Identification of alcohol abuse and alcoholism with biological parameters

Comparison between different methods of detecting patients with excessive consumption of alcohol

A study of excessive alcohol consumption was carried out on 2,114 adult somatic outpatients. All patients were evaluated by the following methods: Blood-chemical tests (serum gamma-glutamyltransferase (S-GT), serum aspartate aminotransferase (S-ASAT) and ethanol), patient's and doctor's questionnaires, and analysis of data from psychiatric records, social welfare registers and alcohol ambulatory services. Records from psychiatric clinics detected 48% of the patients. Forty per cent of the alcohol patients had S-GT levels greater than 0.9 mu kat/l. S-ASAT and blood ethanol levels were of little informative value. The doctors recognized excessive consumption (greater than 280 g of ethanol/week). The combination of S-GT and questionnaires to patients and doctors detected 63% of the alcohol patients. Both in epidemiological studies and in clinical practice it seems appropriate to use combinations of different methods to detect patients with underlying alcohol problems.

Biomarkers in alcoholism

Alcoholism ranks as one of the main current threats to the health and safety of people in most Western countries. Therefore, a high priority should be given to aims at reducing its prevalence through more effective diagnosis and early intervention. The need for objective methods for revealing alcohol abuse in its early phase has also been widely acknowledged. It is postulated here that the diagnosis of alcohol use disorders could be markedly improved by a more systematic use of specific questionnaires and laboratory tests, including blood ethanol, serum gamma-glutamyltransferase (GGT), carbohydrate-deficient transferrin (CDT), and mean corpuscular volume of erythrocytes (MCV). Recent research has provided new insights into the relationships between ethanol intake, biomarkers, and factors affecting their diagnostic validation, including gender, age, and the effects of moderate drinking and obesity. It appears that the concept of reference intervals for several ethanol-sensitive parameters in laboratory medicine needs to be revisited. CDT is currently the most specific marker of alcohol abuse, and when combined with GGT using a mathematically formulated equation a high sensitivity is reached without loss of assay specificity. Possible new biomarkers include minor ethanol metabolites (protein-acetaldehyde condensates and associated autoimmune responses, ethylglucuronide, and phosphatidylethanolamine), 5-hydroxytryptophol, and genetic markers although so far their routine applications have been limited.

Differential expression of toll-like receptors 2 and 4 in patients with liver cirrhosis

OBJECTIVE

Toll-like receptors (TLR) 2 and 4 were shown recently to mediate lipopolysaccharide (LPS)/endotoxin effects in vivo. Absence of clinical features, such as fever and leucocytosis, frequent infections, and up-regulation of anti-inflammatory cytokines suggest systemic differential regulation of LPS effects in patients with chronic endotoxinaemia due to liver cirrhosis.

DESIGN

Regulation of TLR2 and TLR4 represents a possible pathway to control LPS-induced immune responses in liver cirrhosis.

METHODS

We compared the expression of TLR2 and TLR4 in peripheral blood mononuclear cells (PBMC) (n = 28) and in liver biopsies (n = 20) of controls and of patients with liver cirrhosis by applying the reverse transcriptase polymerase chain reaction technique. The data were correlated to serum levels of LPS and CD14.

RESULTS

Expression of TLR2 was up-regulated (P < 0.01 to P < 0.05) in the PBMC of patients with high serum endotoxin levels, while TLR4 expression in patients at Child-Pugh stage A was down-regulated, irrespective of the origin (alcoholic or viral) of cirrhosis. A strong and significant correlation between expression of TLR2 and serum LPS (r = 0.638, P < 0.01) and soluble CD14 (r = 0.550, P < 0.05) was observed. Intrahepatic expression of TLR2/4 was not altered significantly in patients with liver cirrhosis.

CONCLUSION

Our data indicate LPS-driven regulation of TLR2/4 in patients with liver cirrhosis, suggesting involvement in mechanisms of systemic LPS hyporesponsiveness.

Role of selenium depletion in the etiopathogenesis of depression in patients with alcoholism [corrected]

Chronic heavy alcohol consumption adversely affects both macronutrients and micronutrients. Alcohol use affects selenium status. Considerable evidence suggests that selenium status may modify mental function. The author suggests that the effects of alcohol intake on mood, behavior, and cognition may be partly mediated by biological changes related to selenium deficiency. It has been observed that there is a trend towards the normalization of selenium levels in patients with alcoholism after a relatively short period of abstinence from alcohol. It has also been observed that when depression develops in persons with alcoholism, they are likely to improve fairly rapidly after a relatively short period of abstinence from alcohol without therapy aimed at the depressive symptoms. The author suggests that improvement in depressed patients after a period of abstinence from alcohol might be in part related to the normalization of selenium status. Treatment and prevention of comorbid alcoholism and mood disorders require more attention by research workers, practicing physicians, and the general public. Future studies of the etiology and pathogenesis of mood disorders in patients with alcoholism are merited.

Blood alcohol concentration and management of road trauma patients in the emergency department

BACKGROUND

The effects of blood alcohol on injury after crash are controversial, and safe limits are not settled. We examined if a positive blood alcohol concentration, even in a nontoxic range, affects management and outcome of injured patients after road crashes.

METHODS

In this prospective cohort study, we recruited all adult subjects admitted to an emergency department within 4 hours after a road crash. Outcomes were mortality or expected permanent disability, and data related to patients' management.

RESULTS

Alcohol-positive trauma patients were more frequently critical at admission (odds ratio [OR], 1.89; 95% confidence interval [CI], 1.18-3.02), and had an increased risk of combined mortality or expected permanent disability (OR, 1.67; 95% CI, 1.08-2.58), need for intensive care (OR, 1.87; 95% CI, 1.01-3.46), surgery (OR, 1.91; 95% CI, 1.37-2.66) and blood transfusions (OR, 2.09; 95% CI, 1.20-3.64), and acute medical complications (OR, 1.94; 95% CI, 1.33-2.85). All these events were explained by higher trauma severity. Only the risk of unsuspected injuries, diagnosed only at final evaluation, was independently associated with a positive blood alcohol concentration (OR, 4.98; 95% CI, 3.62-6.87), in addition to trauma severity and preexisting chronic conditions. Blood alcohol measurement significantly improved the accuracy in predicting unsuspected injuries, from 81.3% to 86.2%.

CONCLUSION

In injured patients after a road crash, a positive blood alcohol concentration increases the chance that the final diagnosis will include more injuries than initially documented. More careful monitoring is needed in alcohol-positive trauma patients, independent of clinical status, injury severity, and overt symptoms of alcohol intoxication.

Immunological parameters in patients suffering from alcohol-dependence syndrome

Alcohol abuse is a major cause of abnormal liver development and activity. In addition to enzymatic malfunction, alcohol and its metabolites induce changes in the levels of some liver antigens, resulting in immunological disturbance. The purpose of the present study is to correlate the severity of liver function impairment with the length of alcohol abuse, in order to be able to use such tests as indicative of the severity of Alcohol Dependence Syndrome. Thirty-one alcohol abusers were allocated to three groups on the basis of the levels of their liver enzymes, and were tested for a variety of immunological parameters and skin reactions. The data indicate that even though not all immunological values measured differed significantly from the control values, in those that did (granulocytes, lymphocytes, CD4/CD8 ratio, C3, IgG, IgM and some skin positive reactions), the biggest difference was between the healthy volunteers and the group with the longest abuse period. It is suggested that changes in selected immunological parameters in alcohol abusers may indicate the severity of their liver dysfunction.

Gene expression of TNF-receptors in peripheral blood mononuclear cells of patients with alcoholic cirrhosis

BACKGROUND/AIMS

Elevated concentrations of tumor necrosis factor receptors have been detected in alcoholic cirrhosis, but it remains unknown whether or not peripheral blood mononuclear cells are a source of tumor necrosis factor receptors and reflect the clinical disease activity of patients with advanced alcoholic liver disease.

METHODS

Twenty-two abstinent patients in different stages of alcohol-induced cirrhosis according to the criteria of the Child-Pugh classification (Child-Pugh stage A: 4, Child-Pugh stage B: 10, Child-Pugh stage C: 8) were compared with four healthy individuals. Semi-quantitative reverse transcriptase-polymerase chain reaction was used for the measurement of the expression of tumor necrosis factor-alpha, soluble tumor necrosis factor receptors-p55, -p75, interleukin-10 and inducible nitric oxide synthase in unstimulated peripheral blood mononuclear cells.

RESULTS

Unstimulated peripheral blood mononuclear cells of patients with alcoholic cirrhosis demonstrate a stage-dependent enhanced RNA expression of tumor necrosis factor-alpha (healthy controls 0/4, Child-Pugh stage A 2/4, stage B 10/10, stage C 8/8; p<0.01). The mRNA expression of TNF-receptors-p55/-p75 is significantly higher in patients with severe alcoholic cirrhosis (Child-Pugh stage B or C patients) than healthy controls (p<0.05), while peripheral blood mononuclear cells from patients with Child-Pugh stage A show a similiar pattern of gene expression to healthy controls. No significant up-regulation of interleukin-10 was found. Inducible nitric oxide synthase was detectable in Child-Pugh stage C (p<0.05).

CONCLUSIONS

Unstimulated peripheral blood mononuclear cells of patients with severe alcoholic cirrhosis (Child-Pugh stage B and C) demonstrate a systemic leukocyte activation and gene expression of tumor necrosis factor-alpha and tumor necrosis factor receptors-p55/-p75, which is correlated with the activity of the disease. Our data confirm previous studies that reported a correlation between plasma levels of pro-inflammatory cytokines and the severity of alcoholic cirrhosis. The role of interleukin-10 and inducible nitric oxide synthase in the pathogenesis of alcoholic cirrhosis remains to be fully elucidated.

Cytokine gene expression in peripheral blood mononuclear cells reflects a systemic immune response in alcoholic chronic pancreatitis

BACKGROUND

Recent data provide evidence of a systemic inflammatory response in severe acute pancreatitis; in contrast, the exact immune mechanisms underlying chronic pancreatitis remain unclear.

METHODS

To investigate the immune response in the clinical features of chronic pancreatitis, we investigated the gene expression of tumor necrosis factor-alpha (TNF-alpha), tumor necrosis factor receptor (TNFR)-p55 and -p75 and inducible nitric oxide synthase (iNOS) in peripheral blood mononuclear cells (PBMC) of 18 patients with late-stage alcoholic chronic pancreatitis of different disease activity (Balthazar criteria).

RESULTS

Semiquantitative reverse transcriptase-polymerase chain reaction revealed a significantly enhanced gene expression of TNF-alpha (P < 0.05), TNFR-p55 (P < 0.05) and TNFR-p75 (P < 0.01) in unstimulated PBMC of patients with advanced chronic pancreatitis (11/18 with calcifications) compared to healthy controls (n = 8). No significant difference was found between patients with mild acute pancreatitis and patients with an inactive quiescent pancreatitis. Moreover, no expression of inducible nitric oxide synthase was detectable.

CONCLUSIONS

The enhanced gene expression of TNFR-p75, TNFR-p55 and TNF-alpha in unstimulated PBMC demonstrates an enhanced leucocyte activation in patients with late-stage chronic pancreatitis and suggests a pathogenetic role of the cytotoxic TNF-alpha pathway in the clinical features of alcoholic chronic pancreatitis. The pathogenetic role of nitric oxide in chronic pancreatitis remains to be fully elucidated.

Alcohol abuse, alcoholism, and damage to the immune system--a review

Chronic alcohol abuse exacts a major social and medical toll in the United States and other Western countries. One of the least appreciated medical complications of alcohol abuse is altered immune regulation leading to immunodeficiency and autoimmunity. The consequences of the immunodeficiency include increased susceptibility to bacterial pneumonia, tuberculosis, and other infectious diseases. In addition, the chronic alcoholic often has circulating autoantibodies, and recent investigations indicate that the most destructive complications of alcoholism, such as liver disease and liver failure, may have a component of autoimmunity. Current research on altered cytokine balance produced by alcohol is leading to new insights on the regulation of the immune system in the chronic alcoholic. There is also recent development of exciting new techniques designed to improve or restore immune function by manipulation of cytokine balance. Although much remains to be learned, both in the abnormalities produced by alcohol and in the techniques to reverse those abnormalities, current progress reflects a rapidly improving understanding of the basic immune disorders of the alcoholic.

Prevalence of ethanol consumption may be higher in women than men in a university health service population as determined by a biochemical marker: whole blood-associated acetaldehyde above the 99th percentile for teetotalers

To estimate ethanol consumption by university students attending a student health facility, a biochemical marker of alcohol intake [whole blood associated acetaldehyde (WBAA)] was quantified by fluorimetric HPLC. Over a two year period we studied blood samples, coded by date and sex, from 645 females and 332 males, and compared the results to previously established reference ranges for teetotalers by sex. Men had higher absolute values for WBAA than women (9.9 versus 9.5 microM in the present study). However, significantly greater numbers of women (74%) than men (44%) had WBAA levels above the 99th percentile for teetotalers. Variations occurred during the academic year, with significant elevations occurring in the late fall and winter months. Testing of WBAA levels in a student health service may be important especially for women to facilitate counseling on the dangers of alcohol abuse.

Alcohol level at head injury and subsequent psychotropic treatment during trauma critical care

Alcohol intoxication at the time of traumatic brain injury (TBI) presents many complications for critical care treatment. This is the first reported data on psychotropic dosages administered to TBI patients in the critical care setting. In this study, the blood alcohol level (BAL)-positive patients (n = 14) tended to be older (P = 0.095), have lower admission Glascow Coma Scores (P = 0.031), and spent more days on respirators (P = 0.125) than the BAL-zero patients (n = 21). The BAL-positive group received more days of narcotics and benzodiazepines with markedly higher average daily doses, not statistically significant. These results are a basis for studying relationships between medication, treatment variables, and outcomes for TBI patients and then developing specific medication guidelines.

Assessment and management of individuals under the influence of alcohol in police custody

Individuals taken into police custody are commonly under the influence of alcohol. Some of these individuals are dependent on alcohol and suffer from withdrawal symptoms. Morbidity and mortality in this group is high, and deaths have been recorded in police custody. There are no specific guidelines on the assessment and management of individuals under the influence of alcohol taken into police custody. This article outlines the clinical features, assessment, investigations and management of these individuals based on a review of the literature.

Carbohydrate-deficient transferrin as a marker of alcohol abuse: relationship to alcohol consumption, severity of liver disease, and fibrogenesis

Carbohydrate-deficient transferrin (CDT) measurements have been widely examined as a marker of excessive alcohol consumption, yet the information on the sensitivity of this method has remained controversial. In addition, little is known of the relationship of this marker and the severity of alcoholic liver disease (ALD). To clarify these issues, we analyzed serum samples from 373 alcohol abusers, including 200 problem drinkers with no apparent liver pathology, 173 patients with clinical or morphological evidence of ALD, and 42 healthy controls. CDT was analyzed by anion-exchange chromatography followed by radioimmunoassay. At a specificity of 100%, the sensitivity of CDT was 36% in problem drinkers reporting a mean of 710 +/- 80 (mean +/- 2SE) g of ethanol/week, as compared with the sensitivities of 44% and 35% for gamma-glutamyltranspeptidase (GGT) and mean corpuscular volume (MCV), respectively. In a subgroup of problem drinkers (n = 51) with the highest ethanol intakes (1160 +/- 180 g of ethanol/week) and severe dependence, the sensitivity of CDT increased to 64%, compared with 55% for GGT and 39% for MCV. In ALD, the CDT values were significantly higher than in the alcoholics with nonliver pathology. However, when such patients were classified according to the clinical, laboratory, and morphological severity of liver disease, CDT was found to be primarily elevated in those with the early stage of ALD, such that there was a significant negative correlation between CDT and the combined morphological index of disease severity (rs = -0.315, p < 0.05). ALD markers of fibrogenesis were elevated more frequently than CDT, showing significant positive correlations with the indices of disease severity.(ABSTRACT TRUNCATED AT 250 WORDS)

Modulation of T-cell adhesion markers, and the CD45R and CD57 antigens in human alcoholics

Direct and indirect evidence indicates that T cells are altered in alcoholics. The most commonly reported changes under direct examination have been consistent with an increased level of activation as reflected by shifts in the ratio of common leukocyte antigen isoforms expressed at the cell surface, by increases in the expression of class II antigen, or by alterations in the expression of various adhesion molecules. Functional evidence for T-cell abnormality includes loss of delayed hypersensitivity and a number of findings attributed to dysregulation of B cells by alcoholic T cells; these include the widely reported distrubances of immunoglobulin production in vivo and a range of abnormal responses when T and B cells are combined in vitro. Detailed flow cytometric examination of T cells from alcoholics with or without active liver disease reveals a significant loss of L-selectin CD8+ T cells, but not usually of CD4+ T cells. There is an inverse increase in the expression of CD11b on the CD8+ cells that have decreased L-selectin+ percentages. Both CD8+ and CD4+ T cells in alcoholics display a significant loss of the CD45RA isoform and a gain of cells exhibiting the CD45RO isoform. Other surface alterations include increased expression of CD57, a marker most commonly associated on T cells with conditions of chronic increased antigenic exposure. It is argued that these and other T-cell alterations in alcoholics are cytokine-driven in part and result in T-cell differentiation states that are functionally inappropriate.(ABSTRACT TRUNCATED AT 250 WORDS)

Enzymes and circulating proteins as markers of alcohol abuse

The identification of alcohol abuse is an important social and clinical objective for which various biochemical procedures have been utilized, serum enzymes and circulating proteins being predominant. Tests are required to detect alcohol abuse as screening procedures in the general population as well as for the specific diagnosis of those presenting as hospital inpatients or outpatients, especially when liver disease is present or suspected. The amino-transferases are of limited value, although the mitochondrial isoenzyme of aspartate amino-transferase has been strongly advocated and is quite useful in detecting alcoholics among patients with liver disease. Gammaglutamyl transferase, by contrast, is raised in all forms of liver disease but can identify 30-50% of those consuming excessive amounts of alcohol before organic damage becomes manifest. Serum carbohydrate-deficient transferrin (CDT) is raised in many alcohol abusers without and most with liver damage, but is rarely elevated in other forms of liver disease. Haemoglobin-associated acetaldehyde, the newest biochemical index to be evaluated in alcoholics, is one of several adducts formed by the reaction of acetaldehyde with various proteins, and antibodies to these adducts may contribute, at least in part, to immunological tissue damage provoked by chronic excessive consumption of alcohol. Its assay is technically complex and it appears to be present in higher concentrations in heavy drinkers than in those who fulfill the criteria of addictive alcohol abuse. Many other markers have been introduced in the last decade but the search for a reliable index continues. CDT comes closest at the present time to matching the desired specificity, although it is of limited value in screening unselected non-hospitalized subjects.

Distribution of adipose tissue and muscle mass in alcoholic men

An elevated waist to hip ratio (WHR) has been found to be a predictor for several prevalent diseases. To examine the potential role of alcohol in the elevation of WHR, established alcoholic men without severe liver damage who were in adequate nutritional condition were compared with organized teetotalers matched for age, height, and body weight; the groups had similar total body fat content and lean body mass. Computed tomographic (CT) measurements at thigh and trunk levels showed a significant increase in the visceral adipose tissue (AT) areas and a slight decrease of muscle areas in the gluteal and femoral regions of the alcoholics. The alcoholic men had 48% of their AT areas of trunk scans localized retroperitoneally and intraperitoneally compared with 38% for the teetotalers (P < .01). The difference seemed to be more marked for retroperitoneal than for intraperitoneal AT (97 v 60 cm2, P < .01). The elevated visceral AT areas seemed to be independent of smoking. It was concluded that the increased WHR of alcoholics may include not only changes in AT, but also in muscle tissue distribution.

Comparative evaluation of the clinical utility of three markers of ethanol intake: the effect of gender

We evaluated three markers of ethanol intake [whole blood associated acetaldehyde (WBAA), serum beta-hexosaminidase, and gamma-glutamyl transpeptidase (GGT)] in four groups of subjects: teetotalers (n = 104), random insurance applicants or "normals" (n = 1,010), subjects enrolling in an alcohol treatment program or "alcoholics" (n = 31), and subjects attending outpatient drug/alcohol treatment follow-up clinics (n = 128). Significant differences (p < 0.004 for each assay and each comparison) were found in the mean values between teetotalers and normals and normals and alcoholics. Male teetotalers and normals had significantly (p < 0.002) higher levels of WBAA than females of the same group. Male normals had significantly higher levels of GGT than females (p < 0.001). GGT increased with age in the normal population into the fifth decade and decreased thereafter. WBAA was the most sensitive assay with 97% of alcoholics having values above the 99th percentile for the teetotaler population (vs. 66% for serum beta-hexosaminidase and 70% for GGT). None of the alcoholic subjects had values for all three assays below the 99th percentile for teetotalers compared with 21% of those in follow-up and 72% of normals. We conclude that WBAA appears to be the best of the three markers studied and that measurement of multiple markers for ethanol use appears clinically useful and incremental.

Identification of alcoholic liver disease or hidden alcohol abuse in patients with elevated liver enzymes

The aim of this prospective study was to identify alcoholic liver disease or covert alcohol abuse in unselected consecutive patients referred to a gastroenterologic out-patient's clinic for elevated liver enzymes. One-hundred-and-thirteen patients were questioned about alcohol consumption, trauma history and loss of driver's licence. Laboratory tests claimed to reflect alcohol consumption and liver biopsy were taken. Using data from patients with the highest (26 patients) and lowest (29 patients) stated consumptions, logistic regression analysis identified violence score (trauma score + driver's licence score) and a laboratory index combining MCV, ASAT/ALAT ratio and IgA values as significant independent predictors of alcohol abuse (index = 2.3 x violence score +1.08 x laboratory index-3.19). Twenty-six patients openly admitted alcohol abuse (> 300 g week-1) and 85% of these had alcoholic liver damage. The index identified a further 12 patients as abusers who stated an intermediate alcohol consumption (25-300 g week-1). Half of these had alcoholic liver damage. Thus, a total of 34% of the patients were identified as abusers and in one-third of these the abuse was covert.

Antabuse treatment for excessive users of alcohol

Antabuse treatment has mostly been applied to alcohol dependent patients although the heavy users of alcohol are responsible for the major parts of alcohol related problems in our societies. The heavy users of alcohol should be identified both by the general practitioners and the hospital doctors in any field and the first intervention should be a health interview connected with a biological monitoring of alcohol damages and thereby many patients would be motivated for moderate drinking. If this is not the case, heavy users should be encouraged to a 6 or better a 12 months supervised treatment with Antabuse. This treatment has especially been effective in employees with work-related alcohol problems.

Laboratory markers of ethanol intake and abuse: a critical appraisal

Laboratory markers for ethanol intake and abuse and chronic alcoholism currently in use have been critically reviewed. The merits and pitfalls of each test have been evaluated. The clinical use of the new test of carbohydrate-deficient transferrin has been particularly emphasized. Carbohydrate-deficient transferrin currently provides the highest specificity and sensitivity of all commonly used markers of alcoholism.

Oral effects of drug abuse

Drug abuse is a major problem in the U.S. and most other countries of the world today. Many studies, surveys, and case reports have described the adverse social and medical effects of drug abuse; yet surprisingly little is known about the specific effects of many of these drugs in the oral cavity. This article reviews the current state of knowledge concerning the systemic and oral effects of drugs of abuse and the dental management of addicted patients.

Carbohydrate-deficient transferrin (CDT) in serum as a possible indicator of heavy drinking in young university students

Carbohydrate-deficient transferrin (CDT) in serum was studied as a possible marker of heavy drinking in a sample of 187 female and 102 male 1st year university students from Finland. CDT was measured by a new radioimmunoassay (Pharmacia CDT RIA). Alcohol consumption was measured on a quantity-frequency scale. For female students CDT was 18.2 +/- 0.45 units/liter (mean +/- SEM) and for male students 13.3 +/- 0.48 units/liter. 9.6% of female students and 7.8% of male students had elevated CDT with a cut-off level of 26 units/liter for females and 20 units/liter for males. The correlation between CDT and reported alcohol consumption was 0.30 (p less than 0.001) for females and 0.25 (p = 0.014) for males. Those reporting a consumption of at least 10 kg of pure ethanol per year were considered as heavy drinkers (3.7% of females and 22.5% of males). In female students the average CDT of heavy drinkers did not differ significantly from that of social drinkers but in teetotalers CDT was significantly (p less than 0.03) lower than in female alcohol users. In male students the average CDT of heavy drinkers was higher than the average of social drinkers (p less than 0.1) and significantly higher than the average of teetotalers (p less than 0.001). In the detection of heavy drinking among male students elevated CDT had a specificity of 96.2% and a sensitivity of 21.7%.(ABSTRACT TRUNCATED AT 250 WORDS)

New Alcohol Markers-How Useful Are They in Population Studies: The Svalbard Study 1988-89

Regular high consumption of alcohol in selected populations have, with high precision, been identified by two new alcohol markers; carbohydrate-deficient transferrin and mitochondrial aspartate aminotransferase. To test these markers in an unselected population, gamma-glutamyltransferase (GGT), carbohydrate-deficient transferrin (CDT), and mitochondrial aspartate aminotransferase (mAST) were measured in the Norwegian population, 310 males and 171 females, aged 18 to 60 years, living at Svalbard. Using self-reported alcohol intake as gold standard, sensitivity, specificity, positive predictive value, and likelihood-ratio were estimated according to different cutoff-points for alcohol intake and for the tests. In contrast to earlier studies, the sensitivity was in general low. With a specificity of 90% or higher, the sensitivity did not exceed 26% for any of the tests. Whereas CDT showed its best discriminatory power at lower intake of alcohol, GGT discriminated best at higher levels. Parallel and serial analysis of CDT and GGT indicated a conditional independence between the tests, as well as at higher and at lower levels of alcohol consumption. mAST was judged as not suitable in population studies.

Studies of urine-associated acetaldehyde as a marker for alcohol intake in mice

A study was undertaken in 16 male C57BL mice to evaluate the effect of ethanol intake via the drinking water (10% v/v) on urinary-associated acetaldehyde. Eight received ethanol and 8 served as controls. Urinary-associated acetaldehyde (UAA) was measured using a fluorigenic high performance chromatographic assay. Ethanol consumption did not impair growth over the two weeks of the experiment. Following administration of ethanol, UAA increased and remained significantly elevated over levels seen in controls until ethanol administration ceased (11.3 +/- 3.6 SEM microM for ethanol-consuming mice vs. 0.69 +/- 0.33 microM for controls). Ethanol in the urine was found to interfere with the assay for acetaldehyde. However, following cessation of ethanol, acetaldehyde in urine was found to be significantly elevated in urine at 24 hours, after ethanol levels were no longer detectable. In conclusion, measurement of urinary-associated acetaldehyde discriminates ethanol-consuming from nonconsuming mice during ethanol ingestion as well as 24 hours following cessation of ethanol when ethanol levels are no longer detectable in urine. Thus measurement of urinary acetaldehyde may be a useful marker for monitoring ethanol intake.

Serum beta-hexosaminidase in young university students

In a sample of 203 first-year university students, serum beta-hexosaminidase (beta-HEX) was studied as a possible marker of heavy drinking. There are no previous studies on beta-HEX in a young nonalcoholic population. All students were healthy and without regular medication except the use of p-pills in 49 of the 123 female students. Alcohol consumption was measured on a frequency-volume scale. Serum beta-HEX did not correlate with reported drinking, gamma-glutamyl transferase (GGT), mean corpuscular volume (MCV) nor alcohol problems. The mean beta-HEX of 26 teetotalers did not differ from that of the heaviest drinking group (n = 25). A new finding was a significant (p = 0.009) increase of serum beta-HEX in female students using oral contraceptives. We conclude that serum beta-HEX is a poor indicator of alcohol consumption in young university students and if elevated the use of p-pills must be considered.

Activated CD-8 cells and HLA DR expression in alcoholics without overt liver disease

Lymphocytes from alcoholics without liver disease were immunophenotyped by flow cytometry immediately after admission for detoxication and again after 4 to 10 days of abstinence. We found a small but significant elevation of T lymphocytes at admission compared to controls and decreases in the numbers of B cells and natural killer cells in many patients. A significant elevation of activated T cells was confirmed. The ratio of activated T cells to activated non-T cells was also substantially increased, but declined slightly during early withdrawal. The increase in activated T cells was due mostly to increased numbers of activated CD8hi cells. These activation changes did not revert toward normal as quickly as the other changes and may represent an indication of immune damage at a preclinical stage. An additional finding of interest was a substantial decrease in the expression of HLA DR on CD4+ and non-T cells. The significance of this decrease is not known, but we speculate that it may result in a decline in the efficiency of antigen presentation.

The Tromsø Study: the positive predictive value of gamma-glutamyltransferase and an alcohol questionnaire in the detection of early-stage risk drinkers

Based on the measurement of gamma-glutamyltransferase and a questionnaire on frequency of alcohol intake, 338 early-stage risk drinkers were identified from more than 20,000 participants in a health survey programme. Two-thirds (225) of these subjects were questioned regarding their 'true' alcohol intake at the first consultation. Positive predictive values were calculated for true daily intake of 30 and 40 g alcohol d-1 for men (20 and 30 g alcohol d-1 for women) on the basis of gamma-glutamyltransferase activity and the response to a questionnaire. The positive predictive values for a risk intake of 30 g d-1 in men increased from 0.49 to 0.88, with increasing values for gamma-glutamyltransferase activity and increasing frequency of alcohol intake. The corresponding values for a risk intake of 40 g d-1 were 0.34-0.75. In women, increasing gamma-glutamyltransferase activity gave no increase in positive predictive values. The estimates for increasing frequency of alcohol intake were unreliable due to small numbers.

Screening for alcoholism in a psychiatric hospital

The prevalence of alcoholism is generally underestimated in patients in private practices, general hospitals and psychiatric institutions. Even though the World Health Organization has advocated the concurrent use of laboratory test results and questionnaires for screening, these methods are seldom used together. In this study, patients admitted consecutively to the North Bay Psychiatric Hospital were screened for alcoholism using the Michigan Alcoholism Screening Test (MAST) and gamma-glutamyl-transferase plasma level. Unexpectedly, 56.7% of the entire sample were identified as possible alcoholics; of these, 73.5% were men and 26.5% were women. When rates for men and women were looked at separately, it was found that 66.2% of the men and 40.6% of the women were alcoholic. Participants who tested positive on one or both of the screening tests were offered a more complete evaluation of their drinking behaviour. A diagnosis of alcoholism was confirmed in 88.2% of the patients who agreed to participate further. The question remains whether the high prevalence rates found are a function of the particular sample studied (i.e., patients in a hospital which typically serves a socially disadvantaged sector of the population) or reflects a feature of the general population in this catchment area. A study is currently underway in general hospitals of North Eastern Ontario in an attempt to answer this question.

Studies of whole blood associated acetaldehyde as a marker for alcohol intake: effect of gender in mice

A study was undertaken in C57BL mice to evaluate the effect of gender on whole blood associated acetaldehyde following exposure to ethanol in the drinking water (10% v/v). Whole blood associated acetaldehyde (WBAA) was measured from capillary blood samples using a fluorigenic high performance chromatographic assay on days 0, 7, 15 and 27. Ethanol consumption did not impair growth of either male or female mice when compared to controls. Following administration of ethanol, WBAA increased in both male and female mice but marked gender differences were apparent. Female mice consumed more fluid relative to body weight than males (155 +/- 27 S.D. vs. 124 +/- 19 ml/kg/day, p less than 0.001), but had lower mean WBAA levels during the four weeks of ethanol administration (137 +/- 37 vs. 318 +/- 66 nmol/g hemoglobin, p less than 0.001). WBAA levels in male mice were stable over the course of the experiment. Female mice were found to have peak WBAA levels on day seven after which time levels decreased significantly. These experiments emphasize gender differences in ethanol metabolism as well as the need to establish norms based on gender for assays of ethanol consumption which use acetaldehyde adducts with blood proteins.

Detection of alcohol problems in a hospital setting

Three hundred and six adult medical and family practice inpatients at a university-affiliated teaching hospital were assessed for problem drinking using: (1) a short questionnaire containing the CAGE (a 4-question, self-report screening measure), and (2) a standardized review of medical records (an examination of specific blood chemistries and the physicians' and nurses' notes). Each patient completed one of two randomly assigned questionnaires containing the CAGE within the first 48 h of admission: a "Health Habits Questionnaire" or an "Alcohol Questionnaire." No significant differences were found between the two questionnaires with regard to the number of CAGE items endorsed. Overall, 16.9% of the subjects endorsed two or more CAGE items. Using the chart screening method, 11.4% of the total subjects were considered "probable" or "definite" problem drinkers. The screener's reading of the physicians' notes was the variable most important in determining overall chart screening assessment. The correlation between the two screening measures was relatively low (r = .38, p less than .001), suggesting that the two measures identify different populations of problem drinkers.

Alcohol consumption and synthesis of ethyl esters of fatty acids in adipose tissue

Ethyl esters of fatty acids (EEFA) have been found to be formed during ethanol metabolism. Human adipose tissue contains high concentrations of free fatty acids, the substrate for EEFA synthesis, and might therefore be a tissue with great potential for EEFA formation. In order to explore their potential usefulness as markers of alcohol abuse, the EEFA concentration and the activity of EEFA-synthesizing enzyme were therefore determined in adipose tissue from men belonging to the following categories: teetotalers, social drinkers, alcoholics under treatment, or established alcoholics found to have died as a result of alcohol intoxication. In order to estimate the half-life of EEFA and the synthase activity induction, the alcoholics were examined after different time periods of abstinence from alcohol. Comparisons were also made with several established markers of alcohol abuse. EEFA were not found in teetotalers, and were found in low concentrations in some of the social drinkers. EEFA were found in several alcoholics, and the forensic cases had high concentrations. EEFA-synthesizing enzyme activity was found in all subjects, increasing from teetotalers to social drinkers, and being 2-fold higher in alcoholics and 5-fold higher in dead alcoholics. The induction of the enzyme after abstinence appeared to have a half-life of the order of several weeks. Correlations were found between EEFA synthase activity and previously established markers of alcohol abuse known to remain for a long time period after abstinence, such as mean erythrocyte corpuscular volume. This preliminary study suggests the possibility that EEFA synthase induction in adipose tissue might have a longer half-life than previously used markers of alcohol abuse. It is therefore suggested that the induction of EEFA synthase might be a potentially useful new marker for alcohol abuse because of its apparent proportionality to alcohol intake over a prolonged time period, its presumed specificity, and long-term elevation after alcohol abstinence. This potential marker should be analysed further.

A comparative blinded study in miniature swine of whole blood-, hemoglobin-, platelet-, plasma-, and lymphocyte-associated acetaldehyde as markers for ethanol intake

Blood samples were obtained from miniature swine maintained on 0, 2, or 6 g/kg/24 hr ethanol for 8 months (N = 6 in each group). Samples from drinking pigs were taken after 8 hr of ethanol abstinence and all were coded and sent for "blinded" analysis. A fluorigenic high performance liquid chromatographic assay was used to quantify whole blood-associated acetaldehyde, hemoglobin-associated acetaldehyde, plasma-associated acetaldehyde, platelet-associated acetaldehyde, and lymphocyte-associated acetaldehyde. Detectable levels of acetaldehyde were found in each sample in both drinking and nondrinking pigs. Analysis of whole blood-associated acetaldehyde was most discriminatory in distinguishing nondrinking from drinking pigs (mean 21.4 +/- 1.0 microM for nondrinkers vs. 24.6 +/- 1.5 SD for the group consuming 2 g/kg ethanol, p = 0.001). Measurements of hemoglobin-associated acetaldehyde normalized to protein concentration (250 +/- 47 nmoles/g vs. 203 +/- 33 SD, p less than 0.05 drinking vs. nondrinking pigs) and platelet-associated acetaldehyde (0.46 0.34 vs. 0.15 +/- 0.16 nmoles/3 x 10(8) platelets, p = 0.05 drinking vs. nondrinking pigs) were also useful in discriminating drinking from nondrinking animals. Analysis of plasma-associated acetaldehyde and lymphocyte-associated acetaldehyde were not useful as markers of ethanol consumption.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic value of serum gamma-glutamyl-transferase activity and mean corpuscular volume in alcoholic patients with or without cirrhosis

In an attempt to assess the diagnostic values of serum gamma-glutamyltransferase (GGT) and mean corpuscular volume (MCV) variations as markers of liver disease and of abstinence in alcoholic patients, we compared 174 patients with alcoholic cirrhosis, 175 with noncirrhotic alcoholic liver disease and 67 patients with nonalcoholic cirrhosis. GGT and MCV values were checked three times, the day of admission, 7 days later, and on the last sample available during follow-up (1 to 12 months), and were compared according to the liver disease and abstinence. A decrease of GGT activity during the 1st week of hospitalization was noted in alcoholics with (-9 IU/liter) or without (-13 IU/liter) cirrhosis and not in nonalcoholic cirrhosis (+8 IU/liter), without MCV variations. During follow-up, median GGT activity was strikingly different in abstinent patients with (27 IU/liter) or without (21 IU/liter) cirrhosis and in nonabstinent patients (99 IU/liter and 123 IU/liter, respectively) (p less than 0.001). MCV decrease was noted in alcoholics whatever their abstinence or not, contrasting with the absence of decrease in nonalcoholic patients. For the diagnosis of alcoholism in cirrhotic patients, the positive predictive value (PPV) of a GGT or a MCV decrease during the 1st week of hospitalization was 0.82 and 0.78, respectively, and the negative predictive value (NPV) was 0.33 and 0.70, respectively. For abstinence during follow-up, the PPV of a GGT activity less than 50 IU/liter was 0.92 and the NPV was 0.65.(ABSTRACT TRUNCATED AT 250 WORDS)

Alcoholism in lesbians: developmental, symbolic interactionist, and critical perspectives

Alcoholism is a significant health concern for lesbian women, with an incidence rate perhaps three times that of the general population. The relationships among the development of alcoholism in women, the experience of stigmatization, and the complex facets of lesbian identity and lesbian community are explored. This exploration provides for a more comprehensive and critical analysis of alcoholism in lesbians. As a phenomenon of women's health, alcoholism is examined using the perspectives of developmental theory, symbolic interactionism, and critical theory. The author offers insights and implications for health care, research, and theory building.

Alcohol intake and blood pressure in young adults: the CARDIA Study

Associations between self-reported average daily alcohol intake and blood pressure were assessed in 5031 black and white men and women ages 18-30 from the Coronary Artery Risk Development in Young Adults Study (CARDIA). In general, intake was positively but weakly related to both systolic and diastolic blood pressure. Associations with systolic pressure were generally stronger than those with diastolic pressure. With average daily alcohol intake categorized as none, 0.1-9.9 ml, 10.0-19.9 ml, 20.0-29.9 ml, and 30.0+ ml, mean systolic pressure, adjusted for age, body mass index, education, smoking, and physical activity, increased progressively with increasing intake in black and white men and in white women. Mean diastolic pressure increased progressively with increasing intake only in white men and women, but was highest for those averaging 30.0+ ml per day in black women as well as white men and women. Mean pressures were also compared for those averaging 75.0+ ml per day (men) or 50.0+ ml per day (women) vs those reporting no intake. Differences in adjusted mean pressures for white men were 3.2 mmHg (95% confidence limits (CL) -0.3, 6.8) for systolic pressure and 1.7 mmHg (-1.6, 5.0) for diastolic pressure. In black men differences were 4.4 mmHg (1.4, 7.4) and 3.4 mmHg (0.6, 6.3), respectively. Differences in white women were 1.4 mmHg (-2.5, 5.3) for systolic pressure and 0.9 mmHg (-2.7, 4.5) for diastolic pressure and for black women, -0.2 mmHg (-4.3, 3.8) and 1.9 mmHg (-1.9, 5.8). Separate analyses in smokers and nonsmokers of the associations between alcohol intake and blood pressure suggested that associations may differ by smoking status in some sex-race groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Studies of whole blood associated acetaldehyde as a marker for alcohol intake in mice

Thirty C57BI mice were randomized into two groups. Group 1 served as controls while Group 2 was given 10% V/V ethanol with the drinking water. Whole blood- associated acetaldehyde (WBAA) was measured on capillary blood samples using a fluorigenic high performance chromatographic assay. WBAA peaked at Day 2. A stable mean plateau of 263 +/- 71 SD with a range of 160-400 nmoles/g hemoglobin WBAA was found in the group consuming ethanol compared with 122 +/- 17 SD and a range of 88-150 nmoles/g hemoglobin for controls (p less than 0.001). When ethanol was discontinued, levels of WBAA declined and became similar to those of controls by 9 days following cessation of ethanol. The quantitative difference between ethanol-consuming and control animals and also the rapid rise of whole blood-associated acetaldehyde and the relatively slow decline following cessation of ethanol intake indicate that such a test might be a useful monitor of drinking behavior.

Alcoholism: a challenging physician-patient encounter

Physicians can be most helpful to alcoholic patients, whatever the stage of progression of their illness, by adopting the following strategies: 1. Become familiar with the interactional dynamics that result from denial so as to improve data gathering and interpretation, resulting in better diagnostic acumen. Expect to feel uncomfortable because of the interpersonal nature of alcoholism's defenses. Tolerate these feelings through helping the patient to see how uncomfortable he is because of the illness. 2. Adopt a nonjudgmental stance regarding the complex origins of the problem, and develop the skills to communicate respect and compassion to people who feel demoralized, ashamed, afraid, depressed, and hopeless. 3. Support and encourage the patient in surmounting the obstacles to accepting each day the responsibility for participating in whichever form of treatment fits his or her stage of the illness. 4. Refuse to give up on the patient, unless the patient manifests irreversible cognitive impairments that preclude participation in active treatment for alcoholism.

Separation of different forms of transferrin by isoelectric focusing to detect effects on the liver caused by xenobiotics

Several genetic variants and also isoforms of transferrin differing in carbohydrate structure can be separated by polyacrylamide or agarose gel isoelectric focusing. Numerous blood plasma or serum samples can be analyzed in parallel in each gel. Studies of the heterogeneity of transferrin have already revealed many results of importance to different fields of human medicine. Gene typing can give important and useful information for paternity determination and in forensic medicine. The gene type C 2 seems to have increased frequency in certain malfunctions. Futhermore, functional abnormalities of liver cells can be revealed by determination of the concentrations of transferrin isoforms differing mainly in their carbohydrate parts. The isoforms can be quantified with zone immunoelectrophoresis assay. Thus valuable information can be obtained about important modulated regulations of cell and membrane functions, even when these are disturbed by disease and xenobiotics. The information may be useful e.g. in the detection of individuals suffering from toxic effects, to identify toxic agents and exposure conditions. Studies of house painters revealed that exposure to different types of paints had an effect on transferrin. Determination of the concentration of the isotransferrin with pI 5.7 in blood samples from alcoholics can be used as a marker for the detection of liver dysfunction and for the monitoring of therapy treatments. In addition, by analyzing the isotransferrins a rare genetic abnormality can be detected.

Ethanol elimination-rates determined by breath analysis as a marker of recent excessive ethanol consumption

The rate of ethanol elimination was studied in two groups of men by means of an Alcotest 7010 breath analyser. The experimental group consisted of 15 skid-row alcoholics undergoing detoxification. Their median daily ethanol consumption was 211 (range 26-476) g pure ethanol during the last year. The control group was made up of 12 age-matched healthy social drinkers consuming 9 (range 4-23) g day-1 pure ethanol during the last year. The median ethanol elimination-rate in the elimination phase was 0.25 (range 0.13-0.31) g 1-1 h-1 during the detoxification period in the experimental group. This value was approximately 70% higher than in the control group (0.14(0.12-0.17) g 1-1 h-1). Some correlation was found between reported ethanol intake, and the calculated ethanol elimination-rate, as well as gamma glutamyl transferase (GGT), alanine amino transferase (ALAT), aspartate amino transferase (ASAT), glutamate dehydrogenase (GLDH), mean corpuscular volume (MCV) and HDL-cholesterol. Of these measures, ethanol elimination-rate showed highest sensitivity and efficiency for detection of ethanol consumption above the limit of 50 g per day.

Murine models for acquired immune deficiency syndrome

The mouse has been suggested as a host for comparative studies of several aspects of Human Acquired Immune Deficiency Syndrome (AIDS). Models include studies where part or all of the genome of Human Immunodeficiency Virus (HIV) has been incorporated into murine DNA in living mice. However, the most promising opportunities for study of immunological changes, vaccine development, cofactor involvement in disease, and anti-retroviral and immunostimulatory drug testing involve infection with murine retroviruses which cause many functional changes similar to AIDS. The viruses' effects on immune systems are reviewed with special emphasis. LP-BM5 murine leukemia virus which infects T and B cells, and macrophages. LP-BM5 infection suppresses cell functions while causing polyclonal lymphocyte activation. Murine immunological characterization, availability of inbred mouse strains, economy of using mice versus primates or humans models, and similarity of immune change caused by murine retroviruses compared to those seen in AIDS caused by HIV encourage rapid development of the LP-BM5 murine leukemia model.

Transferrin and mitochondrial aspartate aminotransferase in young adult alcoholics

Two recently proposed biochemical markers of alcoholism, namely, quantitation of plasma transferrin variant (Tf5.7) and the ratio of plasma mitochondrial aspartate aminotransferase (m-AspAT) to total AspAT (t-AspAT), were tested for their ability to detect young adult alcoholics. Another commonly used biochemical test, namely, activity of plasma gamma glutamyltransferase (GGT) was included as a comparison. Although mean values of GGT, TF5.7, total transferrin (Tftot), m-AspAT and t-AspAT in alcoholics were significantly higher than those in controls, there were too many overlapping values in each test between alcoholics and controls to render any of these tests suitable as a marker for young adult alcoholics. Depending on cut-off limits, the sensitivity of each test ranged from 0-52% and the specificity ranged from 80-97%. Moreover, the m-AspAT/t-AspAT and Tf5.7/Tftot ratios were not significantly different between alcoholics and controls. A stepwise linear discriminant function analysis of all the variables resulted in a slight increase in classification sensitivity (66%) but a decrease in specificity (77%). The relatively short duration (mean = 5.6 years) of heavy alcohol intake and the time elapsed (mean = 5.8 days) since the alcoholics last consumed alcohol very likely contributed to the low sensitivity. Young adults might also be more resilient with regard to the damaging biochemical effects of ethanol. Abnormal biochemical values might reverse to normal values much more quickly in young adult alcoholics than in those who are older and have more years of alcohol abuse.

Rapid association of acetaldehyde with hemoglobin in human volunteers after low dose ethanol

A fluorigenic high performance liquid chromatographic (HPLC) method was used to determine plasma (PA) and hemoglobin-associated (HbAA) acetaldehyde levels following a pulse of 0.3 g/kg ethanol to volunteers from whom bloods were drawn serially for 8 hours on the clinical research unit. On discharge from the research unit, the volunteers were instructed to avoid ethanol for 28 days. The results were compared to previously published results in teetotalers and alcoholic individuals reporting for treatment at an inpatient detoxification facility. Following ethanol ingestion, the peak levels of ethanol and both plasma and hemoglobin-associated acetaldehyde were detected at the 30 min time point and plasma levels were less than those associated with hemoglobin (31 +/- 16 S.D. and 159 +/- 48 S.D. nmol/g respectively, p less than 0.001). PA and HbAA returned to baseline values following ethanol ingestion within 3.5 hours. PA returned to within 1 standard deviation of levels found in teetotalers by 5 days, whereas HbAA remained elevated for the 28 days of the study. These data provide evidence that measurement of PA and HbAA may provide a useful marker for relatively acute and chronic ethanol ingestion respectively.

Diagnosis of alcoholism

Alcoholism is among the most prevalent of the difficult diseases to establish diagnoses in medicine. This article outlines a number of steps to help in identifying the alcoholic patient. These include: a careful history, several laboratory blood tests, simple paper-and-pencil tests, and recognition of alcohol-related medical disorders.

Screening for alcoholism

Alcoholism is one of the largest public health problems of the nation and is a significant cofactor in such ubiquitous diseases as hypertension, developmental abnormalities, heart failure, liver failure, and many other conditions. The cost to the nation's health is immense. One strategy for reducing morbidity and cost has been to establish methods for screening in order to increase recognition rates leading to increased rates of therapeutic intervention. In this article, the rationale for two methods of alcohol screening, brief interviews and biological markers of excessive drinking, the relevant statistical issues bearing on this problem, and the current research on screening exams are reviewed and summarized. Finally, some of the newer approaches toward alcoholism screening as well as the consequences to the medical care system should alcohol screening eventuate on a large scale are briefly described.

Effect of chronic ethanol ingestion on alpha-mannosidase isoenzymes in rat liver

Identification of biochemical changes induced by ethanol ingestion would aid in the diagnosis and management of many alcohol-related problems in man. In this paper we identify a pH 5.5 alpha-mannosidase activity in the rat which is affected by chronic ethanol consumption. Chronic (16 wk) ingestion of alcohol (36% of calories) causes the activity of this alpha-mannosidase (thought to be the cytosolic alpha-mannosidase) in liver to decrease by 50%. We hypothesize that this deficiency of (pH 5.5) alpha-mannosidase activity may account for the reduced rate of secretion of glycoproteins by livers of alcohol-fed rats reported by other investigators (Volentine et al, Hepatology 1987;7:490-495).