recommended Dietary Allowances ranges. After the patients stopped drinking, they increased their intake of all major nutrients, especially carbohydrates. A subgroup of 11 patients whose recent dietary intake by history was corroborated by their urinary nitrogen excretion had no change in total caloric intake after they stopped drinking.

Plasma lipids and apolipoprotein A-I and A-II levels in alcoholic patients.

This prospective study compared total plasma lipids, high-density lipoprotein cholesterol (HDL-C), and apolipoproteins A-I (apo A-I) and A-II (apo A-II) in 72 alcoholic patients and in 285 nonalcoholic controls. The HDL-C in the alcoholic group was not significantly different from that in the nonalcoholic controls. Alcoholic men had significantly higher levels of cholesterol and triglycerides and lower levels of apo A-I when compared with nonalcoholic controls. Alcoholic women had significantly higher levels of cholesterol and apo A-II when compared with nonalcoholic controls. Serial measurements in 25 alcoholic patients showed a significant decline in HDL-C, apo A-I, and apo A-II levels during the 4-wk hospital stay. HDL-C demonstrated its expected inverse relationship with plasma triglyceride level and its direct relationship with apo A-I, apo A-II, and the hepatic enzyme aspartate aminotransferase.

Patient-spouse agreement on the drinking behaviors of alcoholics.

Because investigators have expressed concern about the validity of alcoholism self-report measures, attention has been focused on the use of spouse or other collateral ratings of patient drinking behaviors. Previous studies have shown that spouse ratings of alcoholics on the Self-Administered Alcoholism Screening Test (SAAST) were reliable and a valid means of screening for alcoholism. In the current study, our objectives were to attempt to replicate the earlier findings in a new and larger sample and to determine whether the various content dimensions of the SAAST show similar patient-spouse agreement. The SAAST results of 240 patient-collateral pairs showed that the mean percentage agreement over the 35 items of the SAAST was 76.5%. Patient-spouse agreement ranged from 84.7% on the component "family alcohol problems" to 68.5% on "loss of control." When patients were classified as alcoholic or nonalcoholic on the basis of spouse ratings on the SAAST, correct classification occurred 98% of the time. Correct conjoint classification by both patient and spouse occurred 95.4% of the time. Thus, we found a high level of agreement between patient and spouse on the SAAST ratings and confirmed that spouse SAAST ratings of drinking behavior of patients provide a reliable diagnosis of alcoholism.

The use of a self-administered alcoholism screening test (SAAST) in a medical center.

A self-administered alcoholism screening questionnaire was given routinely to 100 patients admitted to an alcoholism treatment unit as well as to 100 randomly selected patients in a medical population. The questionnaire differentiated the alcoholic group from the general medical group of patients. It was also successful in identifying the "hidden alcoholic" in the general medical population. It is concluded that this device would be a valuable part of a general medical screening questionnaire to detect the presence of alcoholism in the general medical-surgical patients.

Use of clonidine in a mixed-drug detoxification regimen: possibility of masking of clinical signs of sedative withdrawal.

Clonidine hydrochloride masked the signs of sedative withdrawal when it was used in detoxification of a patient with sedative-opiate-amphetamine dependence. Therefore, we urge caution in the use of clonidine in mixed-drug detoxification regimens.

Diagnosis of alcoholism with a self-administered alcoholism screening test: results with 1,002 consecutive patients receiving general examinations.

Since 1972 we have used the Self-Administered Alcoholism Screening Test (SAAST) in impatient alcoholics and their spouses and in patients from a general medical population. The SAAST, a 35-item test with a yes/no format, was administered to 1,002 consecutive Mayo Clinic patients who generally were not acutely ill and were requesting an annual examination or a general reexamination for chornic but stable problems. Of the 1,002 patients, 5.4% gave responses to the SAAST that would indicate the presence of possible or probable alcoholism. The medical record review on a random selection of patients revealed a false-negative rate of 6.7%. We believe that the SAAST is an effective tool for the detection of alcoholism and that it can be used in the general medical setting.

Developments in the treatment of alcoholism.

The treatment of alcoholism has changed during the past 2 decades. Notable developments have occurred in pharmacotherapy, psychotherapy, and health-care delivery. A better understanding of the biologic basis for addiction has led to clinical trials of medications that target neuroreceptors. One such medication is the opiate antagonist naltrexone, which decreases the craving for alcohol. Psychosocial interventions continue to be the mainstay of alcohol treatment programs. The efficacy of three different therapies was demonstrated in a study called Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity). This study, however, did not prove the patient-treatment "matching" hypothesis. In addition to therapies provided by addiction specialists, interest is growing in the use of brief motivational techniques in primary-care settings. As the field of addiction responds to an unfolding health-care delivery system, a broader range of treatment options in conjunction with a greater opportunity to individualize patient care is evolving.

Tobacco chewing an unusual case of drug dependence.

This case report is that of a 53-year-old man without current evidence of significant psychiatric disorder who requested treatment for dependence on chewing-tobbaco. During his successful treatment in the Alcoholism and Drug Dependence Unit, we noted several similarities between his tobacco chewing and other drug dependencies.

Alcoholism in elderly persons: medical aspects and prognosis of 216 inpatients.

We describe 216 elderly patients (65 years of age or older) who were treated for alcoholism in an inpatient treatment program. Emphasis is placed on the demographics, medical characteristics, results of laboratory tests, outcome of treatment, and various comparisons of early- and late-onset alcoholism. The frequency of serious medical disorders among these patients was higher than would be expected for the overall population of a similar age. Elderly alcoholics have more abnormal results of commonly used laboratory tests than do younger alcoholics. Our data show that the elderly alcoholic can be successfully treated in a medically oriented inpatient treatment program. The concept of less-intensive treatment for the elderly alcoholic is generally not supported. More-intensive treatment may be necessary for some of these patients because of the high frequency of accompanying major medical and psychiatric problems. Early-onset alcoholism predominated, but we found no major differences between the two groups.

Alcoholism in elderly persons: a study of the psychiatric and psychosocial features of 216 inpatients.

The medical records of 216 elderly persons, admitted to the hospital for treatment of alcoholism, were reviewed. Concern of family and friends was the most common factor motivating patients for admission. Patients with late-onset alcoholism reported an association between a life event and problem drinking more frequently than did the early-onset alcoholics. The most common associated psychiatric disorders were tobacco dependence (67%), organic brain syndrome (25%), atypical or mixed organic brain syndrome (19%), and affective disorder (12%). Fourteen percent of patients also had a drug abuse or dependence problem, all using legally prescribed drugs. Psychiatric diagnoses and results of psychologic testing did not differ between early-onset and late-onset alcoholism groups. In a 60-patient cohort studied for correlation of outcome of treatment for alcoholism with major psychiatric diagnoses, no associations were found.

A controlled study of lithium carbonate in the treatment of alcoholism.

A prospective double-blind placebo-controlled trial conducted during a 6-month period showed that lithium carbonate was no better than placebo in producing total abstinence in patients with alcoholism, regardless of whether they were depressed. A high dropout rate, the effect of compliance, and difficulties in measuring improvement in these patients impose some limitations in interpreting the results of this study.

Learning and memory impairment in older, detoxified, benzodiazepine-dependent patients.

The effects of benzodiazepine dependence on the ability to learn and remember new material (determined with the Auditory-Verbal Learning Test) were studied in 20 detoxified, benzodiazepine-dependent patients who were 55 years of age or older and in a drug-dependence rehabilitation program. The patients were matched approximately for age, sex, and IQ with 20 detoxified, alcohol-dependent patients in the same rehabilitation program and 22 control subjects from a community sample. Neuropsychologic testing was performed a mean of 6 to 10 days after the patients had been completely detoxified from the addicting substance. The benzodiazepine-dependent patients had more difficulty with tests of learning and short-term and delayed recall than did the alcohol-dependent or control group. The difference between the benzodiazepine-dependent patients and the control group was statistically significant. The results suggest that benzodiazepine dependence in older people can cause memory impairment that persists into the early drug-free period.

A study of HLA antigens in alcoholism.

The concept that alcoholism may be inherited has been suggested on the basis of twin and adoption studies and the further evidence that alcoholism is commonly seen in several members of a family. Genetic marker studies that have been conducted among alcoholics have often yielded seemingly contradictory results. Thus far, genetic marker studies involving HLA antigens have not been used in the study of alcoholism. In the current study, we identified and performed HLA typing in 52 alcoholics to determine whether a significant difference existed between the frequency of HLA-A and HLA-B locus antigens in an alcoholic population and that in a control population consisting of 1,704 nonalcoholic blood donors. In this study, we could not demonstrate a difference in the occurrence of these antigens between the two populations.

Alcoholism in physicians.

The Self-Administered Alcoholism Screening Test was completed by physicians attending an annual continuing medical education meeting. Of the responding physicians, 12% were identified as abstainers, 81% were classified as not alcohol-dependent drinkers, 5% were classified as possibly alcoholic, and 2% were classified as probably alcoholic. These results were similar to those obtained in a nonphysician general medical patient population previously given the same questionnaire. The data show that the prevalence of alcoholism among a group of physicians is not substantially different from that in a general medical population.

Point prevalence of alcoholism in hospitalized patients: continuing challenges of detection, assessment, and diagnosis.

OBJECTIVE: To measure a 1-day point prevalence of alcohol dependence among hospitalized patients and to assess practices of detection, evaluation, and diagnosis of alcohol problems. PATIENTS AND METHODS: On April 27, 1994, a total of 795 adult inpatients at 2 midwestern teaching hospitals were asked to complete a survey that included the Self-administered Alcoholism Screening Test (SAAST). The records of SAAST-positive patients were reviewed to determine the numbers of patients receiving laboratory screening for alcoholism, addiction consultative services, and a discharge diagnosis of alcoholism. RESULTS: The survey response rate was 84% (667/795). Of the 569 patients who provided SAAST information, 42 (7.4%) had a positive SAAST score and thus were identified as alcohol dependent. Thirteen (31%) of the 42 alcoholic patients received addiction or psychiatric consultative services during their hospitalization. Serum gamma-glutamyltransferase was measured in 4 (11%) of the 38 actively drinking alcoholic patients. Three (7%) of 42 alcoholic patients received a discharge diagnosis of alcohol abuse or dependence. CONCLUSIONS: The alcoholism prevalence rate was lower than those observed in several other US hospitals. Laboratory testing may be underutilized in identifying hospitalized patients who may be addicted to alcohol. Physician use of consultative services and diagnosis of alcohol dependence had not improved from similar observations more than 20 years earlier. These findings may indicate persistent problems in physician detection, assessment, and diagnosis of alcoholism.

Comparison study for identifying promoter allelic polymorphism in interleukin 10 and tumor necrosis factor alpha genes.

Cytokines such as tumor necrosis factor (TNF)-alpha and Interleukin (IL)-10 play significant roles in autoimmunity and transplantation tolerance. Allelic polymorphisms that occur in the regulatory regions of these cytokine genes are closely associated with acute and chronic transplant rejection. The presence of a G-to-A polymorphism at position -308 in the promoter region of the TNF-alpha gene can increase transcription six- to sevenfold. Likewise, the G-A polymorphism at position -1082 of the IL-10 promoter results in lower levels of IL-10 protein. Accordingly, a genotype that dictates the production of high levels of TNF-alpha with low IL-10 capabilities is most likely to generate an inflammatory environment that is less receptive to the transplant. The potential for determining a patient's haplotype before transplantation may be an effective way of monitoring the post-transplant status of such patients. A variety of methodologies that address the detection of mutations have been used both in research and clinical diagnostic tests. This study analyzes the genetic variations in cytokines using two methodologies: the traditional allele-specific oligonucleotide (ASO) polymerase chain reaction (PCR) and the newer and more flexible Invader technology. The sensitivity and specificity of the Invader assay for simultaneous investigation of multiple targets makes it a useful tool in such analyses.

The University of Virginia health promotion and disease prevention program.

INTRODUCTION: Proof of effectiveness now exists for many health promotion and disease prevention practices, yet the importance of this knowledge is not widely appreciated, and a large percentage of the population does not receive this care. Universities with comprehensive academic medical centers are particularly appropriate places for providing health promotion programs. The University of Virginia began a health promotion and disease prevention program for employees in 1990. METHODS: Periodic health risk appraisal, with follow-up and selected interventions, is offered to approximately 14,000 employees as a cost-free fringe benefit. Health risks are assessed with a modification of the Carter Center Health Risk Appraisal. Results are given to participants in group sessions; referrals are made for clinical preventive services and interventions, as needed. RESULTS: During the first three years, 29% of the employee population participated in the program. Participants were more likely to be young, female and not African American. Nearly 96% had one or more risk factors, with an average of 3.6 risk factors overall. Participants on average had 1.8 risk factors for cardiovascular disease; 0.3 for cancer; 0.6 for injury; 0.1 for alcohol abuse; and 0.7 for mental health. Nonparticipants were not receiving similar comprehensive health risk appraisal elsewhere. CONCLUSIONS: University of Virginia employees have multiple health risks, not detected through their usual health care, for which effective interventions are available. This population probably reflects conditions throughout the state and nation. Academic medical centers should place high priority on establishing health promotion programs as part of their responsibilities to society.

Detection of clinically occult prostate cancer.

A large number of cases of prostatic carcinoma are discovered unexpectedly by simple prostatectomy performed for presumed benign disease. The ability to discover these cancers preoperatively is an appealing concept, in other words, to screen: the use of a test to detect a disease in an asymptomatic individual. The ideal screening test would be noninvasive, inexpensive, reliable, and reproducible. It would also have a high sensitivity and specificity, neither allowing a disease process to be missed by a falsely negative result nor leading to unnecessary and more invasive studies by a falsely positive one. It has been suggested that an acceptable screening test have a sensitivity of at least 95 per cent and a specificity of 100 per cent. An equally important criterion for a successful screening program for cancer has to do with the biologic potential of the discovered malignancy. The adage is that more men die with prostate cancer than of prostate cancer. However, the biologic potential of prostate cancer has not been fully elucidated, and it is not entirely clear who will benefit from treatment and who should be left alone. At the present time, noninvasive imaging modalities and biochemical markers are not clinically useful in detecting occult prostatic carcinoma. Furthermore, no study has proved that routine screening reduces the mortality rate from prostate cancer. Many authors believe that screening men for prostate cancer should be regarded as investigational and that currently, only screening programs for breast and cervical cancer have been fully demonstrated to be effective. New studies are needed that include control groups who are not subjected to the early diagnostic modality, assessing both the disadvantages of the screening program and the potential benefits.

The Virginia generalist initiative: lessons learned in a statewide consortium.

In response to Virginia's need for an increased supply of generalist physicians, the state's three medical schools--Eastern Virginia Medical School, Virginia Commonwealth University School of Medicine, and the University of Virginia School of Medicine--have formed a partnership with key governmental stakeholders in the Virginia Generalist Initiative funded by The Robert Wood Johnson Foundation's Generalist Physician Initiative. These state-supported medical schools historically have functioned independently, with little cooperative effort. This paper describes the consortium, its activities, its successes, and its unmet objectives, and uses a series of cases in point to illustrate relevant lessons learned. Some of these lessons are that (1) stakeholders must be involved from the beginning of planning to identify mutual goals and establish consortium protocols; (2) all partners must share a philosophical commitment to the consortium's mission, as well as the time and resources needed; (3) an atmosphere that enables risk-taking behavior must be created; (4) stakeholders must be willing to revise goals and sustain an environment conductive to change; and (5) trust is essential and must be vigilantly maintained. The paper concludes that the Virginia Generalist Initiative has dramatically altered the goals, objectives and programs of the three schools and has succeeded in aligning the schools' strategic objectives with the state's priorities.