Alcohol screening in general practices using the AUDIT: how many response categories are necessary?

AIMS

The Alcohol Use Disorders Identification Test (AUDIT) is a common screening instrument. This study analyses if response categories of the AUDIT might be dichotomized without affecting the psychometric properties of the questionnaire.

METHODS

Participants between 18 and 65 years were recruited from general practices in two northern German cities. In total, 10,803 screenings were conducted (refusal rate: 5.9%). For those who were screened positive, the Munich-Composite International Diagnostic Interview (M-CIDI) was used for identification of 12-month Alcohol Use Disorders and at-risk consumption (exceeding 20/30 g per day). Abstinent subjects and screening positives without diagnostic interview were excluded from the analysis, leaving a sample of 7,112 subjects. ROC-Curves were calculated separately for each item in order to identify an optimal cut-off value. Finally, a version of the AUDIT based on dichotomized items was compared to the original version and its short-form, the AUDIT version based on three questions dealing with consumption AUDIT-C.

RESULTS

As an optimal cut-off value for items on consumption, drinking at least once a week, having more than 1-2 drinks per occasion, and drinking 6 or more drinks in one sitting at least once a month were identified. For all questions on alcohol-related problems or dependence symptoms, having 'ever occurred' differed best between subjects with and without Alcohol Use Disorders or at-risk consumption. Sensitivity and specificity of the dichotomized version of the AUDIT did not differ from the original version, and both full versions performed superior compared to the AUDIT-C.

CONCLUSION

Data indicate that the AUDIT response categories may be dichotomized without affecting its validity.

Susceptibility to diphtheria in adults: prevalence and relationship to gender and social variables

Recent outbreaks of diphtheria have drawn attention to the re-emergence of this disease. This study investigated susceptibility to diphtheria in north-east Germany and its relationship to gender and social factors. A study population of 4275 individuals recruited for the population-based Study of Health in Pomerania (SHIP) was available for analysis. IgG antibodies against diphtheria toxin were determined by ELISA and were used to define susceptibility to diphtheria (i.e., IgG titres < 0.1 IU/mL). The prevalence of susceptibility to diphtheria was 32.4%. Multivariate analysis revealed 45% increased odds of women being susceptible to diphtheria. Women who had not received diphtheria toxoid vaccination during the previous 10 years had four-fold increased odds of being susceptible to diphtheria toxin compared with unvaccinated men. None of the social factors investigated was associated with susceptibility status. It was concluded that a high proportion of middle-aged adults was susceptible to diphtheria. Women lacked seroprotection more often than men, which might be explained, in part, by gender-specific immune responses following vaccination. There is a need for information campaigns to improve public awareness of these problems.

[Smoking behavior in adolescents: a comparison of population-representative, regional or selectively assessed data and implications for prevention]

INTRODUCTION

The prevalence of adolescent smoking underlines the necessity of preventive measures, which goals are based on representative data. It is not known whether schools participate in prevention interventions, where smoking constitutes a relatively big or minor problem.

OBJECTIVE

This study examines a population of adolescents on (a) different smoking variables and (b) compares them with representative, population based data.

METHODS

Survey of n = 324 adolescents of grade 7-10 in 3 schools in Greifswald and surroundings that were ready to participate in a prevention curriculum.

RESULTS

In total, 80% of the students under examination indicated to have at least tried smoking in their lifetime. Daily smokers were 31%, 18% were occasional smokers, 39% have indicated that they hat tried to quit without success. These figures vary across age, grade and sex. Smoking prevalence is comparable between schools ready to participate in prevention and regionally assessed data, but much higher than population based data would have estimated.

CONCLUSION

The goal of preventive measures can not be solely grounded on representative, population-based data, but needs (a) to be regionally defined and (b) to consider the population actually participating in such prevention interventions. The readiness to participate is not higher in schools where smoking constitutes a comparable minor problem. Preventive measures are applied in schools where the problem is perceived.

[Why woman postpartum resume smoking]

BACKGROUND

Following a successful period of nicotine abstinence during pregnancy approximately 50% of all women relapse to smoking during the 6 months after delivery. About 34% of all children are exposed to environmental tobacco smoke due to maternal smoking. The objectives of this study are: (a) which women postpartum intend to start smoking again, (b) how does the intention to resume smoking influence the smoking status after 6 months and (c) what are the individual reasons to start smoking again.

METHOD

Four weeks after giving birth (T0) sociodemographic variables, smoking behaviour before pregnancy and the intention to resume smoking were assessed in a sample of 301 women who stopped smoking before or during pregnancy. Six months after giving birth (T1) 285 women answered questions regarding their smoking behaviour and reasons for relapse.

RESULTS

After giving birth 13% of the women intended to start smoking again. There was no statistical difference between women intending to start and women not intending to start smoking again with regard to sociodemography and smoking behaviour (p > 0.05). Six months later of these significantly more women smoked compared to the women without intention to resume smoking (68% vs. 27%, chi2 = 23.6; df = 1, p < 0.05, OR = 5.5). Individual reasons to resume smoking were reported by 50 % of the women, stress being the most frequent reason.

DISCUSSION

At least one of ten women who were abstinent during the course of their pregnancy intends to start smoking again. They do not differ from women not intending to resume smoking. The intention to resume smoking has a predictive value for an early relapse, but also every fourth woman without intention resumes smoking. Just half of the women report a personal reason for relapsing. The results underline the need for proactive interventions for relapse prevention.

Inverse association between periodontitis and respiratory allergies

BACKGROUND

Periodontitis is an infection with systemic effects and a high prevalence among adults. In the aetiology of allergic diseases the hygiene hypothesis claims that infections in early infancy may protect against allergic diseases.

OBJECTIVE

The aim of the present analyses was to investigate the independent relation between periodontitis and respiratory allergies such as hayfever, house dust mite (HDM) allergy and asthma.

METHODS

From the Study of Health in Pomerania (SHIP) a total number of 2837 subjects aged 20 to 59 years were included in the analysis. In our study population 326, 111 and 114 subjects were classified as suffering from hayfever, HDM allergy or asthma, respectively. The attachment loss (AL) were measured. Periodontitis was defined according to the percentage of surfaces which exceeded 3 mm AL [healthy: 0-7.7%, mild: 7.8-28.6%, moderate: 28.7-63.9%, severe: >63.9%]. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression.

RESULTS

After adjustment for confounding factors these analyses revealed inverse associations between periodontitis and hayfever as well as periodontitis and HDM allergy. For increasing AL, a trend of decreasing risk could be observed for hayfever (healthy: reference; mild AL: OR 0.87 [95%-CI 0.6-1.2]; moderate AL: OR 0.80 [95% CI 0.6-1.2]; server AL: OR 0.53 [95% CI 0.3-0.9]; P(trend)=0.01) and for HDM allergy (healthy: reference; mild AL: OR 0.80 [95% CI 0.5-1.3]; moderate AL: OR 0.64 [95% CI 0.3-1.2]; server AL: OR 0.39 [95% CI 0.2-0.9]; P(trend)=0.02). Furthermore, for asthma were observed a slightly inverse association in the full-adjusted model (healthy: reference; mild AL: OR 1.10 [95% CI 0.6-2.0]; moderate AL: OR 0.96 [95% CI 0.5-1.8]; server AL: OR 0.48 [95% CI 0.2-1.0]; P(trend)=0.11).

CONCLUSION

There is an inverse association between periodontitis and respiratory allergies. Our results might support the hygiene hypothesis.

Association between cardiac disorders and a decades-previous history of diphtheria

A long, prior history of diphtheria is common among middle-aged and elder European adults. The aim of the present study was to determine whether the risk of reduced ventricular function and impaired intraventricular conduction is increased in individuals with a history of diphtheria. A study population of 2,480 subjects (1,222 women) aged 45 years or older who were recruited for the Study of Health in Pomerania were available for the present analyses. Left ventricular function was assessed by echocardiography. Intraventricular conduction blocks were diagnosed using electrocardiograms. Multivariable analyses revealed that individuals with a history of diphtheria had neither an increased odds for reduced fractional shortening (OR 1.21, 95% CI 0.69-2.11; p=0.51) nor an increased odds for intraventricular conduction blocks (OR 0.90, 95% CI 0.55-1.46; p=0.67). However, regression models revealed two-way interactions between the exposure variable and hypertension with respect to both endpoints. A history of diphtheria increased the odds for both endpoints in normotensive but not in hypertensive individuals. The findings show that a history of diphtheria several decades previously in a patient is a risk marker for reduced cardiac function and impaired intraventricular conduction in individuals at low risk for these disorders.

Blood pressure, renal function, and proteinuria in children with unilateral renal agenesis

BACKGROUND/AIM

Unilateral renal agenesis (URA) is a model for a reduced nephron number that is believed to be a risk factor for blood pressure (BP) elevation and reduced renal function. The aim of the study was to investigate BP and renal function in children with URA.

METHODS

Data on children with URA from two pediatric nephrology centers were firstly retrospectively reviewed (renal ultrasound and scintigraphy, clinical BP, creatinine clearance, urinalysis). Children with normal renal ultrasound and scintigraphy were thereafter investigated using ambulatory BP monitoring.

RESULTS

Twenty-nine children with URA were investigated--14 children with an abnormal kidney (mostly scarring) and 15 children with healthy kidneys. Hypertension was diagnosed on the basis of clinical BP in 57% of the children with abnormal kidneys and on the basis of ambulatory BP monitoring in 1 child (7%) with healthy kidneys. The mean ambulatory BP in children with normal kidneys was not significantly different from that in controls. Forty-three percent of the children with abnormal kidneys had a reduced renal function, but none of children with normal kidneys.

CONCLUSIONS

Children with abnormalities of a solitary kidney have often hypertension, proteinuria, or a reduced renal function. In contrast, children with healthy solitary kidneys have BP and renal function similar to those of healthy children.

High prevalence of febrile urinary tract infections after paediatric renal transplantation

BACKGROUND

Adult data suggest that urinary tract infections occur frequently after renal transplantation (RTx) and contribute to mortality and graft loss; data in children are limited. Therefore, we evaluated prevalence, short and long-term morbidity and confounding factors of febrile UTI (fUTI) after paediatric RTx.

METHODS

In a retrospective cross-sectional study of three centres, we analysed data on 110 children followed for 4.9+/-3.4 years after successful transplantation.

RESULTS

40/110 (36%) patients had at least one fUTI at a median time of 0.98 years (range 0.02-8.96) after RTx; 11 patients (28%) had recurrent fUTI. Serum creatinine (SCr) rose significantly from 1.15+/-1.13 to 1.83+/-1.69 mg/dl, (P<0.001) during the fUTI, declining to baseline values after treatment. At the last followed-up calculated mean, GFR was comparable between fUTI and non-fUTI groups (75+/-26 vs 71+/-22 ml/min/1.73 m2). During fUTI mean, C-reactive protein (CRP) increased to 123+/-75 mg/l. Febrile UTI were significantly more frequent in girls compared to boys (22/44 vs 18/66, P<0.05) but occurred significantly earlier in boys than in girls [median 0.63 (range 0.02-4.15) vs 1.07 (0.04-8.96) years after RTx; P<0.02]. Also, patients with urinary tract malformations (UTMs) and neurogenic bladder as underlying diagnosis and those with urological surgery prior to transplantation had an increased risk for fUTI.

CONCLUSION

fUTI is a frequent complication with significant short-term morbidity especially in girls and children with UTMs, neurogenic bladder and those with urological surgery. Long-term follow-up and prospective studies confirming specific risk factors, preventive measures and impact on graft survival are necessary.

[Characteristics of risk groups with an insufficient demand for dental services - results of the study of health in Pomerania (SHIP)]

AIM

The purpose of this study was to identify risk groups for low dental care utilisation and to highlight adequate determinants for necessary action.

METHODS

The database was the "Study of Health in Pomerania" (SHIP), a cross-sectional sample drawn from the adult population (20 - 79 years) in a northeast region of Germany. 4310 of 7008 randomly selected inhabitants participated in the examinations (response rate 68.8 %). The use of dental care in the last year was analysed using logistic regression according to the conceptual model by Andersen and Newman.

RESULTS

Multivariate analysis revealed that participation in the bonus scheme system of the statutory sickness funds (OR = 8.2) and participation in the bonus system of the private health insurance companies (OR = 2.6) as "enabling resources" predicted dental care use in the last year. "Objektive need" (OR = 1.02) is weaker associated with dental care utilisation than "subjective need", for instance the attitude towards need of regular dental checkups. Presence of own teeth is a significant predictor for dental care utilization (OR = 3.3), whereas edentulous persons, those with complete denture prosthesis, don't think about possible oral problems and don't visit the dentist at least once a year. Among "predisposing factors" only gender and education were significant determinats for dental care utilization.

CONCLUSIONS

The conclusions concerning the significant influence of subjective need and promotional impact of the bonus scheme are important for health care. Financial incentives and motivation for regular prevention should be continued and upgraded. Measures to improve preventive dental care utilization should focus on persons with low educational levels and on men with inadequate dental care utilisation. The mental anchorage of the term "oral health" rather than the conventional term "dental health" is important, so that edentulous persons become conscious of regular prevention pointers to maintain a high quality of life.

Krankenhauspatienten mit riskantem Alkoholkonsum sind offen für Beratung

AIMS

The aim of this study was to determine predictors for openness to alcohol-related counselling among general hospital patients with alcohol problems. We wanted to test whether those with less severe alcohol problems and those with a lack of motivation for behaviour charge or with a lack of motivation to seek help would agree to participate in alcohol-related counselling.

METHOD

A total of 1150 hospital patients with alcohol dependence, alcohol abuse, at-risk drinking or excessive drinking were interviewed. They were asked about their attitude towards alcohol-related counselling, about their motivation to change their drinking and about their motivation to seek professional help. A multi-variable logistic regression analysis was calculated to determine predictors for agreement to counselling.

RESULTS

A total of 66 % of all participants agreed to receive information on professional help and on how they could help themselves. Among these were 77 % of the alcohol dependent participants and 56 % of the non-dependent participants. Motivation to change and motivation to seek help were identified as the most significant predictors for agreement to counselling. However, 63 % of the participants open for counselling were not yet ready to change their habits and 62 % were not yet ready to seek profession help.

CONCLUSION

The majority of hospital patients with less severe alcohol problems as well as the majority of hospital patients not ready to seek more intensive professional help were open for alcohol-related counselling. Given a systematic screening, this opens up the opportunity for addiction counsellors, hospital physicians or nurses to actively offer counselling.

Epidemiological evaluation of the multifactorial aetiology of abfractions

The purpose of this study was to determine risk indicators for the aetiology of abfractions (cervical wedge-shaped defects) on teeth using dental and medical variables obtained in a population-based sample of the cross-sectional epidemiological 'Study of Health in Pomerania' (SHIP). Medical history, dental, and sociodemographic parameters of 2707 representatively selected subjects 20-59 years of age with more than four natural teeth were checked for associations with the occurrence of abfractions using a two-level logistic regression model on a tooth and a subject level. The estimated prevalence of developing abfractions generally increased with age. The following independent variables were associated with the occurrence of abfractions: buccal recession of the gingiva, odds ratio (OR) = 6.7; occlusal wear facets of scores 1, 2 and 3, OR = 1.5, 1.9, 1.9; tilted teeth, OR = 1.4; inlays, OR = 1.6; toothbrushing behaviour, OR = 1.9 to 2.0 (two and three times a day versus once a day). First premolars had the highest estimated risk for developing abfractions, followed by the second premolars. Maxillary and mandibular teeth behaved similarly in terms of abfractions, with the exception of mandibular canines, which had a much lower estimated risk of incurring abfractions than did maxillary canines. The results of this analysis indicated that abfractions are associated with occlusal factors, like occlusal wear, inlay restorations, altered tooth position and tooth brushing behaviour. This study delivers further evidence for a multifactorial aetiology of abfractions.

Post-partum intention to resume smoking

Little is known about the motivational background of smoking after a period of nicotine abstinence during pregnancy. The study examines the intention to resume smoking (IRS) in the post-partum period and its predictive value for smoking within 12 months post-partum. In a sample of 301 women recruited from obstetric wards who reported having stopped smoking during pregnancy, data on IRS, sociodemographic variables, recent smoking behaviour and smoking in the social network were collected. Smoking status was assessed 6 and 12 months after pregnancy. Among all formerly smoking women, 39 (13%) intended to resume smoking and 262 (87%) intended to maintain abstinence. Women with IRS returned to smoking more often than women without IRS [77 versus 45%, odds ratio (OR) = 4.1, 95% confidence interval (CI): 1.89-9.05]. In a logistic regression model, IRS (OR = 3.7, 95% CI: 1.51-9.01) and number of months currently abstinent (OR = 0.9, 95% CI: 0.76-0.96) attained statistical significance. IRS proved to be the main predictor for relapse; yet, women with no IRS are at risk to restart smoking again, too. IRS offers a cue for tailoring interventions.

Smoking status, obesity and hypertension in a general population sample: a cross-sectional study

BACKGROUND

In some studies, hypertension is more common in never and former smokers than in current smokers.

AIM

To examine the associations between hypertension and smoking status, when divided into subgroups by overweight and obesity.

DESIGN

Cross-sectional study.

METHODS

We used data from a national health survey with a probability sample of the national population of Germany aged 18 to 79 (n = 6903 with complete data). Smoking status data were collected via questionnaire. Obesity and overweight were assessed by body mass index, hypertension by blood pressure measurement and by participants' statements about antihypertensive treatment. Analyses were adjusted for gender, age, history of coronary artery disease, serum cholesterol levels, alcohol drinking, exercise, and education.

RESULTS

Obese former smokers who were abstinent for 3 or more years had an adjusted odds ratio (OR) 3.6 (95% confidence interval, CI 2.3-5.7) for mild hypertension (> or =140 mmHg systolic or > or =90 mmHg diastolic blood pressure) and an adjusted OR 6.5 (95%CI 3.6-11.8) for moderate or severe hypertension (> or =160 mmHg systolic or > or =100 mmHg diastolic). Normal weight never or former smokers did not differ from normal weight current smokers smoking > or =15 cigarettes/day with regard to likelihood of hypertension (normal weight never smokers, OR 1.1, 95%CI 0.8-1.5; normal weight former smokers, abstinent 3 or more years, OR 0.8, 95%CI 0.5-1.3).

DISCUSSION

In this nationally representative sample, never or former smoking was unrelated to hypertension among normal weight individuals.

A randomized crossover trial comparing sevelamer with calcium acetate in children with CKD

BACKGROUND

A multicenter, randomized, open-label, crossover study was performed to compare the efficacy and safety of sevelamer, a calcium-free phosphate binder, with calcium acetate in pediatric patients with chronic kidney disease (CKD).

METHODS

Children (age, 0.9 to 18 years) with CKD undergoing hemodialysis or peritoneal dialysis or with a glomerular filtration rate of 20 or greater and less than 60 mL/min/1.73 m2 (> or = 0.33 and < 1.00 mL/s/1.73 m2) were randomly assigned to the following treatment scheme: 2 weeks of washout followed by 8 weeks of treatment with either sevelamer or calcium acetate in a crossover fashion. Phosphorus, calcium, and intact parathyroid hormone in serum were measured every 2 weeks, and phosphate binder dosages were adjusted, if needed. Serum lipid and vitamin concentrations were measured at the beginning and end of each treatment period. The primary end point was the decrease in serum phosphorus levels after 8 weeks of treatment.

RESULTS

Forty-four patients were screened. Altogether, data for 18 patients (5 girls) aged 12.4 +/- 4.1 years were used for the crossover analysis. There was no significant difference in serum phosphorus levels at 8 weeks after the start of treatment in both groups. Total cholesterol (-27%) and low-density lipoprotein cholesterol (-34%) levels decreased significantly with sevelamer treatment (P < 0.02 and P < 0.005). An increased incidence of hypercalcemia (P < 0.0005) was observed with calcium acetate treatment, whereas metabolic acidosis was more frequent with sevelamer treatment (P < 0.005).

CONCLUSION

Treatment of children with CKD with sevelamer and calcium acetate provides similar phosphorus level control. The marked decrease in lipid levels and lower rate of hypercalcemia may augment the long-term benefit of sevelamer.

Evaluation of single nucleotide polymorphisms in the phosphodiesterase 4D gene (PDE4D) and their association with ischaemic stroke in a large German cohort

Genetic fine mapping of the first locus identified for genetically complex forms of stroke, STRK1 (which has been mapped to chromosome 5q12 in Icelandic families), has identified the phosphodiesterase 4D gene (PDE4D) gene as a good candidate gene. Association analysis of single nucleotide polymorphisms (SNPs) in the PDE4D gene in an Icelandic stroke cohort demonstrated genetic association between six SNPs in the 5' region of PDE4D and ischaemic stroke. The present study aimed to test whether the same six SNPs in PDE4D were also associated with stroke in a large stroke cohort from northern Germany (stroke patients with acute completed ischaemic stroke: n = 1181; population based controls: n = 1569). None of the six SNPs showed significant association with ischaemic stroke in the whole stroke sample before and after adjustment for conventional stroke risk factors (age, sex, hypertension, diabetes, and hypercholesterolaemia). Haplotype analysis did also not reveal any significant association. Marginally positive statistical measures of association in the subgroup with cardioembolic stroke did not remain significant after correction for multiple testing. In conclusion, this study was unable to demonstrate an association between the six SNPs which had showed significant single marker association with stroke in the Icelandic stroke cohort and ischaemic stroke in a large German cohort.

Associations of perceived work strain with nicotine dependence in a community sample

BACKGROUND

Little is known about work strain and smoking, and even less about work strain and nicotine dependence.

AIM

To investigate the relations of perceived work strain with nicotine dependence among an adult general population sample.

METHOD

Cross sectional survey with a probability sample of residents of a northern German area with 4075 participants, aged 18-64 years (participation rate 70.2%). The current study is based on 2549 participants who were working 15 or more hours per week. Face to face at-home computer aided interviews (World Health Organization Composite International Diagnostic Interview) were carried out. Work strain, defined as high work demand and low work control, was assessed with a questionnaire. Nicotine dependence was diagnosed according to the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association. In addition, the Fagerström Test for Nicotine Dependence (FTND) was used.

RESULTS

Subjects with work strain had an odds ratio of 1.6 (95% CI 1.2 to 2.3) for nicotine dependence compared to those who had no work strain. In a general linear model, higher work strain was associated with a stronger relation between work demand and work control and the FTND. The findings were adjusted for alcohol use disorders, occupational status, age, and sex.

CONCLUSION

Perceived work strain is related to nicotine dependence in this general adult population.