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Lim N, Leventhal TM, Thomson MJ, Hassan M, Thompson J, Adams A, Chinnakotla S, Humphreville V, Kandaswamy R, Kirchner V, Pruett TL, Schuller L, McCarty M, Lake J. Protocolized screening and detection of occult alcohol use before and after liver transplant: Lessons learned from a quality improvement initiative. Clin Transplant 2023; 37:e15036. [PMID: 37218656 DOI: 10.1111/ctr.15036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 05/09/2023] [Accepted: 05/13/2023] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Detection of alcohol (ETOH) use with biomarkers provides an opportunity to intervene and treat patients with alcohol use disorder before and after liver transplant (LT). We describe our center's experience using urine ethyl glucuronide (EtG) and serum phosphatidylethanol (PEth) in alcohol screening protocols. METHODS Single-center, retrospective review of patients presenting for LT evaluation, patients waitlisted for LT for alcohol-associated liver disease (ALD), and patients who received a LT for ALD over a 12-month period, from October 1, 2019 through September 30, 2020. Patients were followed from waitlisting to LT, or for up to 12 months post-LT. We monitored protocol adherence to screening for ETOH use- defined as completion of all possible tests over the follow-up period- at the initial LT visit, while on the LT waitlist and after LT. RESULTS During the study period, 227 patients were evaluated for LT (median age 57 years, 58% male, 78% white, 54.2% ALD). Thirty-one patients with ALD were placed on the waitlist, and 38 patients underwent LT for ALD during this time period. Protocolized adherence to screening for alcohol use was higher for PEth for all LT evaluation patients (191 [84.1%] vs. 146 [67%] eligible patients, p < .001), in patients with ALD waitlisted for LT (22 [71%] vs. 14 (48%] eligible patients, p = .04) and after LT for ALD, 20 (33 [86.8%] vs. 20 [52.6%] eligible patients, p < .01). Few patients with a positive test in any group completed chemical dependency treatment. CONCLUSIONS When screening for ETOH use in pre- and post-LT patients, protocol adherence is higher using PEth compared to EtG. While protocolized biomarker screening can detect recurrent ETOH use in this population, engagement of patients into chemical dependency treatment remains challenging.
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Affiliation(s)
- N Lim
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - T M Leventhal
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - M J Thomson
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - M Hassan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - J Thompson
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - A Adams
- Division of Transplant Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - S Chinnakotla
- Division of Transplant Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - V Humphreville
- Division of Transplant Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - R Kandaswamy
- Division of Transplant Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - V Kirchner
- Division of Abdominal Transplantation, Stanford University, Palo Alto, California, USA
| | - T L Pruett
- Division of Transplant Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - L Schuller
- University of Minnesota Physicians, Minneapolis, Minnesota, USA
| | - M McCarty
- Complex Care Analytics, Fairview Health Services, Minneapolis, Minnesota, USA
| | - J Lake
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
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Back SE, Flanagan JC, Killeen T, Saraiya TC, Brown DG, Jarnecke AM, Rothbaum AO, Joseph J, Ana ES, de Arellano A, Shoemaker HL, Dixon RA, Nietert PJ, Brady KT. COPE and oxytocin for the treatment of co-occurring PTSD and alcohol use disorder: Design and methodology of a randomized controlled trial in U.S. military veterans. Contemp Clin Trials 2023; 126:107084. [PMID: 36646315 PMCID: PMC9998357 DOI: 10.1016/j.cct.2023.107084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND A significant proportion of individuals with alcohol use disorder (AUD) also meet criteria for posttraumatic stress disorder (PTSD). Military veterans are at increased risk for developing co-occurring AUD/PTSD, with prevalence rates 2-4 times higher than the general population. Research is needed to develop more effective treatments for this common comorbidity. The current investigation addresses this need by examining the synergistic effects of a novel pharmacotherapy combined with psychotherapy for co-occurring AUD/PTSD among veterans. Accumulating evidence suggests that the neuropeptide oxytocin (OT) is a promising pharmacotherapy to augment psychotherapy for AUD/PTSD. OT targets neurobiological and behavioral dysregulation common to both AUD and PTSD, in particular, corticolimbic connectivity. Human and animal studies show OT reduces alcohol self-administration, tolerance, and withdrawal; enhances fear extinction; and promotes prosocial behaviors. The current study builds on previous work by examining OT among veterans with AUD/PTSD receiving Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE), an evidence-based integrated treatment. METHODS This paper describes the rationale, design, and methodology of a Stage II, 12-week, double-blind, randomized clinical trial of intranasal OT (40 IU) versus placebo combined with COPE among veterans (N = 180) with current AUD/PTSD. In addition, the effects of treatment on corticolimbic connectivity will be examined using functional magnetic resonance imaging (fMRI) at pre- and post-treatment. CONCLUSIONS The proposed study will provide new knowledge and mechanistic insights to accelerate research in this understudied area and may lead to improved treatment outcomes for co-occurring AUD/PTSD. CLINICALTRIALS gov: NCT04523922.
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Affiliation(s)
- Sudie E Back
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
| | - Julianne C Flanagan
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Therese Killeen
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Tanya C Saraiya
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Delisa G Brown
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Amber M Jarnecke
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Alex O Rothbaum
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jane Joseph
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Elizabeth Santa Ana
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Abigail de Arellano
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Hannah L Shoemaker
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Reagan Ashley Dixon
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Paul J Nietert
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kathleen T Brady
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
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3
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Nielsen DG, Andersen K, Nielsen AS, Nielsen F, Behrendt S, Bilberg R, Bogenschutz M, Bühringer G, Mellentin AI. Comparison of self-reported alcohol consumption and ethyl glucuronide in hair in a sample of 60+ year -olds treated for DSM-5 alcohol use disorder. Addict Biol 2022; 27:e13231. [PMID: 36301220 PMCID: PMC9786874 DOI: 10.1111/adb.13231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 07/17/2022] [Accepted: 08/26/2022] [Indexed: 01/24/2023]
Abstract
There is a lack of evidence for the consistency between self-reported alcohol consumption (SRAC) and concentrations of ethyl glucuronide in hair (hEtG) among elderly patients treated exclusively for alcohol use disorder (AUD). Hence, this study assessed the consistency between these two measures in these patients. A total of 190 patients with AUD were assessed for SRAC using Form 90 and hEtG, 14 or 22 weeks after treatment conclusion. Patients were grouped according to SRAC (g/day) and corresponding hEtG concentrations (pg/mg): 0 and <5 (abstinence), 0.1-14.3 and 5.0-9.9 (low consumption), 14.4-21.4 and 10.0-15.9 (moderate consumption), 21.5-59.9 and 16.0-30 (high consumption) and ≥60 and >30 (excessive consumption). The extent of underreporting and overreporting was examined by crosstabulations, and inter-rater reliability was reported by kappa correlations. Associations and effect modification were examined by conditional logistic regression. Due to multitesting, p-values ≤0.01 were considered significant. Underreporting was found in 96 patients (50.5%) and overreporting in 41 patients (21.6%). The kappa coefficients varied between 0.19 and 0.34. HEtG was more likely to detect low, moderate and high alcohol consumption compared with SRAC (ORs between 5.1 and 12.6, all p-values <0.01), but SRAC and hEtG did not differ significantly with respect to identification of abstinence (OR = 1.9, p = 0.05). Inconsistency between the outcome measures was found in a considerable number of the patients. More studies examining the consistency between SRAC and specific direct biomarkers of alcohol in this population seem warranted.
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Affiliation(s)
- Dorthe Grüner Nielsen
- Unit for Clinical Alcohol Research, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Kjeld Andersen
- Unit for Clinical Alcohol Research, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark,BRIDGE, Brain Research, Inter‐Disciplinary Guided Excellence, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark,Open, Odense Patient data Explorative NetworkOdense University HospitalOdenseDenmark
| | - Anette Søgaard Nielsen
- Unit for Clinical Alcohol Research, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark,BRIDGE, Brain Research, Inter‐Disciplinary Guided Excellence, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Flemming Nielsen
- Environmental Medicine, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Silke Behrendt
- Unit for Clinical Alcohol Research, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark,Institute for PsychologyUniversity of Southern DenmarkOdenseDenmark
| | - Randi Bilberg
- Unit for Clinical Alcohol Research, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Michael Bogenschutz
- NYU Grossman School of MedicineNew York CityNew YorkUSA,Health Sciences CenterUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Gerhard Bühringer
- Unit for Clinical Alcohol Research, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark,Institute of Clinical Psychology and PsychotherapyTechnische Universität DresdenDresdenGermany,IFT Institut für TherapieforschungMunichGermany
| | - Angelina Isabella Mellentin
- Unit for Clinical Alcohol Research, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark,BRIDGE, Brain Research, Inter‐Disciplinary Guided Excellence, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark,Tele‐Psychiatric Center, Region of Southern DenmarkOdenseDenmark
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4
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Staufer K, Huber-Schönauer U, Strebinger G, Pimingstorfer P, Suesse S, Scherzer TM, Paulweber B, Ferenci P, Stimpfl T, Yegles M, Datz C, Trauner M. Ethyl glucuronide in hair detects a high rate of harmful alcohol consumption in presumed non-alcoholic fatty liver disease. J Hepatol 2022; 77:918-930. [PMID: 35605744 DOI: 10.1016/j.jhep.2022.04.040] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 03/05/2022] [Accepted: 04/21/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Non-alcoholic fatty liver disease (NAFLD) and alcohol-related liver disease (ALD) cannot reliably be distinguished by routine diagnostics, and the role of alcohol consumption in metabolic dysfunction-associated fatty liver disease (MAFLD) remains unclear. We investigated alcohol consumption in patients with presumed NAFLD and ALD using novel objective alcohol markers. METHODS In total, 184 consecutive patients were included in this prospective observational study. Alcohol intake was assessed by ethylglucuronide in hair (hEtG) and urine (uEtG); the utility of these measures for alcohol detection was compared to Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), carbohydrate deficient transferrin (CDT), mean corpuscular volume (MCV), gamma-glutamyltransferase (GGT), and ALD/NAFLD index (ANI). Clinical characteristics of patients with NAFLD and ALD were re-assessed after reclassification based on repeated moderate (≥10 g <60 g EtOH/day) and excessive (≥60 g EtOH/day) alcohol consumption, and patients were retrospectively reclassified based on MAFLD criteria. RESULTS Repeated moderate to excessive alcohol consumption was detected in 28.6%, 28.5%, and 25.0% of patients with presumed NAFLD, ALD or MAFLD, respectively. ANI score, AUDIT-C, uEtG, and hEtG showed AUCs of 0.628, 0.733, 0.754, and 0.927 for the detection of repeated moderate to excessive alcohol consumption, respectively. The indirect markers CDT, MCV and GGT were not reliable. Patients with repeated moderate or excessive alcohol consumption were significantly more often male, had a significantly lower BMI, and suffered significantly less often from type 2 diabetes or impaired glucose tolerance. CONCLUSIONS In total, 28.6% of patients with presumed NAFLD, and 25.0% with MAFLD are at risk of alcohol-related liver damage. AUDIT-C, uEtG and hEtG should be used to screen for alcohol consumption in patients with fatty liver disease. LAY SUMMARY Fatty liver disease can be caused by metabolic factors and/or alcohol consumption. The diagnosis of non-alcoholic fatty liver disease (NAFLD) is based on the exclusion of harmful alcohol consumption, while metabolic dysfunction-associated fatty liver disease (MAFLD), which has been proposed as a new name for NAFLD, is based on the presence of metabolic comorbidities and allows for alcohol consumption. Herein, we show that up to 29% of patients diagnosed with NAFLD and 25% with MAFLD are at risk of alcohol-related liver damage. We show that ethyl glucuronide (a metabolite of alcohol) in the hair and urine can accurately detect potentially harmful alcohol consumption in these patients - as such, these tests should be integrated into routine diagnostic work-up for patients with fatty liver disease.
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Affiliation(s)
- Katharina Staufer
- Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria; Department of General Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria.
| | - Ursula Huber-Schönauer
- Department of Internal Medicine, Krankenhaus Oberndorf, Teaching Hospital of the Paracelsus Private Medical University of Salzburg, Oberndorf, Austria
| | - Georg Strebinger
- Department of Internal Medicine, Krankenhaus Oberndorf, Teaching Hospital of the Paracelsus Private Medical University of Salzburg, Oberndorf, Austria
| | - Philipp Pimingstorfer
- Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria; Department of Internal Medicine 2 for Nephrology, Endocrinology, Rheumatology, and Gastroenterology, Johannes Kepler University Linz, Med Campus III, Linz, Austria
| | | | | | - Bernhard Paulweber
- First Department of Medicine, Paracelsus Private Medical University of Salzburg, Salzburg, Austria
| | - Peter Ferenci
- Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria
| | - Thomas Stimpfl
- Department of Laboratory Medicine, Division of Toxicology, Medical University of Vienna, Vienna, Austria
| | - Michel Yegles
- Laboratoire National de Santé, Service de Toxicologie médico-légale, Dudelange, Luxembourg
| | - Christian Datz
- Department of Internal Medicine 2 for Nephrology, Endocrinology, Rheumatology, and Gastroenterology, Johannes Kepler University Linz, Med Campus III, Linz, Austria
| | - Michael Trauner
- Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria
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5
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Grottenthaler JM, Konzelmann A, Stiegler A, Hinterleitner C, Bott SM, Klag T, Werner CR, Hinterleitner M, Königsrainer A, Batra A, Malek NP, Nadalin S, Berg CP. Significance and clinical impact of routinely tested urinary ethyl glucuronide after liver transplantation - development of a risk score. Transpl Int 2021; 34:2257-2265. [PMID: 34358363 DOI: 10.1111/tri.14007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND & AIMS Alcohol abuse after liver transplantation can seriously impact graft and patient survival. However, to date, there is no defined standard procedure to identify patients consuming alcohol after liver transplantation. The aim of this study was to analyze the diagnostic value and clinical impact of routinely measured urinary ethyl glucuronide (uEtG) - a metabolite of ethanol - in patients after liver transplantation. METHODS Data of 362 consecutive patients after liver transplantation who visited the University Hospital of Tuebingen for outpatient follow-up were analyzed. RESULTS 48 patients (13%) displayed positive uEtG results. The uEtG positive group contained significantly more patients with pre transplant alcoholic liver disease. However, two thirds of the uEtG positive patients had no history of pre transplant alcoholic liver disease. Several clinical parameters were significantly associated with positive uEtG. In order to enable a more cost-effective application of uEtG in the future, a clinical risk score was developed (specificity 0.95). CONCLUSIONS Routine testing for uEtG reveals a considerable percentage of patients practicing alcohol intake after liver transplantation. Application of our proposed risk score could help focusing uEtG testing on patients at risk.
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Affiliation(s)
- Julia M Grottenthaler
- Department of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology, and Geriatrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Annette Konzelmann
- Department of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology, and Geriatrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Anette Stiegler
- Department of Psychiatry and Psychotherapy, Section Addiction Medicine and Addiction Research, University Hospital Tuebingen, Tuebingen, Germany
| | - Clemens Hinterleitner
- Department of Medical Oncology and Pneumology, University Hospital Tuebingen, Tuebingen, Germany
| | - Sarah M Bott
- Department of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology, and Geriatrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Thomas Klag
- Department of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology, and Geriatrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Christoph R Werner
- Department of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology, and Geriatrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Martina Hinterleitner
- Department of Medical Oncology and Pneumology, University Hospital Tuebingen, Tuebingen, Germany
| | - Alfred Königsrainer
- Department of General-, Visceral- and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Anil Batra
- Department of Psychiatry and Psychotherapy, Section Addiction Medicine and Addiction Research, University Hospital Tuebingen, Tuebingen, Germany
| | - Nisar P Malek
- Department of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology, and Geriatrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Silvio Nadalin
- Department of General-, Visceral- and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Christoph P Berg
- Department of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology, and Geriatrics, University Hospital Tuebingen, Tuebingen, Germany
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Efficacy of mindfulness-based relapse prevention in veterans with substance use disorders: Design and methodology of a randomized clinical trial. Contemp Clin Trials 2021; 105:106393. [PMID: 33857680 DOI: 10.1016/j.cct.2021.106393] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/22/2022]
Abstract
Mindfulness based interventions have been shown to be efficacious in treating depression, anxiety, pain and substance use disorders (SUDs). Mindfulness-Based Relapse Prevention (MBRP) is an intervention that integrates cognitive-behavioral relapse prevention and mindfulness meditation practices, in an 8-week, manualized group intervention designed to treat SUDs by helping patients regulate negative emotional states and reactive behavior. This paper describes the rationale, study design and methodology of a two-site, randomized controlled trial comparing MBRP to 12-Step Facilitation (TSF) in military Veterans following completion of intensive outpatient treatment for SUDs. The 8 weeks of 90-min, group-based MBRP or TSF sessions are followed by 3-, 6- and 10-month follow-up period with assessments of alcohol/drug use, quality of life, depression, anxiety, mindfulness and other functional outcomes, such as employment. The primary hypothesis is that MBRP will be significantly better than TSF in promoting recovery and prevention of relapse to substance use in a military Veteran population. The secondary hypothesis is that MBRP will lead to greater improvements in quality of life, depression/anxiety, and functional outcomes, such as employment. This study is designed to provide information about the use of group-based MBRP as a relapse prevention strategy for military Veterans who have completed an intensive SUD clinical treatment program. Clinical Trial Identifier: NCT02326363.
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7
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Mercurio I, Politi P, Mezzetti E, Agostinelli F, Troiano G, Pellegrino A, Gili A, Melai P, Rettagliata G, Mercurio U, Sannicandro D, Lancia M, Bacci M. Ethyl Glucuronide and Ethyl Sulphate in Urine: Caution in their use as markers of recent alcohol use. Alcohol Alcohol 2021; 56:201-209. [PMID: 33170266 DOI: 10.1093/alcalc/agaa113] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/27/2020] [Accepted: 09/29/2020] [Indexed: 01/27/2023] Open
Abstract
AIM To clarify the role of the ethanol metabolites, ethyl glucuronide (EtG) and ethyl sulfate (EtS), in monitoring alcohol consumption. METHOD We recruited 7 female and 17 male volunteers who were instructed to consume a quantity of beer (containing 48 gm ethanol) with food in one session. We examined urinary excretion of EtG and EtS over time and looked for correlations between the concentrations of the metabolites EtG and EtS. RESULTS EtG concentrations in urine varied between 0.026 and 430.372 μg/ml with average values between 11.85 μg/ml (SD 19.75), 30 min after alcohol intake, and 100.39 μg/ml (SD 101.34), 4.5 h after alcohol intake. EtS urinary concentration ranged from 0.006 to 101.432 μg/ml with average values between 4.77 μg/ml (SD 5.42), 30 min after alcohol intake, and 30.14 μg/ml (SD 27.20), 4.5 h after alcohol intake. Spearman's test showed that urinary EtG and EtS correlated significantly at several time points. CONCLUSION The great interindividual variability in their excretion suggests caution in the use of urinary measurement of these metabolites in forensic investigations.
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Affiliation(s)
- Isabella Mercurio
- Section of Legal Medicine, Forensic Science and Sports Medicine, University of Perugia, Perugia 06123, Italy
| | - Pamela Politi
- Section of Legal Medicine, Forensic Science and Sports Medicine, University of Perugia, Perugia 06123, Italy
| | | | - Fausto Agostinelli
- Section of Legal Medicine, Forensic Science and Sports Medicine, University of Perugia, Perugia 06123, Italy
| | | | | | - Alessio Gili
- Department of Experimental Medicine, Hygiene and Public Health Section, University of Perugia, Perugia 06123, Italy
| | - Paola Melai
- Hospital of Perugia, Department of Surgical and Biomedical Sciences ,Section of Forensic Medicine, Perugia 06123, Italy
| | | | - Umberto Mercurio
- Hospital of Potenza, Nephrology and Dialysis Division, Potenza 85100, Italy
| | | | - Massimo Lancia
- Section of Legal Medicine, Forensic Science and Sports Medicine, University of Perugia, Perugia 06123, Italy
| | - Mauro Bacci
- Section of Legal Medicine, Forensic Science and Sports Medicine, University of Perugia, Perugia 06123, Italy
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8
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Grodin EN, Nguyen XT, Ho D, Bujarski S, Ray LA. Sensitivity and specificity of a commercial urinary ethyl glucuronide (ETG) test in heavy drinkers. Addict Behav Rep 2020; 11:100249. [PMID: 32467838 PMCID: PMC7244915 DOI: 10.1016/j.abrep.2020.100249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/10/2020] [Accepted: 01/10/2020] [Indexed: 11/27/2022] Open
Abstract
Introduction To advance the use of alcohol metabolites as biomarkers in the context of alcohol research, the present study tested the sensitivity and specificity of a commercially available urinary ethyl glucuronide (uEtG) test (DrugConfirm Advanced 80hr EtG) in a clinical research context. Methods A community sample of heavy drinkers (N = 68) completed the 30-day Timeline Follow-Back (TLFB) interview and provided a urine sample for uEtG analysis. Analyses of sensitivity and specificity of the uEtG assay were conducted using the following outcomes: (a) past day drinking, (b) past day binge drinking (defined as ≥4 drinks for women and ≥5 drinks for men), (c) past 3-day drinking, and (d) past 3-day binge drinking. Results The majority of participants reported past-3-day drinking (80.9%) and a sizeable minority reported past day drinking (33.8%). While uEtG-based detection of past day drinking and binge drinking was acceptable (sensitivity = 73.91%, and 83.33%; specificity = 80.00% and 66.13%, respectively), detection of any drinking and binge drinking in the past 3 days was poor (sensitivity and specificity of 43.64% and 84.62%, and 39.39% and 62.86%, respectively). Conclusions This study contributes to the mixed findings on the validity of EtG tests, which suggest that commercial uEtG tests with conservative detection thresholds are not a reliable alcohol biomarker without corroborating self-report data. Lower detection thresholds are recommended when using uEtG as an alcohol biomarker. Efforts to reach acceptable levels of sensitivity and specificity with commercial assays hold potential to advance the measurement of alcohol intake, overcoming the pitfalls of self-report data.
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Affiliation(s)
- Erica N Grodin
- University of California Los Angeles, Department of Psychology, Los Angeles, CA, USA
| | - Xuan-Thanh Nguyen
- University of California Los Angeles, Department of Psychology, Los Angeles, CA, USA
| | - Diana Ho
- University of California Los Angeles, Department of Psychology, Los Angeles, CA, USA
| | - Spencer Bujarski
- University of California Los Angeles, Department of Psychology, Los Angeles, CA, USA
| | - Lara A Ray
- University of California Los Angeles, Department of Psychology, Los Angeles, CA, USA.,University of California Los Angeles, Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA, USA.,University of California Los Angeles, Brain Research Institute, Los Angeles, CA, USA
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9
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Design of a randomized controlled trial examining the efficacy of oxytocin to enhance alcohol behavioral couple therapy. Contemp Clin Trials 2019; 82:1-8. [PMID: 31063869 DOI: 10.1016/j.cct.2019.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 04/20/2019] [Accepted: 05/02/2019] [Indexed: 12/15/2022]
Abstract
Combining pharmacological interventions with evidence-based behavioral interventions may help optimize treatment outcomes for alcohol use disorder (AUD). While several effective behavioral interventions for AUD have been developed, the vast majority target individual patients, despite evidence that behavioral interventions for couples have the ability to outperform individual treatments for AUD. Alcohol Behavioral Couples Therapy (ABCT) is an evidence-based behavioral intervention for couples that has been shown to significantly reduce AUD severity as well as improve relationship functioning. Accumulating evidence suggests that the neuropeptide oxytocin has the ability to reduce alcohol craving and consumption, symptoms of tolerance and withdrawal, and ameliorate neurobiological deficits associated with AUD. Furthermore, oxytocin has demonstrated the ability to increase prosocial behavior and cognition, and restore sensitivity to natural rewards such as interpersonal relationships. No study to date has examined the ability of oxytocin to enhance ABCT. Thus, the primary objective of this Phase II study is to examine the effects of oxytocin versus placebo in combination with ABCT in reducing AUD severity and improving relationship functioning. We also will utilize neuroimaging techniques before and after treatment to investigate the underlying pathophysiology of AUD among couples and identify prognostic indicators of treatment outcome. The findings from this study might provide critical new information to help inform clinical practice and accelerate research on the pharmacological treatment of AUD.
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Livingston MD, Cannell B, Muller K, Komro KA. Comparing methods of misclassification correction for studies of adolescent alcohol use. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2018; 44:160-166. [PMID: 29451414 PMCID: PMC5976237 DOI: 10.1080/00952990.2017.1421212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 11/17/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Despite concerns over measurement error, self-report continues to be the most common measure of adolescent alcohol use used by researchers. Objective measures of adolescent alcohol use continue to advance; however, they tend to be cost prohibitive for larger studies. By combining appropriate statistical techniques and validation subsamples, the benefits of objective alcohol measures can be made more accessible to a greater number of researchers. OBJECTIVES To compare three easily implemented methods to correct for measurement error when objective measures of alcohol use are available for a subsample of participants, regression calibration, multiple imputation for measurement error (MIME), and probabilistic sensitivity analysis (PSA), and provide guidance regarding the use of each method in scenarios likely to occur in practice. METHODS This simulation experiment compared the performance of each method across different sample sizes, both differential and non-differential error, and differing levels of sensitivity and specificity of the exposure measure. RESULTS Failure to adjust for measurement error led to substantial bias across all simulated scenarios ranging from a 35% to 208% change in the log-odds. For non-differential misclassification, regression calibration reduced this bias to between a 1% and 23% change in the log-odds regardless of sample size. At higher sample sizes, MIME produced approximately unbiased (between a 0% and 9% change in the log-odds) and relatively efficient corrections for both non-differential and differential misclassification. PSA provided little utility for correcting misclassification due to the inefficiency of its estimates. CONCLUSION Concern over measurement error resulting from self-reported adolescent alcohol use persists in research. Where appropriate, methods involving validity subsamples provide an efficient avenue for addressing these concerns.
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Affiliation(s)
- Melvin D. Livingston
- Department of Biostatistics and Epidemiology, School of Public Health, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Brad Cannell
- Department of Biostatistics and Epidemiology, School of Public Health, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Keith Muller
- Department of Health Outcomes & Policy and Institute for Child Health Policy, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Kelli A. Komro
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Armer JM, Gunawardana L, Allcock RL. The Performance of Alcohol Markers Including Ethyl Glucuronide and Ethyl Sulphate to Detect Alcohol Use in Clients in a Community Alcohol Treatment Programme. Alcohol Alcohol 2016; 52:29-34. [PMID: 27998921 DOI: 10.1093/alcalc/agw072] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 11/13/2022] Open
Abstract
AIMS The ethanol metabolites ethyl glucuronide (EtG) and ethyl sulphate (EtS) are detectable for longer in urine than breath ethanol or urine ethanol after alcohol intake. This study compared the performance of breath ethanol, urine ethanol, urine EtG and EtS to detect alcohol consumption in clients in community alcohol treatment. METHODS Clients attending the community alcohol treatment programme were asked to provide an alcohol diary, breathalyser test and urine for ethanol, EtG and EtS measurement (n = 42). Positive results were defined using the detection limits (breath ethanol and urine ethanol) or clinical cut-offs (EtG: 0.26 mg/L and EtS: 0.22 mg/L). The sensitivities and specificities of each marker to detect alcohol intake <24 and 48-72 h prior were calculated. RESULTS The sensitivities of each alcohol marker to detect alcohol intake <24 h prior were 57, 71, 100 and 100% for breath ethanol, urine ethanol, urine EtG and urine EtS, respectively. The specificity was 100% for urine ethanol and urine EtS. The EtG specificity could be increased to 100% by using a higher cut-off (0.50 mg/L). The sensitivity of all markers (including EtG and EtS) to detect alcohol intake of ≤10 units 48-72 h earlier decreased to 0%. CONCLUSIONS In community alcohol treatment clients, urine EtG and EtS showed the optimum diagnostic performance to detect alcohol intake in the previous 24 h. We propose a flowchart to routinely use EtG and EtS for clients in community alcohol treatment. SHORT SUMMARY The ability of breath ethanol, urine ethanol, urine EtG and urine EtS to detect continued alcohol consumption in clients in community alcohol treatment were compared. Urine EtG and EtS showed the optimum diagnostic performance and we propose a flowchart to routinely use EtG and EtS in community alcohol treatment.
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Affiliation(s)
- Jane M Armer
- Blood Sciences, Clinical Laboratory Medicine, Royal Blackburn Hospital, Blackburn, UK
| | - Lihini Gunawardana
- Discover Drug and Alcohol Recovery Services (Greater Manchester West NHS Foundation Trust), Lancashire, UK
| | - Rebecca L Allcock
- Department of Clinical Biochemistry, Royal Preston Hospital, Sharoe Green Lane, Preston, Lancashire, UK
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Armer JM, Allcock RL. Urine ethyl glucuronide and ethyl sulphate using liquid chromatography-tandem mass spectrometry in a routine clinical laboratory. Ann Clin Biochem 2016; 54:60-68. [DOI: 10.1177/0004563216636648] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Detection of alcohol consumption in clients undergoing treatment for alcohol dependence can be difficult. The ethanol metabolites ethyl glucuronide and ethyl sulphate are detectable for longer in urine than either breath ethanol or urine ethanol. Our aim was to develop a liquid chromatography-tandem mass spectrometry method for urine ethyl glucuronide and ethyl sulphate for use in a routine clinical laboratory and define clinical cut-offs in a large population who had not consumed alcohol for at least two weeks. Methods Urine samples were diluted in 0.05% formic acid in HPLC grade water and then directly injected onto a Waters Acquity ultra high performance liquid chromatography coupled to a Waters TQ Detector. Eighty participants were recruited who had not consumed alcohol for at least two weeks to define cut-offs for urine ethyl glucuronide and ethyl sulphate. Samples and alcohol diaries were also collected from 12 alcohol-dependent clients attending a treatment programme. Results The assay was validated with a lower limit of quantitation of 0.20 mg/L for ethyl glucuronide and 0.04 mg/L for ethyl sulphate. Accuracy, precision, linearity and recovery were acceptable. Cut-offs were established for ethyl glucuronide, ethyl sulphate and ethyl sulphate/creatinine ratio (≤0.26 mg/L, ≤0.22 mg/L and ≤0.033 mg/mmol, respectively) in a non-drinking population. The validated cut-offs correctly identified clients in alcohol treatment who were continuing to drink alcohol. Conclusions A simple liquid chromatography-tandem mass spectrometry method for urine ethyl glucuronide and ethyl sulphate has been validated and cut-offs defined using 80 participants who had not consumed alcohol for at least two weeks. This is the largest study to date to define cut-offs for ethyl glucuronide, ethyl sulphate and ethyl sulphate/creatinine ratio.
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Affiliation(s)
- Jane M Armer
- Department of Clinical Biochemistry, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Rebecca L Allcock
- Department of Clinical Biochemistry, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
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McDonell MG, Skalisky J, Leickly E, McPherson S, Battalio S, Nepom JR, Srebnik D, Roll J, Ries RK. Using ethyl glucuronide in urine to detect light and heavy drinking in alcohol dependent outpatients. Drug Alcohol Depend 2015; 157:184-7. [PMID: 26475403 PMCID: PMC4663163 DOI: 10.1016/j.drugalcdep.2015.10.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/02/2015] [Accepted: 10/01/2015] [Indexed: 11/29/2022]
Abstract
AIMS This study investigated which ethyl glucuronide immunoassay (EtG-I) cutoff best detects heavy versus light drinking over five days in alcohol dependent outpatients. METHODS A total of 121 adults with alcohol use disorders and co-occurring psychiatric disorders took part in an alcohol treatment study. Participants provided self-reported drinking data and urine samples three times per week for 16-weeks (total samples=2761). Agreement between low (100 ng/mL, 200 ng/mL), and moderate (500 ng/mL) EtG-I cutoffs and light (women ≤3 standard drinks, men ≤4 standard drinks) and heavy drinking (women >3, men >4 standard drinks) were calculated over one to five days. RESULTS The 100 ng/mL cutoff detected >76% of light drinking for two days, and 66% at five days. The 100 ng/mL cutoff detected 84% (1 day) to 79% (5 days) of heavy drinking. The 200 ng/mL cutoff detected >55% of light drinking across five days and >66% of heavy drinking across five days. A 500 ng/mL cutoff identified 68% of light drinking and 78% of heavy drinking for one day, with detection of light (2-5 days <58%) and heavy drinking (2-5 days <71%) decreasing thereafter. Relative to 100 ng/mL, the 200 ng/mL and 500 ng/mL cutoffs were less likely to result in false positives. CONCLUSIONS An EtG-I cutoff of 100 ng/mL is most likely to detect heavy drinking for up to five days and any drinking during the previous two days. Cutoffs of ≥500 ng/mL are likely to only detect heavy drinking during the previous day.
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Affiliation(s)
- Michael G. McDonell
- Initiative for Research and Education to Advance Community Health (I-REACH), Washington State University, Box 1495, Spokane, WA 99210, United States
| | - Jordan Skalisky
- Initiative for Research and Education to Advance Community Health (I-REACH), Washington State University, Box 1495, Spokane, WA 99210, United States
| | - Emily Leickly
- Department of Psychiatry and Behavioral Sciences, University of Washington, Box 359911, 325 9 Avenue, Seattle, WA 98195
| | - Sterling McPherson
- Program of Excellence in Addictions Research, Washington State University, PO Box 1495, Spokane, WA 99210,Providence Medical Research Center, Providence Health Care, Spokane, WA 99210, United States
| | - Samuel Battalio
- Department of Psychiatry and Behavioral Sciences, University of Washington, Box 359911, 325 9 Avenue, Seattle, WA 98195
| | - Jenny R. Nepom
- Initiative for Research and Education to Advance Community Health (I-REACH), Washington State University, Box 1495, Spokane, WA 99210, United States
| | - Debra Srebnik
- Department of Psychiatry and Behavioral Sciences, University of Washington, Box 359911, 325 9 Avenue, Seattle, WA 98195
| | - John Roll
- Program of Excellence in Addictions Research, Washington State University, PO Box 1495, Spokane, WA 99210
| | - Richard K. Ries
- Department of Psychiatry and Behavioral Sciences, University of Washington, Box 359911, 325 9 Avenue, Seattle, WA 98195
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Wurst FM, Thon N, Yegles M, Schrück A, Preuss UW, Weinmann W. Ethanol Metabolites: Their Role in the Assessment of Alcohol Intake. Alcohol Clin Exp Res 2015; 39:2060-72. [DOI: 10.1111/acer.12851] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 07/22/2015] [Indexed: 01/12/2023]
Affiliation(s)
- Friedrich M. Wurst
- Paracelsus Medical University; Salzburg Austria
- Center for Interdisciplinary Addiction Research; University of Hamburg; Hamburg Germany
| | | | - Michel Yegles
- Service de Toxicologie; Laboratoire National de Sante; Luxembourg Luxembourg
| | - Alexandra Schrück
- Institute of Forensic Medicine; University of Bern; Bern Switzerland
| | - Ulrich W. Preuss
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine; University of Halle; Halle Germany
| | - Wolfgang Weinmann
- Institute of Forensic Medicine; University of Bern; Bern Switzerland
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Johnson-Davis KL, Slawson MH. Ethyl Glucuronide Positivity Rate in a Pain Management Population. J Anal Toxicol 2015; 39:686-90. [PMID: 26324207 DOI: 10.1093/jat/bkv096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Ethanol may be consumed by some patients as a means to manage their pain or psychiatric disorder. Consequently, there is the potential to consider ethanol a co-therapeutic in pain management. The purpose of this study was to perform a retrospective analysis to evaluate the rate of ethanol use in a population of patients in pain management programs that were evaluated by our in-house pain management drug panel test. Results from this retrospective study showed that 12.6% of patients in a pain management population were positive for the direct ethanol metabolite, ethyl glucuronide (EtG), by immunoassay. Furthermore, 86% of the individuals positive for EtG were also positive for prescription pain medication and illicit drugs. Results presented here suggest that ethanol use should be routinely monitored in pain management populations in an effort to determine any potential adverse effects of ethanol-drug interactions and as a way to further evaluate the effect of ethanol on pain management outcomes. Testing this population of patients suggests that ethanol use is prevalent and the risk of drug-ethanol adverse effects should be monitored in a pain management population.
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Affiliation(s)
- Kamisha L Johnson-Davis
- University of Utah Health Sciences Center, Salt Lake City, UT 84108, USA ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT 84108, USA
| | - Matthew H Slawson
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT 84108, USA ARUP Laboratories, Salt Lake City, UT 84108, USA
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Nanau RM, Neuman MG. Biomolecules and Biomarkers Used in Diagnosis of Alcohol Drinking and in Monitoring Therapeutic Interventions. Biomolecules 2015; 5:1339-85. [PMID: 26131978 PMCID: PMC4598755 DOI: 10.3390/biom5031339] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 05/15/2015] [Accepted: 05/29/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The quantitative, measurable detection of drinking is important for the successful treatment of alcohol misuse in transplantation of patients with alcohol disorders, people living with human immunodeficiency virus that need to adhere to medication, and special occupational hazard offenders, many of whom continually deny drinking. Their initial misconduct usually leads to medical problems associated with drinking, impulsive social behavior, and drunk driving. The accurate identification of alcohol consumption via biochemical tests contributes significantly to the monitoring of drinking behavior. METHODS A systematic review of the current methods used to measure biomarkers of alcohol consumption was conducted using PubMed and Google Scholar databases (2010-2015). The names of the tests have been identified. The methods and publications that correlate between the social instruments and the biochemical tests were further investigated. There is a clear need for assays standardization to ensure the use of these biochemical tests as routine biomarkers. FINDINGS Alcohol ingestion can be measured using a breath test. Because alcohol is rapidly eliminated from the circulation, the time for detection by this analysis is in the range of hours. Alcohol consumption can alternatively be detected by direct measurement of ethanol concentration in blood or urine. Several markers have been proposed to extend the interval and sensitivities of detection, including ethyl glucuronide and ethyl sulfate in urine, phosphatidylethanol in blood, and ethyl glucuronide and fatty acid ethyl esters in hair, among others. Moreover, there is a need to correlate the indirect biomarker carbohydrate deficient transferrin, which reflects longer lasting consumption of higher amounts of alcohol, with serum γ-glutamyl transpeptidase, another long term indirect biomarker that is routinely used and standardized in laboratory medicine.
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Affiliation(s)
- Radu M Nanau
- In Vitro Drug Safety and Biotechnology, University of Toronto, Toronto, ON M5G 0A3, Canada.
| | - Manuela G Neuman
- In Vitro Drug Safety and Biotechnology, University of Toronto, Toronto, ON M5G 0A3, Canada.
- Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, ON M5G 0A3, Canada.
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Lowe JM, McDonell MG, Leickly E, Angelo FA, Vilardaga R, McPherson S, Srebnik D, Roll J, Ries RK. Determining ethyl glucuronide cutoffs when detecting self-reported alcohol use in addiction treatment patients. Alcohol Clin Exp Res 2015; 39:905-10. [PMID: 25866234 DOI: 10.1111/acer.12699] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 02/04/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Ethyl glucuronide (EtG) is an alcohol biomarker with potential utility as a clinical research and alcohol treatment outcome. Debate exists regarding the appropriate cutoff level for determining alcohol use, particularly with the EtG immunoassay. This study determined the EtG immunoassay cutoff levels that most closely correspond to self-reported drinking in alcohol-dependent outpatients. METHODS Eighty adults with alcohol dependence and mental illness, taking part in an alcohol treatment study, provided urine samples 3 times per week for up to 16 weeks (1,589 samples). Self-reported drinking during 120 hours prior to each sample collection was assessed. Receiver operating characteristic analyses were conducted to assess the ability of the EtG immunoassay to detect self-reported alcohol use across 24- to 120-hour time periods. Sensitivity and specificity of EtG immunoassay cutoff levels was compared in 100 ng/ml increments (100 to 500 ng/ml) across 24 to 120 hours. RESULTS Over half (57%) of the 1,589 samples indicated recent alcohol consumption. The EtG immunoassay closely corresponded to self-reported drinking from 24 (area under the curve [AUC] = 0.90, 95% confidence interval [CI]: 0.88, 0.92) to 120 hours (AUC = 0.88, 95% CI: 0.87, 0.90). When cutoff levels were compared across 24 to 120 hours, 100 ng/ml had the highest sensitivity (0.93 to 0.78) and lowest specificity (0.67 to 0.85). Relative to 100 ng/ml, the 200 ng/ml cutoff demonstrated a reduction in sensitivity (0.89 to 0.67), but improved specificity (0.78 to 0.94). The 300, 400, and 500 ng/ml cutoffs demonstrated the lowest sensitivity (0.86 to 0.33) and highest specificity (0.86 to 0.97) over 24 to 120 hours. CONCLUSIONS For detecting alcohol use for >24 hours, the 200 ng/ml cutoff level is recommended for use as a research and clinical outcome.
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Affiliation(s)
- Jessica M Lowe
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
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Gareri J, Rao C, Koren G. Examination of sex differences in fatty acid ethyl ester and ethyl glucuronide hair analysis. Drug Test Anal 2015; 6 Suppl 1:30-6. [PMID: 24817046 DOI: 10.1002/dta.1653] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 01/31/2014] [Accepted: 02/28/2014] [Indexed: 11/09/2022]
Abstract
Clinical studies examining performance of fatty acid ethyl esters (FAEE) and ethyl glucuronide (EtG) in identifying excessive alcohol consumption have been primarily conducted in male populations. An impact of hair cosmetics in producing both false-negative EtG results and false-positive FAEE results has been demonstrated, suggesting a possible bias in female populations. This study evaluates FAEE-positive hair samples (>0.50 ng/mg) from n = 199 female and n = 73 male subjects for EtG. Higher FAEE/EtG concordance was observed amongst male over female subjects. Performance of multiple proposed EtG cut-off levels were assessed; amongst female samples, FAEE/EtG concordance was 36.2% (30 pg/mg), 36.7% (27 pg/mg), and 43.7% (20 pg/mg). Non-coloured hair demonstrated a two-fold increase in concordance (41.8 v. 20.8%) over coloured hair in the female cohort. FAEE levels did not differ between male and female subjects; however they were lower in coloured samples (p = 0.046). EtG was lower in female subjects (p = 0.019) and coloured samples (p = 0.026). A total of n = 111 female samples were discordant. Amongst discordant samples (EtG-negative), 26% had evidence of recent alcohol use including consultation histories (n = 20) and detectable cocaethylene (n = 9); 29% of discordant samples were coloured. False-negative risk with ethyl glucuronide analysis in females was mediated by cosmetic colouring. These findings suggest that combined analysis of FAEE and EtG is optimal when assessing a female population and an EtG cut-off of 20 pg/mg is warranted when using combined analysis. While concordant FAEE/EtG-positive findings constitute clear evidence, discordant FAEE/EtG findings should still be considered suggestive evidence of chronic excessive alcohol consumption.
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Affiliation(s)
- Joey Gareri
- Motherisk Program, Department of Paediatrics, Hospital for Sick Children, 555 University Avenue, Toronto, Canada; Graduate Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
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Himes SK, Dukes KA, Tripp T, Petersen JM, Raffo C, Burd L, Odendaal H, Elliott AJ, Hereld D, Signore C, Willinger M, Huestis MA. Clinical sensitivity and specificity of meconium fatty acid ethyl ester, ethyl glucuronide, and ethyl sulfate for detecting maternal drinking during pregnancy. Clin Chem 2015; 61:523-32. [PMID: 25595440 DOI: 10.1373/clinchem.2014.233718] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND We investigated agreement between self-reported prenatal alcohol exposure (PAE) and objective meconium alcohol markers to determine the optimal meconium marker and threshold for identifying PAE. METHODS Meconium fatty acid ethyl esters (FAEE), ethyl glucuronide (EtG), and ethyl sulfate (EtS) were quantified by LC-MS/MS in 0.1 g meconium from infants of Safe Passage Study participants. Detailed PAE information was collected from women with a validated timeline follow-back interview. Because meconium formation begins during weeks 12-20, maternal self-reported drinking at or beyond 19 weeks was our exposure variable. RESULTS Of 107 women, 33 reported no alcohol consumption in pregnancy, 16 stopped drinking by week 19, and 58 drank beyond 19 weeks (including 45 third-trimester drinkers). There was moderate to substantial agreement between self-reported PAE at ≥19 weeks and meconium EtG ≥30 ng/g (κ = 0.57, 95% CI 0.41-0.73). This biomarker and associated cutoff was superior to a 7 FAEE sum ≥2 nmol/g and all other individual and combination marker cutoffs. With meconium EtG ≥30 ng/g as the gold standard condition and maternal self-report at ≥19 weeks' gestation as the test condition, 82% clinical sensitivity (95% CI 71.6-92.0) and 75% specificity (95% CI 63.2-86.8) were observed. A significant dose-concentration relationship between self-reported drinks per drinking day and meconium EtG ≥30 ng/g also was observed (all P < 0.01). CONCLUSIONS Maternal alcohol consumption at ≥19 weeks was better represented by meconium EtG ≥30 ng/g than currently used FAEE cutoffs.
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Affiliation(s)
- Sarah K Himes
- Chemistry and Drug Metabolism Section, Intramural Research Program, National Institute on Drug Abuse, NIH, Baltimore, MD
| | | | | | | | | | - Larry Burd
- Department of Pediatrics, University of North Dakota School of Medicine, Grand Forks, ND
| | - Hein Odendaal
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Science, Stellenbosch University, Tygerberg, South Africa
| | - Amy J Elliott
- Center for Health Outcomes and Prevention Research, Sanford Research, Sioux Falls, SD
| | - Dale Hereld
- Division of Metabolism and Health Effects, National Institute on Alcohol Abuse and Alcoholism, NIH, Rockville, MD
| | - Caroline Signore
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD
| | - Marian Willinger
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD
| | - Marilyn A Huestis
- Chemistry and Drug Metabolism Section, Intramural Research Program, National Institute on Drug Abuse, NIH, Baltimore, MD;
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Soyka M. Alcohol use disorders in opioid maintenance therapy: prevalence, clinical correlates and treatment. Eur Addict Res 2015; 21:78-87. [PMID: 25413371 DOI: 10.1159/000363232] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Maintenance therapy with methadone or buprenorphine is an established and first-line treatment for opioid dependence. Clinical studies indicate that about a third of patients in opioid maintenance therapy show increased alcohol consumption and alcohol use disorders. Comorbid alcohol use disorders have been identified as a risk factor for clinical outcome and can cause poor physical and mental health, including liver disorders, noncompliance, social deterioration and increased mortality risk. The effects of opioid maintenance therapy on alcohol consumption are controversial and no clear pattern has emerged. Most studies have not found a change in alcohol use after initiation of maintenance therapy. Methadone and buprenorphine appear to carry little risk of liver toxicity, but further research on this topic is required. Recent data indicate that brief intervention strategies may help reduce alcohol intake, but the existing evidence is still limited. This review discusses further clinical implications of alcohol use disorders in opioid dependence.
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Affiliation(s)
- Michael Soyka
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany; Private Hospital Meiringen, Willigen, Meiringen, Switzerland
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Abstract
Patients with psychiatric disorders exhibit several neurobehavioral and neuropsychological alterations compared to healthy controls. However, signature endpoints of these behavioral manifestations have not yet been translated into clinical tests for diagnosis and follow-up measures. Recently, neuroproteomic approaches have been utilized to identify unique signature markers indicative of these disorders. Development of reliable biomarkers has the potential to revolutionize the diagnosis, classification, and monitoring of clinical responses in psychiatric diseases. However, the lack of biological gold standards, the evolving nosology of psychiatric disorders, and the complexity of the nervous system are among the major challenges that have hindered efforts to develop reliable biomarkers in the field of neuropsychiatry and drug abuse. While biomarkers currently have a limited role in the area of neuropsychiatry, several promising biomarkers have been proposed in conditions such as dementia, schizophrenia, depression, suicide, and addiction. One of the primary objectives of this review is to discuss the role of proteomics in the development of biomarkers specific to neuropsychiatry. We discuss and evaluate currently available biomarkers as well as those that are under research for clinical use in the future.
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Singh G. Reflex Testing for Carbohydrate-Deficient Transferrin (CDT) in Insurance Applicants with Elevated High Density Lipoprotein Cholesterol (HDL). J Insur Med 2015; 45:42-7. [PMID: 27584808 DOI: 10.17849/0743-6661-45.1.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectives .- Ascertain the utility of testing carbohydrate deficient transferrin (CDT) levels in insurance applicants with elevated high density lipoprotein cholesterol (HDL) levels. Background .- Chronic alcoholism is not uncommon and is a risk factor for health and longevity and thus of interest to providers of insurance. A number of tests serve as markers of alcohol use, eg, blood alcohol level, elevated liver enzymes, ethyl glucuronide in urine, whole blood associated aldehyde (WBAA), macrocytosis, elevated HDL, elevated CDT and others. WBAA and CDT are usually only done, if some other screening test suggests alcohol use. HDL testing is routinely done for assessing cardiac risk, however, chronic alcohol intake tends to raise HDL and some insurance providers reflex to CDT testing when HDL is elevated. Methods .- A number of the clients of Heritage Labs Inc. have rules in place to test for CDT levels in specimens showing elevated HDL levels. The commonest HDL level that serves as the trigger for reflex testing for CDT is 80mg/dL. The results of this practice were analyzed to assess the utility of reflex testing for CDT to identify chronic alcohol abusers among the applicants. Results .- In examining the results of CDT levels done as a reflex test due to elevated HDL levels, about 2% of the applicants, 0.7% of women and 3% of men, tested positive for elevated CDT levels. Conclusions .- The incidence of elevated CDT levels is high enough to warrant routinely testing for this analyte in applicants, especially men, with high HDL levels.
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Jatlow PI, Agro A, Wu R, Nadim H, Toll BA, Ralevski E, Nogueira C, Shi J, Dziura JD, Petrakis IL, O'Malley SS. Ethyl glucuronide and ethyl sulfate assays in clinical trials, interpretation, and limitations: results of a dose ranging alcohol challenge study and 2 clinical trials. Alcohol Clin Exp Res 2014; 38:2056-65. [PMID: 24773137 DOI: 10.1111/acer.12407] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 02/13/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND The ethanol metabolites, ethyl glucuronide (EtG) and ethyl sulfate (EtS), are biomarkers of recent alcohol consumption that provide objective measures of abstinence. Our goals are to better understand the impact of cutoff concentration on test interpretation, the need for measuring both metabolites, and how best to integrate test results with self-reports in clinical trials. METHODS Subjects (n = 18) were administered, 1 week apart, 3 alcohol doses calibrated to achieve blood concentrations of 20, 80, and 120 mg/dl, respectively. Urinary EtG/EtS was measured at timed intervals during a 24-hour hospitalization and twice daily thereafter. In addition, participants from 2 clinical trials provided samples for EtG/EtS and drinking histories. Cutoffs for EtG/EtS of 100/50, 200/100, and 500/250 ng/ml were evaluated. RESULTS Twelve hours following each challenge, EtG was always positive at the 100 and 200 cutoffs, but at 24 hours sensitivity was poor at all cutoffs following the low dose, and poor after 48 hours regardless of dose or cutoff. Similarly, in the clinical trials EtG sensitivity was good for detecting any drinking during the last 24 hours at the 2 lowest cutoffs, but under 40% during the last 24 to 48 hours. Sensitivity was reduced at the 500 ng/ml cutoff. Discrepancies between EtG and EtS were few. Comparison of self-reports of abstinence and EtG-confirmed abstinence indicated underreporting of drinking. CONCLUSIONS Any drinking the night before should be detectable the following morning with EtG cutoffs of 100 or 200 ng/ml. Twenty-four hours after drinking, sensitivity is poor for light drinking, but good for heavier consumption. At 48 hours, sensitivity is low following 6 drinks or less. Increasing the cutoff to 500 ng/ml leads to substantially reduced sensitivity. Monitoring both EtG and EtS should usually be unnecessary. We recommend EtG-confirmed self-reports of abstinence for evaluation of outcomes in clinical trials.
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Abstract
Alcohol misuse is associated with significant morbidity and mortality. Although clinical history, examination, and the use of self-report questionnaires may identify subjects with harmful patterns of alcohol use, denial or under-reporting of alcohol intake is common. Existing biomarkers for detecting alcohol misuse include measurement of blood or urine ethanol for acute alcohol consumption, and carbohydrate-deficient transferrin and gamma-glutamyl transferase for chronic alcohol misuse. There is a need for a biomarker that can detect excessive alcohol consumption in the timeframe between 1 day and several weeks. Ethyl glucuronide (EtG) is a direct metabolite of ethanol detectable in urine for up to 90 h and longer in hair. Because EtG has high specificity for excess alcohol intake, it has great potential for use in detecting "binge" drinking. Using urine or hair, this noninvasive marker has a role in a variety of clinical and forensic settings.
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Affiliation(s)
- Natalie E Walsham
- Department of Clinical Biochemistry, University Hospital Lewisham, London, United Kingdom
| | - Roy A Sherwood
- Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust, London, United Kingdom.
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Wetterling T, Dibbelt L, Wetterling G, Göder R, Wurst F, Margraf M, Junghanns K. Ethyl glucuronide (EtG): better than breathalyser or self-reports to detect covert short-term relapses into drinking. Alcohol Alcohol 2013; 49:51-4. [PMID: 24133131 DOI: 10.1093/alcalc/agt155] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
AIMS The assessment of relapses is widely used as an outcome measure of alcohol dependence treatment. However, the methods of assessing relapses range from questionnaires to biological markers of alcohol for different time spans. The aim of this study was to compare the relapse rates of weekend home stays during long-term alcohol dependence treatment, assessed by ethyl glucuronide (EtG), breath alcohol tests and self-reports. METHODS Two hundred and ninety-seven alcohol-dependent patients receiving a long-term inpatient treatment programme participated. After a weekend at home (Friday to Sunday) they were evaluated for relapse by personal interviews and with breath alcohol tests. A concomitantly collected urine sample was later assessed for EtG with liquid chromatography-tandem mass spectrometry (LC-MS/MS analysis). RESULTS Of the total, 37.7% of the patients were positive for EtG at least once. Breath alcohol tests had been positive in only 4.4% and in personal interviews only 5.7% of the patients had admitted relapse. 15.6% of EtG tests were positive, but breath alcohol tests were negative (Cohen's kappa = 0.056). Ninety-three per cent of the relapses were only detected by EtG. CONCLUSION In addition to breath alcohol tests and interviews, urinary EtG can clearly improve the verification of relapse in inpatient treatment programmes allowing for weekend stays at home. Without EtG testing, a high amount of relapses will stay undetected.
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Affiliation(s)
- T Wetterling
- Corresponding author: Department of Psychiatry and Psychotherapy, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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Preliminary investigations on ethyl glucuronide and ethyl sulfate cutoffs for detecting alcohol consumption on the basis of an ingestion experiment and on data from withdrawal treatment. Int J Legal Med 2012; 126:757-64. [DOI: 10.1007/s00414-012-0725-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 06/12/2012] [Indexed: 01/03/2023]
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Abstract
Alcohol is associated with significant morbidity and mortality. Subjects abusing alcohol can be identified through clinical history, examination or self-report questionnaires. A range of biomarkers is available for detecting alcohol misuse, but there is still a need for a marker that can detect alcohol consumption in the time window between one day (ethanol) and one week (gamma-glutamyl transpeptidase and carbohydrate-deficient transferrin). Ethyl glucuronide is a direct metabolite that can be detected in urine for up to 90 h and has the potential to become a useful marker of 'binge' drinking. As a non-invasive marker, it could have a role in a variety of clinical and forensic settings.
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Affiliation(s)
- Natalie E Walsham
- Department of Clinical Biochemistry, University Hospital Lewisham, High Street, Lewisham, London SE13 6LH
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Staufer K, Andresen H, Vettorazzi E, Tobias N, Nashan B, Sterneck M. Urinary ethyl glucuronide as a novel screening tool in patients pre- and post-liver transplantation improves detection of alcohol consumption. Hepatology 2011; 54:1640-9. [PMID: 21809364 DOI: 10.1002/hep.24596] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
UNLABELLED Optimal selection of liver transplant candidates and early detection of alcohol relapse after orthotopic liver transplantation (OLT) is necessary to improve long-term outcomes. In this study, urinary ethyl glucuronide (uEtG) was prospectively evaluated as a novel screening tool for alcohol detection in the transplant setting. Overall, 141 liver transplant candidates and recipients, visiting the outpatient clinic for a total of 308 times, were included. At each visit, the alcohol markers, uEtG, ethanol, methanol, and carbohydrate-deficient transferrin (CDT), as well as the state markers, alanine transaminase, aspartate transaminase, gamma glutamyl transpeptidase (GGT), and mean corpuscular volume (MCV), were determined, then compared to patients' self-reports on alcohol intake. Urinary EtG significantly increased the detection rate of alcohol consumption, compared to the other alcohol markers (P < 0.001). In 93% of patients and at 92.5% of visits with positive alcohol markers, alcohol intake was detected by uEtG and/or CDT. Sensitivity and specificity of uEtG were 89.3% and 98.9% and of CDT were 25% and 98.6%, respectively. Urinary EtG was the best independent predictor of alcohol consumption in univariate and multivariate analysis (positive predictive value: 89.3%; negative predictive value: 98.9%; odds ratio: 761.1; P < 0.001). It showed a superior prediction rate, when compared to established alcohol and state markers, as well as to the combination of CDT with MCV and GGT, assessed by net reclassification improvement (NRI) (NRI: 1.01, P < 0.001; NRI: 1.755, P < 0.001). CONCLUSION uEtG is a sensitive, specific, and reliable marker for the detection of recent alcohol intake pre- and post-OLT. In combination with CDT, uEtG should be considered as a tool for routine alcohol screening within the transplant setting.
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Affiliation(s)
- Katharina Staufer
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Postmortem chemistry update part II. Int J Legal Med 2011; 126:199-215. [DOI: 10.1007/s00414-011-0614-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Accepted: 08/22/2011] [Indexed: 02/02/2023]
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