The Alcohol Use Disorders Identification Test (AUDIT) has been developed from a six-country WHO collaborative project as a screening instrument for hazardous and harmful alcohol consumption. It is a 10-item questionnaire which covers the domains of alcohol consumption, drinking behaviour, and alcohol-related problems. Questions were selected from a 150-item assessment schedule (which was administered to 1888 persons attending representative primary health care facilities) on the basis of their representativeness for these conceptual domains and their perceived usefulness for intervention. Responses to each question are scored from 0 to 4, giving a maximum possible score of 40. Among those diagnosed as having hazardous or harmful alcohol use, 92% had an AUDIT score of 8 or more, and 94% of those with non-hazardous consumption had a score of less than 8. AUDIT provides a simple method of early detection of hazardous and harmful alcohol use in primary health care settings and is the first instrument of its type to be derived on the basis of a cross-national study.

/pdf/development-of-the-alcohol-use-disorders-identification-test-3h699nkijs.pdf

Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption-II

Objective To characterize mortality in persons diagnosed with primary pulmonary hypertension and to investigate factors associated with survival. Design Registry with prospective follow-up. Setting Thirty-two clinical centers in the United States participating in the Patient Registry for the Characterization of Primary Pulmonary Hypertension supported by the National Heart, Lung, and Blood Institute. Patients Patients (194) diagnosed at clinical centers between 1 July 1981 and 31 December 1985 and followed through 8 August 1988. Measurements At diagnosis, measurements of hemodynamic variables, pulmonary function, and gas exchange variables were taken in addition to information on demographic variables, medical history, and life-style. Patients were followed for survival at 6-month intervals. Main results The estimated median survival of these patients was 2.8 years (95% Cl, 1.9 to 3.7 years). Estimated single-year survival rates were as follows: at 1 year, 68% (Cl, 61% to 75%); at 3 years, 48% (Cl, 41% to 55%); and at 5 years, 34% (Cl, 24% to 44%). Variables associated with poor survival included a New York Heart Association (NYHA) functional class of III or IV, presence of Raynaud phenomenon, elevated mean right atrial pressure, elevated mean pulmonary artery pressure, decreased cardiac index, and decreased diffusing capacity for carbon monoxide (DLCO). Drug therapy at entry or discharge was not associated with survival duration. Conclusions Mortality was most closely associated with right ventricular hemodynamic function and can be characterized by means of an equation using three variables: mean pulmonary artery pressure, mean right atrial pressure, and cardiac index. Such an equation, once validated prospectively, could be used as an adjunct in planning treatment strategies and allocating medical resources.

Survival in Patients with Primary Pulmonary Hypertension: Results from a National Prospective Registry

Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. While the exact prevalence of resistant hypertension is unknown, clinical trials suggest that it is not rare, involving perhaps 20% to 30% of study participants. As older age and obesity are 2 of the strongest risk factors for uncontrolled hypertension, the incidence of resistant hypertension will likely increase as the population becomes more elderly and heavier. The prognosis of resistant hypertension is unknown, but cardiovascular risk is undoubtedly increased as patients often have a history of long-standing, severe hypertension complicated by multiple other cardiovascular risk factors such as obesity, sleep apnea, diabetes, and chronic kidney disease. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant hypertension is almost always multifactorial in etiology. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance; diagnosis and appropriate treatment of secondary causes of hypertension; and use of effective multidrug regimens. As a subgroup, patients with resistant hypertension have not been widely studied. Observational assessments have allowed for identification of demographic and lifestyle characteristics associated with resistant hypertension, and the role of secondary causes of hypertension in promoting treatment resistance is well documented; however, identification of broader mechanisms of treatment resistance is lacking. In particular, attempts to elucidate potential genetic causes of resistant hypertension have been limited. Recommendations for the pharmacological treatment of resistant hypertension remain largely empiric due to the lack of systematic assessments of 3 or 4 drug combinations. Studies of resistant hypertension are limited by the high cardiovascular risk of patients within this subgroup, which generally precludes safe withdrawal of medications; the presence of multiple disease processes (eg, sleep apnea, diabetes, chronic kidney disease, atherosclerotic disease) and their associated medical therapies, which confound interpretation of study results; and the difficulty in enrolling large numbers of study participants. Expanding our understanding of the causes of resistant hypertension and thereby potentially allowing for more effective prevention and/or treatment will be essential to improve the long-term clinical management of this disorder.

Resistant Hypertension: Diagnosis, Evaluation, and Treatment A Scientific Statement From the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research

Relatively brief interventions have consistently been found to be effective in reducing alcohol consumption or achieving treatment referral of problem drinkers. To date, the literature includes at least a dozen randomized trials of brief referral or retention procedures, and 32 controlled studies of brief interventions targeting drinking behavior, enrolling over 6000 problem drinkers in both health care and treatment settings across 14 nations. These studies indicate that brief interventions are more effective than no counseling, and often as effective as more extensive treatment. The outcome literature is reviewed, and common motivational elements of effective brief interventions are described. There is encouraging evidence that the course of harmful alcohol use can be effectively altered by well-designed intervention strategies which are feasible within relatively brief-contact contexts such as primary health care settings and employee assistance programs. Implications for future research and practice are considered.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1360-0443.1993.tb00820.x

Brief interventions for alcohol problems: a review

The acute phase response among plasma proteins is a normal response to tissue injury and is therefore a fundamental aspect of many diverse disease processes. It probably usually has a beneficial net function in limiting damage and promoting repair but in some circumstances it may have pathological consequences. Sustained high levels of acute phase proteins and especially SAA are associated with the development of amyloidosis in some individuals. Increased concentrations of CRP may, by activating the complement system, contribute to inflammation and enhance tissue damage. Failure of the normal or appropriate CRP response may also possibly have deleterious effects. SAA is a polymorphic protein which is normally present only in trace amounts but which, during the acute phase response, becomes one of the major apolipoproteins associated with high-density lipoprotein particles. The function of apoSAA is not known but it must have considerable physiological significance apart from its role as the putative precursor of amyloid A protein fibrils. CRP and SAP have been very stably conserved throughout vertebrate evolution and homologous proteins are apparently present even in vertebrates. This strongly suggests that they have important functions although these have not yet been precisely delineated. The main role of CRP may be to provide for enhanced clearance of inappropriate materials from the plasma whether these are of extrinsic origin, such as microorganisms and their products, or the autologous products of cell damage and death. The interaction between aggregated CRP and plasma low-density lipoprotein may play a significant part in the normal function of CRP and may also have a role in lipoprotein metabolism, clearance, and deposition. SAP is a normal tissue protein as well as being a plasma protein. Aggregated SAP selectively binds fibronectin and this may represent an aspect of the normal function of SAP. The deposition of SAP in amyloid is evidently not a normal function but it is not known whether this deposition is involved in the pathogenesis of amyloid or whether it is merely an epiphenomenon. In any case immunohistochemical staining for SAP is useful in the diagnosis of amyloid, in investigation of glomerulonephritis, and in studying disorders of elastic tissue. Regardless of its physiological or pathophysiological functions, the assay of serum CRP is a valuable aid to clinical management in a number of different situations and in different diseases provided results are interpreted in the light of full clinical information.(ABSTRACT TRUNCATED AT 400 WORDS)

Acute phase proteins with special reference to C-reactive protein and related proteins (pentaxins) and serum amyloid A protein.

In a continuing screening and intervention programme in Malmo, elevated serum-gamma-glutamyltransferase (GGT) values were used for selection of heavy drinkers. The study population consisted of 585 individuals born 1926-1933 with two consecutive GGT values in the upper decile of the GGT distribution, randomly allocated either to an intervention group of to a control group. The subjects in the intervention group were further investigated and 75% of them were judged to have elevated GGT values caused by alcohol consumption. These individuals were repeatedly encouraged to lower their overall alcohol consumption and GGT measurements were used as biofeedback method in the treatment program. The controls were informed by letter to be restrictive with their alcohol consumption and that they should receive new invitations for measurements of their liver enzymes after 2, 4, and 6 years. The intervention and control groups were well matched and followed over a 2-6-year period. Two and 4 years after the screening investigation, the GGT values in both groups were significantly decreased. There were differences, however, between the two groups with regard to sick absenteeism, hospitalization, and mortality. A significant reduction was found in sick absence during 4 years by 80%, in hospital days during 5 years by 60%, and in mortality during 6 years by 50% in the intervention group compared with the control group. Thus, the intervention program was effective in preventing medico-social consequences of heavy drinking.

Identification and intervention of heavy drinking in middle-aged men: results and follow-up of 24-60 months of long-term study with randomized controls.

Summary

A questionnaire consisting of nine questions about drinking habits was used in a preventive programme for middle-aged males in Malmo. With a cut-off point of two yes-answers to the questions, 66% of a group of heavy drinkers, 73 % of all registered alcoholics and 90% of not previously identified alcoholics were identified. Serum γ-glutamyltransferase (GGT), used as an indicator of heavy alcohol consumption in the screening, was a poor instrument for the detection of alcoholism in the same population, assigning correctly only 35%. In combination, the two tests identified 82% of all registered alcoholics, and 97% of the alcoholics who were registered in the period following the screening investigation. Thus Mm-MAST is a useful screening test for alcoholism in medical screening examinations and may successfully be used in combination with biochemical tests.

Indicators of alcohol consumption: comparisons between a questionnaire (Mm-MAST), interviews and serum gamma-glutamyl transferase (GGT) in a health survey of middle-aged males.

Plasma concentrations of 21 proteins have been determined during three weeks following myocardial infarction. Three major patterns of response were distinguished. (1) C-reactive protein, haptoglobin, antichymotrypsin, fibrinogen, orosomucoid and ai-antitrypsin showed a rapid increase with a maximum on day 5, followed by a partial normalisation on day 21. (2) Prealbumin, albumin, α-lipoprotein, transferrin and immunoglobulin G showed a rapid decrease to 80 % or less on day 5 and restoration to normal values on day 21. (3) Ceruloplasmin and β1c-globulin showed a moderate increase with maximum during the second week. Only slight changes were found for hemopexin, plasminogen, prothrombin, cold insoluble globulin, β1F-globulin and a2-macroglobulin. The immunoglobulin pattern after three weeks was characterized by a small increase most prominent for IgM.

Sequential changes of plasma proteins after myocardial infarction.

The oral and intravenous glucose tolerance tests have been compared in middle-aged, normal-weight male non-smokers, ex-smokers and smokers who participated in a general health screening programme in Malmo, Sweden. Subjects with diabetes, previous gastric resection and/or present medication with diuretic agents were excluded. No difference was found when comparing fasting glucose in non-smokers, ex-smokers and smokers. In the oral glucose tolerance test, plasma glucose at 40 and 60 min increased stepwise from non-smokers (8.7 and 7.4 mmol/l) to ex-smokers (8.9 and 7.5 mmol/l), smokers (9.2 and 7.9 mmol/l) and heavy smokers (9.7 and 8.2 mmol/l). Blood glucose levels at 120 min were inversely arranged. Plasma insulin at 120 min was lower in heavy smokers (16.2 mU/l) than in non-smokers (24.8 mU/l). The mean intravenous glucose tolerance test k-value was lower in smokers than in non-smokers. K-values below 1.0 were twice as common in smokers (30%) as in non-smokers. It is concluded that smoking has a clinically significant influence on both the oral and intravenous glucose tolerance tests.

/pdf/glucose-tolerance-and-smoking-a-population-study-of-oral-and-1l2gh8ly24.pdf

Erik Trell

Papers

Identification and intervention of heavy drinking in middle-aged men: results and follow-up of 24-60 months of long-term study with randomized controls.

Indicators of alcohol consumption: comparisons between a questionnaire (Mm-MAST), interviews and serum gamma-glutamyl transferase (GGT) in a health survey of middle-aged males.

Sequential changes of plasma proteins after myocardial infarction.

Glucose tolerance and smoking: a population study of oral and intravenous glucose tolerance tests in middle-aged men.

Community-based preventive medical department for individual risk factor assessment and intervention in an urban population