Ecological momentary assessment in addiction

Numerous symptoms in psychiatry are subjective (e.g., sadness, anxiety, craving or fatigue), fluctuate and are environment dependent. Accurate measurement of these phenomena requires repeated measures, and ideally needs to be performed in the patient's natural environment rather than in an artificial laboratory environment or a protected hospital environment. The usual paper and pencil questionnaires do not meet these two conditions for reasons of logistics. A recently developed method, ecological momentary assessment (EMA), made it possible to implement these field assessments via ingenious use of various devices (most frequently an electronic diary) coupling an auditory signal with computerized data capture. The subject carries the device with him/her at all times, and data is recorded in vivo in real time. The programming of repeated measures in the form of a Likert scale or pull-down menu is easily achieved. A recall alarm system can help increase compliance. Compared with classical self-report, EMA improves the validity of the assessment of certain symptoms, which are the main evaluation criteria in clinical trials concerning certain pathologies (e.g., craving and treatment of addiction), where measurement was previously liable to bias. This article sets out to present this method, its advantages and disadvantages, and the interest it presents in psychiatry, in particular via three original applications developed by the authors including: measurement of reaction time without the knowledge of the subject in order to test certain cognitive models; use of a graphic solution for the data recorded for functional analysis of disorders; and the use of data collection via mobile phone and text messages, which also enables therapeutic interventions in real time by text messages, personalized on the basis of the situational data collected (e.g., in the case of craving, the associated mood, solitary or group consumption or concomitant occupations).

[Styles of attachment and social support perceived in depressed women]

RESULTS

This study, inspired by the attachment model and research in the field of social support, attempts to reveal the link between styles of attachment, social support and depressive vulnerability.

AIM OF THE STUDY

It investigates current styles of attach-ment and the quality of social support perceived by 35 hospitalized, depressed subjects compared to 35 control subjects who exhibited no pathology. After giving their consent, each subject took part in an in-depth psychological investigation consisting of a recorded clinical interview and various clinical scales.

METHOD

The study presents only the responses to the Perception of Relations questionnaire which distinguishes between four styles of attachment (secure, detached, preoccupied and disorganized) and the Social Support Questionnaire (SSQ6) which contains two dimensions: social availability and social satisfaction. The results were subjected to statistical analyses: a comparative analysis between the two groups and a correlational analysis between the dimensions of social support and the dimensions of style of attachment. On the one hand, the study reveals that the social network is perceived to be less available by depressed subjects, together with the absence of a current intimate relationship with other people, the absence of people to confide in, and a relationship between this absence and the large number of losses experienced by depressed subjects, in particular the loss of figures of attachment (father and mother). On the other hand, depressed subjects tend to exhibit a preoccupied, disorganized style of attachment which is characterized by negative models of the self.

DISCUSSION

The discussion addresses the way these styles of attachment should be understood: do they represent the consequence of the depressive pathology or an older relational style?

An in vivo study of the relationship between craving and reaction time during alcohol detoxification using the ecological momentary assessment

BACKGROUND

To study cognitive interference associated with craving for alcohol, the Ecological Momentary Assessment (EMA) method was used to measure the relationship between craving and reaction time. A secondary aim was the study of the predictive factors for craving during alcohol detoxification. The EMA enables both repeated measures of craving in a natural setting and the recording of reaction time without the patient being aware of this.

METHODS

Craving for alcohol, reaction time, sadness and anxiety were recorded 8 to 12 times a day, over three weeks of detoxification in 14 alcoholics (n=1767 measures), on an electronic diary issuing random prompts. Mixed models were used for statistical analysis (alpha=5%, 1-beta=88%).

RESULTS

Reaction time was significantly increased in univariate analysis when a craving episode occurred but this difference did not persist after multivariate analysis. Craving episodes were more frequent and intense than previously reported. Predictive factors of craving during detoxification were: age, gender, sadness, anxiety and the number of previous detoxifications. Antidepressants, anti-craving medications but not benzodiazepines were negatively associated to craving.

Conséquences à court et long terme d’une exposition prénatale au cannabis

OBJECTIVE

Cannabis is one of the most commonly used drugs by pregnant women. The objective of this review of literature was to examine the association between cannabis use during pregnancy and effects upon growth, cognitive development (memory, attention, executive functions...) and behavior of newborns, children and teenagers.

MATERIAL AND METHODS

We searched for articles indexed in the medline database from 1970 to 2005. The following terms were used in the literature search: cannabis/marijuana, pregnancy, fetal development, newborn, prenatal exposure, neurobehavioral deficits, cognitive deficits, executive functions, cannabinoids, reproduction. Most of the articles were published in English.

RESULTS

Cannabis use during pregnancy is related to diverse neurobehavioral and cognitive outcomes, including symptoms of inattention, impulsivity, deficits in learning and memory, and a deficiency in aspects of executive functions. It seems difficult to identify complications, such as lower birth weight, only attributable to cannabis as opposed to the multiple perinatal complications associated with tobacco smoking.

CONCLUSION

In addition to alcohol and cigarettes, information should be given to women about the potentially harmful effects on fetal development, newborns, children and teenagers of smoking cannabis. Therefore, it seems necessary to develop prevention programs on this subject.

[Progressive cannabis-induced arteritis: a clinical thromboangiitis obliterans sub-group?]

INTRODUCTION

Since the end of the nineteen-nineties, cannabis is not only incriminated in the onset of thromboangiitis obliterans but also in inducing artheromatous lesions in young subjects.

OBSERVATION

A young, Caucasian, 18 year-old man was referred for cannabis withdrawal in the treatment of arteritis of the left leg.

DISCUSSION

Cannabis is by far the illicite psychoactive substance most consumed by the 15-25 year-olds. Data in the literature, notably since the end of the nineteen-nineties, show that cannabis is accused of provoking arterial disease similar to that which is found in Buerger's disease (or thromboangiitis obliterans) in young subjects of whichever sex.

Gene flow among different taxonomic units: evidence from nuclear and cytoplasmic markers in Cedrus plantation forests

Hybridization and introgression are important natural evolutionary processes that can be successfully investigated using molecular markers and open- and controlled-pollinated progeny. In this study, we collected open-pollinated seeds from Cedrus atlantica, Cedrus libani and C. libani x C. atlantica hybrids from three French-plantation forests. We also used pollen from C. libani and Cedrus brevifolia to pollinate C. atlantica trees. The progeny were analyzed using three different types of molecular markers: RAPDs, AFLPs and cpSSRs. Chloroplast DNA was found to be paternally inherited in Cedrus from the progeny of controlled-crosses. Heteroplasmy, although possible, could not be undoubtedly detected. There was no indication of strong reproductive isolating barriers among the three Mediterranean Cedrus taxa. Gene flow between C. atlantica and C. libani accounted for 67 to 81% of viable open-pollinated seedlings in two plantation forests. We propose that Mediterranean Cedrus taxa should be considered as units of a single collective species comprising two regional groups, North Africa and the Middle East. We recommend the use of cpSSRs for monitoring gene flow between taxa in plantation forests, especially in areas where garden specimens of one species are planted in the vicinity of selected seed-stands and gene-conservation reserves of another species.

Long-life physical property preservation and postendodontic rehabilitation with the Composipost

Most coronal radicular reconstructions are made of cast inlay core metals or prefabricated posts covered in composite. The differences in the mechanical properties of these elements create a heterogeneous mass with inconsistent mechanical behavior. Studies using the Finite Element Method have shown the biomechanical disturbances caused by the inclusion of materials with a modulus of elasticity that is superior to that of dentine (i.e., nickel, chrome, zircon, etc). The use of materials with a modulus of elasticity close to that of dentine does not disturb the flow of stress inside the root. To our knowledge, only a composite material structured with programmable mechanical properties would be capable of producing both high mechanical performance and a modulus of elasticity adapted to dentine values. The C-POST, made of carbon epoxy, accommodates the demands of the dentine, as well as the in vitro stress linked to the prosthesis. The internal structure, consisting of long high-performance carbon fibers, unidirectionally and equally stretched, confers a totally original behavior that is adapted to clinical objectives. In addition, the C-POST has a fracture resistance superior to most metals.

Two methods of estimating health costs linked to alcoholism in France (with a note on social costs)

The health costs of alcohol-related problems in France were estimated using two cost evaluation approaches: (1) estimate based on the proportion of cases attributable to alcohol abuse (the alcohol abuse factor); (2) estimate based on prevalence of alcohol abuse for in- and out-patients. For a 10% prevalence of alcohol abuse in the general population, the minimum cost in 1996 was about US$ 2300 million; for a prevalence of 15% it was US$ 2700 million. This cost concerns the health disorders that are linked directly or indirectly to alcohol abuse. It did not allow for injuries from accidents caused by alcohol intoxication and undervalued the cost of out-patient care. Based on the prevalence of alcohol-related disorders seen at hospitals, a percentage of the total in-patient and out-patient costs due to effects of alcohol could be estimated. However, this did not permit an estimate of the cost of care in which alcohol abuse was a risk factor only. Based on the available data showing that between 3% and 10% of inpatients have a directly alcohol-related condition, estimates of in-patient treatment costs varied from US$ 1300 to 2100 million. Among adult out-patients, 20% present with a disorder in which alcohol is a factor or suffer from an alcohol-related illness, which corresponds to a cost of about US$ 1600 million. Thus, these methods yield minimum year's cost estimated between US$ 2500 and 3300 million. These costs are high, compared to the low level of financing for the specialized facilities offering treatment to people in difficulty due to alcohol excess, which was US$ 23 million in that year. As regards social and total costs, estimates from four Western countries have found that about 75% of the total costs of alcohol abuse was attributable to social harm, and 25% to medical costs. Applying this ratio to the French data gives an estimated total cost to French society of about US$ 13 200 million, i.e. 1.04% of the gross national product.

Patients admitted to emergency services for drunkenness: moderate alcohol users or harmful drinkers?

OBJECTIVE

Most of the patients admitted to hospital emergency services are drunk. Some of them may need specific treatment after acute intoxication remits. At present, treatment for alcoholism is offered to less than 5% of these patients. The authors evaluated the biological markers carbohydrate-deficient transferrin (CDT) and gamma-glutamyltransferase (GGT) in patients admitted for acute alcohol intoxication (per DSM-IV criteria) supported by blood alcohol assay. These tests distinguished between otherwise moderate alcohol users who were acutely intoxicated and harmful drinkers or alcohol-dependent patients.

METHOD

The authors conducted an exhaustive survey 24 hours a day during 2 nonconsecutive months. The study involved 166 patients (124 men and 42 women) who were admitted for acute alcohol intoxication as a principal or additional diagnosis. Their blood was analyzed for alcohol, GGT, and CDT levels. The CAGE questionnaire was administered, and social and demographic data were collected.

RESULTS

About 80% of the population studied displayed elevated GGT or CDT levels (65.7% had CDT levels >60 mg/liter; 41.6% had GGT levels >65 IU/liter). Less than 10% of the patients with acute alcohol intoxication revealed results in the normal range for both markers and a negative finding on the CAGE questionnaire.

CONCLUSIONS

Patients admitted to emergency services with high blood alcohol levels should not be assumed to be moderate drinkers. Any drunkenness should be interpreted as a sign of likely harmful alcohol consumption or alcohol dependency requiring clinical and biological tests, including GGT and CDT assays. Specific treatment for alcoholism should be systematically offered to these patients.

Objective diagnosis of alcohol abuse: compared values of carbohydrate-deficient transferrin (CDT), gamma-glutamyl transferase (GGT), and mean corpuscular volume (MCV)

BACKGROUND

Alcohol abuse is roughly twice as common as alcohol dependence. Subjects with alcohol problems are usually diagnosed only when medical complications are present. Therefore, both doctors and patients need a method for early diagnosis of alcohol abuse.

METHODS

The mean corpuscular volume, gamma-glutamyl transferase, and carbohydrate-deficient transferrin in alcohol abusers, alcohol-dependent patients, and "nonalcohol hospital" individuals were compared.

RESULTS

For objective diagnosis of alcohol abuse, we found a sensitivity of 24%, a specificity of 96%, and a global predictive value of 63% for mean corpuscular volume; a sensitivity of 42%, a specificity of 76%, and a global predictive value of 61% for gamma-glutamyl transferase; and a sensitivity of 67%, a specificity of 97%, and a global predictive value of 84% for carbohydrate-deficient transferrin.

CONCLUSIONS

Carbohydrate-deficient transferrin proves to be the best marker of alcohol abuse. It allows objective detection so that therapeutic action can be started early, which is easier and more effective than in alcohol dependence.

Hospital morbidity of alcohol use disorders in the center of France

BACKGROUND

The Auvergne region of central France has the third highest mortality rate in the country for alcohol-related disorders and the highest level of alcohol consumption among young people.

METHODS

An exhaustive cross-sectional study of regional hospital morbidity related to alcohol was undertaken on a single day in May 1998, including 9,552 hospital beds. All inpatients age 16 and older in the Departments of Medicine, Surgery, Obstetrics and Gynecology, Psychiatry, and Medium-Stay Services were studied. The aim was to define alcohol-related behavior patterns (by using the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV] criteria of abuse and dependence and the CAGE questionnaire) and to measure the proportion of nonsomatic alcohol-related care dispensed in hospital.

RESULTS AND CONCLUSIONS

The prevalence of alcohol use disorders in all wards was 20%. Half of these patients were alcohol dependent, a quarter were diagnosed as alcohol abusers, and a quarter had an alcohol-related problem that was not identified during the stay. Alcohol use disorders were more common in male inpatients (34% vs. 8% in female inpatients) and in certain age groups. One male subject in two and one female subject in five between 34 and 45 years had an alcohol-related problem. Almost 25% of male inpatients studied between the ages of 16 and 20 years had an alcohol-related problem, but only half had been diagnosed previously. Hospital care for alcohol-related health problems was seriously inadequate. On average, 38% of patients diagnosed with an alcohol use disorder received relevant nonsomatic alcohol care, of which 13% were alcohol abusers and 50% were alcohol-dependent patients.

SIGNIFICANCE

This exhaustive study demonstrates the degree of alcohol-related morbidity among hospitalized patients, which is particularly high in men, in the Auvergne region of France. The study emphasizes the lack of diagnosis, particularly for the young, and the apparent deficiencies in the hospital management of these patients.

[Estimation of health care cost for alcoholism in France: advantages and limitations of two evaluation methods]

TWO CALCULATION SCHEMES: We estimated the cost of health care related to alcoholism using two different medicoeconomic approaches. PREVALENCE OF ALCOHOLISM: Corresponding costs of alcohol-related conditions can be calculated from the prevalence of alcoholism in hospitalized and ambulatory patients. It is however impossible to calculate the alcohol-related cost, even for heavy drinkers, when alcohol is involved as a risk factor. METHOD ONE: For a 10% prevalence of excessive alcohol intake in the general population, the minimal cost in 1996 would be approximately 14 billion francs ($2.2 billion). For a 15% prevalence, it would reach 16 billion ($2.6 billion). This cost only concerns diseases directly or indirectly related to alcoholism. The estimated hospital cost of diseases directly related to alcoholism, that is alcoholic dependence and psychosis, cirrhosis, and upper airway-digestive cancers, reaches 6 to 6.5 billion francs ($1-$1.03 billion) respectively for a 10 or 15% prevalence. Total costs (hospital and ambulatory costs) are between 6.4 and 6.9 billion francs ($1.02-$1.04 billion). For diseases where alcohol is only a risk factor, the minimal cost varies between 7.5 and 9.5 billion francs ($1.20-$1.51 billion). METHOD TWO: With this method, the minimal total cost is to the order of 20 billion francs ($3.75 billion) with half being hospital costs and half ambulatory costs. This cost only concerns alcohol in overt disease states. Costs related to alcohol as a risk factor are not included in this estimation as there is no known coefficient for attribution. HIGH COST OF ALCOHOLISM: Both of our methods used a minimizing estimation scheme and found total costs to lie in the range of 15 ñ 20 billion francs ($2.38-$3.75 billion). Extrapolating from studies conducted in other countries where social costs amounted to 75% of total costs, it can be considered that alcoholism in France costs more than 80 billion francs ($12.7 billion) a figure exceeding 1% of the GNP.

Six deaths linked to concomitant use of buprenorphine and benzodiazepines

AIMS

Buprenorphine at high dosage became available in 1996 for substitution treatment in France. This drug is considered particularly safe and has become widely available in general medical practice. We investigated the possible implication of a buprenorphine-benzodiazepine association in six deaths of known abusers.

DESIGN

Full investigation of cause of death was conducted for six drug abusers.

SETTING

The deaths occurred in two regions of France (Auvergne and Lorraine). Assays were carried out by the Institut de Medecine Legale at Strasbourg, France, one of the few French laboratories equipped to assay buprenorphine.

MEASUREMENT

First, the blood and urine underwent triple exhaustive screening. Secondly, buprenorphine and norbuprenorphine were analysed in all the autopsy samples by HPLC/MS.

FINDINGS

Benzodiazepine-buprenorphine associations were found in every case; no other substances that could account for the death were found. The tissue concentrations were markedly higher than the blood levels.

CONCLUSION

If the number of deaths linked to such drug misuse proves high, it may be necessary to review how buprenorphine is dispensed.

Usefulness of carbohydrate-deficient transferrin in alcoholic patients with normal gamma-glutamyltranspeptidase

The biological diagnosis of alcoholism is conducted routinely by assay of gamma-glutamyltranspeptidase (GGT) and mean corpuscular volume (MCV). However, their low specificity and sensitivity have prompted research to find other more reliable parameters. Stibler showed an increase in desialylated transferrin [carbohydrate-deficient transferrin (CDT)] in alcoholic patients. The normal value of the serum CDT concentration is under 60 mg/liter; a value between 60 and 100 mg/liter indicates probable alcoholism, and a value > 100 mg/liter indicates a very high probability of alcoholism (specificity: 99%). Its sensitivity ranges from 60 to 91%, and its specificity ranges from 92 to 100%. Its half-life is 17 +/- 4 days. CDT is thus a useful laboratory marker, but its assay is costlier and more complex than that of GGT. This study concerns 31 alcohol-dependent patients as defined by DSM-IV, with GGT levels in the normal range. It evaluates CDT at day 0 and its time course after 15 days withdrawal. GGT and MCV were assayed concomitantly. Remarkably, the results show a sensitivity of 83.9 (26 positives of 31) in this particular population and a specificity of 92.2. The fall in CDT after 15 days withdrawal was 36%. CDT is thus a particularly useful marker for the diagnosis and follow-up of alcoholics with normal GGT levels.

Alcohol use disorders in French hospital patients

The prevalence of alcohol use disorders in hospital patients was studied in all the hospitals of one area of France. Alcohol disorders were diagnosed by the head nurse or a physician in the hospital where the patient was being attended, and by means of the CAGE self-questionnaire. This descriptive survey, carried out on one particular day, concerned 7626 patients. The prevalence of alcohol disorders was 18%, whereas only 6% of the admissions were for alcohol-related pathologies. Prevalences were 25% in men and 7% in women, 10% in persons aged under 25 years and 43% in men aged between 36 and 55 years. In all, one patient in two was diagnosed directly, though only one in four in the age range under 25 years. These results suggest that too few patients with alcohol use disorders are identified in hospitals, especially in certain age groups and certain types of ward.

[Comparison between iopamidol and ioxaglate in digital arteriography of the lower limbs]

This prospective study concerning 100 subtraction angiographies of the lower limbs compared two iodine concentrations of iopamidol (300 and 370 mg l/l) and ioxaglate (320 and 350 mg l/l). More pain and movements disturbed the subtraction with iopamidol 370 in comparison with ionic contrast media (p < 0.005). The quality of the contrast was better with ioxaglate 350 (p = 0.05) than with the others. This one appears to be a good compromise for this type of examination.