Alcohol consumption and the risk of alcohol related cirrhosis in women

Sex-specific association between alcohol consumption and liver cirrhosis: An updated systematic review and meta-analysis

Different studies have shown that females develop liver diseases at lower levels of alcohol consumption than males. Our aim was to quantify the dose-response relationship between alcohol consumption and the risk of liver cirrhosis by sex and identify the differences between females and males. A systematic review was conducted using PubMed/Medline and Embase to identify longitudinal and case-control studies that analyzed the relationship between the level of alcohol use and liver cirrhosis (LC) incidence, and mortality (ICD-8 and ICD-9 codes 571 and ICD-10 codes K70, K73, K74). Pooled relative risks (RR) were calculated by random effects models. Restricted cubic splines were used to model the dose-response relationship. A total of 24 studies were included in the analysis. There were collectively 2,112,476 females and 924,853 males, and a total of 4,301 and 4,231 cases of LC for females and males, respectively. We identified a non-linear dose-response relationship. Females showed a higher risk for LC compared to males with the same amount of alcohol consumed daily. For instance, drinking 40 g/day showed RRs of 9.35 (95% CI 7.64-11.45) in females and 2.82 (95% CI 2.53-3.14) in males, while drinking 80 g/day presented RRs of 23.32 (95% CI 18.24-29.82) in females and 7.93 (95% CI 7.12-8.83) in males. Additional analyses showed that a higher risk for females was found for morbidity and for mortality. Understanding the influence of sex on the association of alcohol consumption and the risk of LC is needed to develop recommendations and clinical guidelines for prevention and treatment.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022299680, identifier CRD42022299680.

Effects of noncontingent ethanol, DHEA, and pregnanolone administration on ethanol self-administration in outbred female rats

Previous research from this laboratory demonstrated that male outbred rats (Long-Evans) can be trained to prefer ethanol (10% v/v) over water during 30-min home-cage sessions and that higher ethanol concentrations (18-32% v/v) can serve as a reinforcer under various operant schedules. Further, we have shown that two neurosteroids, dehydroepiandrosterone (DHEA) and pregnanolone, can readily decrease ethanol self-administration in males. The present study used the same procedures in an attempt to systematically replicate the previous findings in female outbred rats. Rats were first trained to self-administer ethanol in the home cage using a saccharin-fading procedure. Subsequently, a two-bottle preference test was initiated by substituting different ethanol concentrations after subjects reliably consumed 10% ethanol alone. Water was always available during this phase. Next, subjects were transitioned to a fixed-ratio 10 (FR-10) schedule of reinforcement with 0.1 mL of ethanol (18% v/v) serving as the reinforcer so that a concentration-effect curve could be established. Upon completion, subjects were transitioned to an FR-10 FR-20 multiple schedule of ethanol (32% v/v) and food reinforcement to determine whether noncontingent ethanol, DHEA, and pregnanolone could selectively decrease ethanol intake. Not surprisingly, female subjects preferentially consumed ethanol over water at concentrations of 3.2-18% (v/v) during the home-cage procedure, and significantly increased the mean dose of ethanol consumed and blood ethanol concentration (BEC). Similarly, increasing concentrations under an FR-10 schedule significantly increased the dose of ethanol presented and BEC compared to control (water). Finally, under the multiple schedule, noncontingent injections of ethanol (0.32-1.8 g/kg), DHEA (10-100 mg/kg), and pregnanolone (1.8-32 mg/kg) dose-dependently decreased food- and ethanol-maintained responding and the dose of ethanol presented. BEC was significantly decreased by the neurosteroids, but increased by ethanol due to its noncontingent administration. Together, these data replicate only a subset of the data previously obtained in males, suggesting there are sex differences particularly with respect to the effects of DHEA and pregnanolone.

Opportunities to Prevent Alcoholic Liver Cirrhosis in High-Risk Populations: A Systematic Review With Meta-Analysis

BACKGROUND

Alcoholic liver cirrhosis is preventable and caused by heavy drinking. Few in the general population may be at risk and interventions targeting individuals at high risk may be a more feasible opportunity for prevention than interventions targeting the whole population.

METHODS

We conducted a systematic review to identify opportunities to prevent alcoholic liver cirrhosis in high-risk populations. Following MOOSE guidelines, we included observational studies published between 1980 and 2017. Prospective studies of alcohol-problem cohorts were included to investigate whether alcohol-problem cohorts qualify as high-risk populations for alcoholic liver cirrhosis. Studies on the alcohol amount consumed by alcoholic liver cirrhosis patients were included to compare with the amount consumed by the general population. Moreover, studies on alcohol-related healthcare contacts prior to alcoholic liver cirrhosis diagnosis were included to identify opportunities to offer prevention interventions. Of 7198 screened references, 38 studies (N = 120,928) were included.

RESULTS

Alcohol-problem cohorts qualified as high-risk populations with an incidence of alcoholic liver cirrhosis ranging from 7 to 16% after 8-12 years. The alcohol amount consumed by alcoholic liver cirrhosis patients was high compared to the general population. For example, 45% (95%CI 34, 56) of alcoholic liver cirrhosis patients were drinking >110 g alcohol/day. Finally, there were opportunities to reach alcoholic liver cirrhosis patients prior to diagnosis; 40-61% of alcoholic liver cirrhosis patients had a previous alcohol-related healthcare contact.

CONCLUSIONS

We conclude that alcohol-problem cohorts are high-risk populations for alcoholic liver cirrhosis and there seems to be opportunities to reach later alcoholic liver cirrhosis cases with preventive interventions in healthcare settings.

Lifetime drinking history in patients with alcoholic liver disease and patients with alcohol use disorder without liver disease

OBJECTIVE

To determine the differences in lifetime alcohol intake (LAI) and drinking patterns between patients with alcoholic liver disease (ALD) and alcohol use disorder (AUD) without notable liver injury and between males and females with ALD.

METHODS

Alcohol drinking patterns were assessed using the Lifetime Drinking History (LDH) a validated questionnaire, during an outpatient visit. Patients with AUD, currently in addiction treatment, were matched for gender and age (±5 years) with the ALD group.

RESULTS

A total of 39 patients with ALD (26 males and 13 females; median age 58) and equal number of AUD patients were included (median age 56 years). The onset age for alcohol drinking and duration of alcohol consumption was similar in ALD and AUD. The number of drinking days was higher in women with ALD than in women with AUD: 4075 [(3224-6504) versus 2092 (1296-3661), p = .0253]. The LAI and drinks per drinking day (DDD) were not significantly different between patients with ALD and AUD. Females with ALD had lower LAI than males with ALD: 32,934 (3224-6504) versus 50,923 (30,360-82,195), p = .0385, fewer DDD (p = .0112), and lower proportion of binge drinking as compared to males with ALD (p = .0274).

CONCLUSIONS

The total LAI was similar in patients with ALD and AUD. The number of drinking days over the lifetime was associated with the development of ALD in females. Females with ALD had significantly lower alcohol consumption than men with ALD despite similar duration in years of alcohol intake which supports the concept of female propensity of ALD.

Drinking patterns and biochemical signs of alcoholic liver disease in Danish and Greenlandic patients with alcohol addiction

OBJECTIVES

High alcohol intake per capita and a high prevalence of hepatitis B in the population of Greenland is well documented. However, very few studies have been concerned with alcoholic liver diseases in Greenlanders, suggesting a lower prevalence of alcoholic liver disease among Greenlanders. This study was designed to document the prevalence of alcoholic liver diseases in Greenlanders with a high alcohol intake, and to describe and compare the populations of patients with alcohol addiction in Greenland and Denmark.

STUDY DESIGN

Clinical cross-sectional study of patients attending alcohol treatment centres in Greenland and Denmark regarding clinical and biochemical signs of liver disease.

METHODS

One hundred patients from each country answered a questionnaire about demographic variables, social conditions and alcohol consumption patterns. Each patient was examined clinically and biochemically with respect to signs of liver disease, and, when indicated, liver biopsies were taken.

RESULTS

42 % of the Greenlanders and 91% of Danes had abnormal liver function tests. The average Serum-Aspartate amino transferase (ALAT) was 40.0 U/L in Greenlanders and 52.0 U/L in Danes. No liver biopsies with cirrhosis or fibrosis were found in Greenland, whereas three with fibrosis and ten with cirrhosis were found in Denmark.

CONCLUSIONS

There seems to be a lower prevalence of liver disease in Greenlanders with a high alcohol intake, compared to Danes with similar alcohol patterns.

Sex Differences in Animal Models: Focus on Addiction

The purpose of this review is to discuss ways to think about and study sex differences in preclinical animal models. We use the framework of addiction, in which animal models have excellent face and construct validity, to illustrate the importance of considering sex differences. There are four types of sex differences: qualitative, quantitative, population, and mechanistic. A better understanding of the ways males and females can differ will help scientists design experiments to characterize better the presence or absence of sex differences in new phenomena that they are investigating. We have outlined major quantitative, population, and mechanistic sex differences in the addiction domain using a heuristic framework of the three established stages of the addiction cycle: binge/intoxication, withdrawal/negative affect, and preoccupation/anticipation. Female rats, in general, acquire the self-administration of drugs and alcohol more rapidly, escalate their drug taking with extended access more rapidly, show more motivational withdrawal, and (where tested in animal models of "craving") show greater reinstatement. The one exception is that female rats show less motivational withdrawal to alcohol. The bases for these quantitative sex differences appear to be both organizational, in that estradiol-treated neonatal animals show the male phenotype, and activational, in that the female phenotype depends on the effects of gonadal hormones. In animals, differences within the estrous cycle can be observed but are relatively minor. Such hormonal effects seem to be most prevalent during the acquisition of drug taking and less influential once compulsive drug taking is established and are linked largely to progesterone and estradiol. This review emphasizes not only significant differences in the phenotypes of females and males in the domain of addiction but emphasizes the paucity of data to date in our understanding of those differences.

Toll-like Receptors in the Vascular System: Sensing the Dangers Within

Toll-like receptors (TLRs) are components of the innate immune system that respond to exogenous infectious ligands (pathogen-associated molecular patterns, PAMPs) and endogenous molecules that are released during host tissue injury/death (damage-associated molecular patterns, DAMPs). Interaction of TLRs with their ligands leads to activation of downstream signaling pathways that induce an immune response by producing inflammatory cytokines, type I interferons (IFN), and other inflammatory mediators. TLR activation affects vascular function and remodeling, and these molecular events prime antigen-specific adaptive immune responses. Despite the presence of TLRs in vascular cells, the exact mechanisms whereby TLR signaling affects the function of vascular tissues are largely unknown. Cardiovascular diseases are considered chronic inflammatory conditions, and accumulating data show that TLRs and the innate immune system play a determinant role in the initiation and development of cardiovascular diseases. This evidence unfolds a possibility that targeting TLRs and the innate immune system may be a novel therapeutic goal for these conditions. TLR inhibitors and agonists are already in clinical trials for inflammatory conditions such as asthma, cancer, and autoimmune diseases, but their study in the context of cardiovascular diseases is in its infancy. In this article, we review the current knowledge of TLR signaling in the cardiovascular system with an emphasis on atherosclerosis, hypertension, and cerebrovascular injury. Furthermore, we address the therapeutic potential of TLR as pharmacological targets in cardiovascular disease and consider intriguing research questions for future study.

[Wine consumption and prevention of coronary artery disease]

There is a J-shaped correlation between the amount of alcohol consumed per day and overall mortality risk and an inverse correlation between the amount of alcohol consumed per day and cardiovascular mortality. The evidence is stronger for men than for women. The correlations are independent of the type of alcoholic beverage predominantly consumed. Possible mechanisms explaining the cardioprotective, antiatherosclerotic effects of moderate alcohol consumption are inhibition of platelet aggregation, increase in serum high density lipoprotein (HDL) levels and prevention of diabetes mellitus. The two latter mechanisms can also explain a delayed progression of atherosclerosis due to alcohol consumption. The beneficial effects are counteracted by detrimental effects of alcohol on the incidence of cancer diseases, liver cirrhosis, violence and accidents; therefore, alcohol consumption in general cannot be recommended for prevention of cardiovascular diseases.

Liver disease in patients undergoing head and neck surgery: Incidence and risk for postoperative complications

OBJECTIVES/HYPOTHESIS

Head and neck cancer patients have multiple risk factors for liver disease. However, little is known about the incidence of liver disease or the safety of surgery in these patients.

STUDY DESIGN

We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2013.

METHODS

We identified patients undergoing head and neck surgery and excluded them if preoperative laboratory data were missing. Patients were classified as having liver disease if their preoperative aspartate aminotransferase-to-platelet ratio index was ≥ 0.7, and as having advanced liver disease if their Model for End-Stage Liver Disease-Sodium score was ≥ 10. We compared the rate of postoperative complications using multivariable logistic regression.

RESULTS

Among 19,138 eligible patients, the incidence of any degree of liver disease was 6.8% for aerodigestive tract surgery and 3.3% for controls. The 30-day mortality rate after major head and neck surgery, which included composite resection; free tissue transfer; and total laryngectomy with advanced, mild, and no liver disease, was 14.6%, 3.0%, and 0.9%, respectively (P < 0.001). For nonmajor surgery, the mortality rate was 3.0%, 0.3%, and 0.3%, respectively (P < 0.001). On multivariable analysis, patients with advanced liver disease experienced a six-fold higher rate of 30-day mortality (odds ratio 6.1; 95% confidence interval, 2.9-12.8).

CONCLUSION

There is a high risk to detect liver disease in patients undergoing head and neck surgery of the aerodigestive tract. Those with advanced liver disease are at high risk for perioperative mortality, and this risk should be judiciously considered in medical/surgical decision making and postoperative care.

LEVEL OF EVIDENCE

2c. Laryngoscope, 127:102-109, 2017.

Urinary enterolactone associated with liver enzyme levels in US adults: National Health and Nutrition Examination Survey (NHANES)

Phyto-oestrogens are a family of plant-derived xeno-oestrogens that appear to have beneficial effects on human health. To date, no data are available about phyto-oestrogen consumption affecting liver health in a population. The present study aimed to explore the relationship of urinary phyto-oestrogen metabolites with serum liver enzymes in US adults. A nationally representative sample of US adults in the National Health and Nutrition Examination Survey (NHANES) 2003–10 was analysed. The cross-sectional study sample consisted of 6438 adults with data on urinary phyto-oestrogen levels, serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and γ-glutamyl transaminase (GGT) concentrations and data on other potential confounders. Multivariate logistic regression and linear regression were applied to assess associations between urinary phyto-oestrogen levels and ALT, AST, ALP and GGT concentrations. We found a remarkable association between urinary enterolactone and GGT in both adult males (OR 0·37, 95 % CI 0·22, 0·61; P= 0·003) and females (OR 0·37, 95 % CI 0·26, 0·54; P= 0·009). Moreover, elevated enterolactone levels were inversely associated with ALT and AST levels in adult males. However, no association was present between levels of urinary daidzein, O-desmethylangolensin, equol, enterodiol or genistein with liver enzyme levels in this population. The present study results provide epidemiological evidence that urinary enterolactone levels are associated with liver GGT levels in humans. This suggests a potential protective effect of enterolactone on human liver function. However, the underlying mechanisms still need further investigation.

A retrospective study of gender differences in depressive symptoms and risk of relapse in patients with alcohol dependence

BACKGROUND AND OBJECTIVES

The aim of this study was to investigate potential gender differences in situations associated with heavy alcohol drinking.

METHODS

Data from 395 alcohol dependent patients participating in the Mayo Clinic Intensive Addiction Program were evaluated. Each participant completed the inventory of drug taking situations (IDTS), Penn alcohol craving scale (PACS), patient health questionnaire (PHQ-9), and/or Beck depression inventory (BDI). Gender differences in IDTS scores representing three domains (negative, positive, and temptation) of situations associated with heavy alcohol use were examined.

RESULTS

Women with alcohol dependence report a higher frequency of heavy drinking in unpleasant emotional (IDTS negative scores mean ± SD women vs. men: 52.3 ± 22.1 vs. 43.8 ± 21.8; p = .0006), and as a result of temptation (IDTS temptation scores mean ± SD women vs. men: 40.4 ± 23.0 vs. 35.3 ± 20.8; p = .035). Upon admission, women also scored significantly higher on depressive symptoms as measured by the BDI (23.4 ± 11.4 vs. 18.2 ± 9.8, p < .001). After controlling for depressive symptom severity as a covariate, the IDTS gender differences were no longer significant.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Our results suggest that unpleasant or temptation based emotional situations are a vulnerability risk factor for heavy drinking particularly in females. This risk appears to be at least partially driven by depressive symptom burden. Future research is needed to further investigate this finding.

Serum lipid profile in alcoholic cirrhosis: A study in a teaching hospital of north-eastern India

Background:

Alcoholic cirrhosis is often associated with impaired lipid metabolism. However, there are only a few studies regarding lipid profile in alcoholic cirrhosis that have been undertaken in India. The aim of the study is to assess the degree of alteration of serum lipid profile in alcoholic cirrhotic patients and also to detect its relationship with the age of the patients and the alcohol consumption pattern.

Patients and Methods:

This cross-sectional study was conducted in a teaching hospital of north-eastern India for 1 year with 100 patients with alcoholic cirrhosis (cases) and 50 healthy individuals (controls) without history of alcohol consumption. A questionnaire of personal characteristics including history of alcoholism was completed for each patient. Serum lipid profile (total, low-density lipoprotein (LDL), high-density lipoprotein (HDL) cholesterol and triglyceride) was recorded for each case and control. t test of significance was applied for statistical analysis.

Results:

Majority of the cases were in the 41-50 years age group. There was no relationship of cirrhosis with the type of alcoholic beverage, but a definite relationship was observed with the quantity and the duration of alcohol consumption. In patients with cirrhosis, the total serum cholesterol level was decreased. There was a significant decrease in serum HDL and LDL cholesterol compared with the control group ( P < 0.001). However, the serum triglyceride levels were significantly increased in alcoholic cirrhotic patients compared with the control group ( P < 0.001).

Conclusion:

In this study, we found that there was marked alteration of serum lipid profile values in patients with alcoholic cirrhosis compared with normal, non-cirrhotic individuals. Therefore, a search for lipid profile abnormality should be performed in every cirrhotic patient.

Effects of moderate red wine consumption on liver fat and blood lipids: a prospective randomized study

BACKGROUND

There have been no human prospective randomized studies of the amount of alcohol that can induce hepatic steatosis.

METHODS

Thirty-two healthy women and twelve healthy men (34 ± 9 years of age) were randomized to consume 150 ml of red wine/day for women (16 g ethanol/day) or double that amount for men (33 g ethanol/day), or to alcohol abstention for 90 days. Participants underwent proton-nuclear magnetic-resonance spectroscopy for measurement of hepatic triglyceride content (HTGC). Blood samples for assessment of cardiovascular risk were drawn before and after the intervention.

RESULTS

After exclusion of three subjects with steatosis at baseline a trend towards increased HTGC was apparent for red wine (before median: 1.1%, range 0.2-3.9%, after median: 1.1%, range 0.5-5.2 %, P = 0.059) a difference that was statistically significant compared with abstainers (p = 0.02). However, no subject developed hepatic steatosis. Low-density lipoprotein (LDL)-cholesterol was lowered by red wine (-0.3 mmol/l, SE -0.1, 95% CI -0.6 to -0.04).

CONCLUSIONS

Moderate consumption of red wine during three months increased HTGC in subjects without steatosis at baseline. However, since not a single participant developed steatosis we suggest that the threshold of alcohol consumption to define nonalcoholic fatty liver disease should not be lower than the amount in our study.

Genetic polymorphism at codon 10 of the transforming growth factor-β1 gene in patients with alcoholic liver cirrhosis

Background/Aims

Transforming growth factor beta1 (TGF-β1) is a key cytokine in the production of extracellular matrix. A genetic polymorphism at codon 10 of the TGF-β1 gene is associated with liver fibrosis. We investigated the effect of genetic polymorphisms at codon 10 on the development of alcoholic liver cirrhosis (ALC).

Methods

In total, 119 controls and 182 patients with ALC, were enrolled in the study. Clinical and laboratory data including total lifetime alcohol intake were collected at enrollment. The genotype at codon 10 was determined for each patient by single-strand conformation polymorphism.

Results

There were three types of genetic polymorphism at codon 10: homozygous proline (P/P), heterozygous proline/leucine (P/L), and homozygous leucine (L/L). Among the controls, the proportions of P/P, P/L, and L/L were 26.1%, 44.5%, and 29.4%, respectively in the ALC group, these proportions were 23.1%, 43.4%, and 33.5%, respectively. The genotype distribution did not differ between the controls and the ALC group. In the ALC group, age, total lifetime alcohol intake, and distribution of Child-Pugh class did not differ with the genotype. Of the male patients with ALC (n=164), the proportions of P/P, P/L, and L/L were 20.1%, 44.5%, and 35.4%, respectively the genotype distribution did not differ between the male controls and the male ALC patients.

Conclusions

The genotype at codon 10 in TGF-β1 does not appear to influence the development of ALC. Further study is needed to investigate other genetic factors that influence the development of ALC in patients with chronic alcohol intake.

The rising tide of liver Cirrhosis mortality in the UK: can its halt be predicted?

AIM

To explore whether it is possible to predict future United Kingdom (UK) death rate of liver cirrhosis based on birth cohort models.

METHOD

Routinely available mortality data were plotted graphically to display the trends in cirrhosis mortality by birth cohort in several countries. Data for Italy, France, Portugal, USA, Canada, Scotland and England & Wales were plotted by birth cohort.

RESULTS

The current increase in cirrhosis mortality in the UK countries is being driven by a birth cohort effect. Later birth cohorts have much higher death rates than preceding ones. This pattern was seen in Western European and North American countries, which had also experienced increases in liver cirrhosis mortality. However, after the increases, those countries had sudden and persistent falls in death rates. For each country, the dramatic reversal of death rates occurred at a single calendar period and in every age group simultaneously.

CONCLUSION

Prediction of future death rates using information from previous cohorts is not possible due to the occurrence of sudden reversals in death rates. The sudden fall in the death rates of several birth cohorts suggests that reversing the current UK trend of rising liver cirrhosis deaths is possible.

A cohort study of the effect of alcohol consumption and obesity on serum liver enzyme levels

OBJECTIVE

To conduct a cohort study of the effect of alcohol and obesity on liver enzymes in China.

METHODS

To study 500 individuals of liver enzymes normality randomly in the 1999-year epidemiological survey, and liver enzyme levels (461 complete data) in 2006.

RESULTS

Logistic-regression analysis showed a daily alcohol intake of at least 40 g, duration of drinking at least 10 years, and obesity, which were closely related to abnormality in liver enzyme levels; the relative risk (95% confidence interval) was 2.014 (1.108-3.662), 2.085 (1.106-3.928), and 1.772 (1.140-2.754), respectively (all P<0.05). According to the value of daily alcohol intake/duration of drinking and body mass index (BMI) to categorize, seven-year cumulative incidence of liver enzymes levels abnormality for the daily alcohol intake at least 40 g and obesity group or the duration of drinking at least 10 years and obesity group was the highest, 51.47 and 47.12%, respectively. No significant dose-response relationship was found between daily alcohol intake/duration of drinking and liver enzyme level abnormalities.

CONCLUSION

The risk of alcohol consumption and obesity-inducing liver injury together is far greater than the risk of a single factor inducing liver injury. An alcoholic threshold effect may be more important than a dose-response effect on liver enzyme levels.

Alcoholic liver injury: Influence of gender and hormones

This article discusses several subjects pertinent to a consideration of the role of gender and hormones in alcoholic liver injury (ALI). Beginning with an overview of factors involved in the pathogenesis of ALI, we review changes in sex hormone metabolism resulting from alcohol ingestion, summarize research that points to estrogen as a cofactor in ALI, consider evidence that gut injury is linked to liver injury in the setting of alcohol, and briefly review the limited evidence regarding sex hormones and gut barrier function. In both women and female animals, most studies reveal a propensity toward greater alcohol-induced liver injury due to female gender, although exact hormonal influences are not yet understood. Thus, women and their physicians should be alert to the dangers of excess alcohol consumption and the increased potential for liver injury in females.

Measurement of food and alcohol intake in relation to chronic liver disease

It is well established that the consumption of alcohol is implicated in both the cause and progression of chronic liver disease. The quantity of drink that is consumed, the pattern of drinking and type of alcoholic beverages consumed are all possible factors in disease aetiology. The impact of specific dietary components on the cause and progression of chronic liver disease is unclear although it is known that obesity, and hence the over-consumption of energy, is a predictor of fatty liver. Work to elucidate the role of both diet and alcohol in the aetiology of liver disease is hindered by the methods currently available to measure dietary (including alcohol) intake. The validity and reliability of retrospective methods of assessing diet are limited by their reliance on memory and, for the 24 h recall, the short-time period of intake assessed and its inability to assess variability across the week. Prospective methods which measure food and drink intake at the time of consumption, and include weighed or estimated food diaries, are useful for prospective cohort studies but are expensive and have a high respondent burden. For estimation of alcohol intake retrospectively, the Cognitive Lifetime Drinking questionnaire, which prompts responses using a lifetime calendar, is a useful tool but still depends on memory. More work is required to develop valid, reliable and easily administered tools for measurement of both diet and alcohol.

Risk factors for alcohol-related liver injury in the island population of China: A population-based case-control study

AIM: To investigate the association of alcohol dose, duration of drinking and obesity with abnormal alcohol-related liver injury indicators, the prevalence of alcohol-related liver injury in the island population of China.

METHODS: Randomized multistage stratified cluster sampling from the island population of China was used in the population-based case-control study. Then interview, physical examination, laboratory assessments and ultrasonography were done.

RESULTS: Daily alcohol intake ≥ 20 g, duration of drinking ≥ 5 years and obesity were closely related to alcohol-related liver injury (P < 0.05). The odds-ratio (OR) (95% CI) was 1.965 (1.122-3.442), 3.412 (1.789-6.507) and 1.887 (1.261-2.824), respectively. The prevalence rate of alcohol-related liver injury in ≥ 20 g daily alcohol intake group and < 20 g daily alcohol intake group was 37.14% and 12.06%, respectively. The prevalence rate of alcohol-related liver injury in ≥ 5 years drinking group and < 5 years drinking group was 34.44% and 8.53%, respectively. No significant dose-response relation was found between daily alcohol intake and abnormal alcohol-related liver injury indicators as well as between duration of drinking and abnormal alcohol-related liver injury indicators. There was no significant difference in the prevalence of alcohol-related liver injury between beer drinking group and yellow rice wine drinking group, hard liquor drinking group, multiple drinking group.

CONCLUSION: The risk threshold of daily alcohol intake is 20 g and duration of drinking inducing alcohol-related liver injury 5 years in the island population of China. Liver injury induced by obesity should be concerned.

Light to moderate alcohol consumption is associated with lower frequency of hypertransaminasemia

OBJECTIVES

The effect of light to moderate alcohol consumption on the liver is controversial. To determine the association between light to moderate alcohol consumption and frequency of hypertransaminasemia, a cross-sectional and a subsequent longitudinal cohort study were conducted using annual health checkup data at a Japanese workplace.

METHODS

We analyzed 1,177 male subjects (age 20-59) without HCV or HBV infection or other chronic liver diseases. To determine the association between alcohol consumption (none or minimal <70 g/wk, light > or =70 g and <140 g/wk, moderate > or =140 g and <280 g/wk, excessive > or =280 g/wk) and hypertransaminasemia, we performed multiple logistic regressions. We then followed 326 subjects without a history of fatty liver or hypertransaminasemia up to 5 years for incidental hypertransaminasemia and performed Cox proportional hazard regressions.

RESULTS

Excess alcohol consumption was associated with increased odds of hypertransaminasemia (adjusted odds ratio [AOR]versus none or minimal consumption 1.4[1.1-1.93], P= 0.023). There was significant interaction between age group and alcohol consumption (P < 0.01). In the younger group, moderate consumption was associated with decreased odds (AOR 0.5 [0.3-0.9], P= 0.032), while in the older group, light consumption was associated with decreased odds (AOR 0.6 [0.4-1.0], P= 0.036) and excess consumption was associated with increased odds (AOR 1.6 [1.1-2.3], P= 0.014) of hypertransaminasemia. During follow-up, moderate consumption was associated with decreased incidence of hypertransaminasemia versus none or minimal consumption (adjusted hazard ratio 0.4 [0.1-0.9], P= 0.02).

CONCLUSION

Light to moderate alcohol consumption may protect against the development of hypertransaminasemia among male subjects without other liver conditions. Further studies are required before recommending light to moderate alcohol consumption.

Ethanol elimination rates in men and women in consideration of the calculated liver weight

The purpose of the study was to examine gender differences on the pharmacokinetics of ethanol. Sixty-eight healthy men and 64 healthy women with normal body mass indexes received between 0.79 and 0.95 g ethanol/kg body weight in the form of their choice after they had eaten a "typical" breakfast. The aimed concentration for both genders was a blood alcohol concentration C(0) of 0.104 g/dl. Blood samples in the elimination phase were taken in 10- to 20-min intervals beginning after completion of absorption. The maximum blood ethanol concentration was 0.0819+/-0.0184 g/dl for women and 0.0841+/-0.0155 g/dl for men. The hourly ethanol elimination rate, calculated over a linear function, in blood of 0.0179+/-0.0030 g/dl/h in women was significantly higher than the 0.0159+/-0.0029 g/dl/h for men (P<.0001). In relation to the liver weight, the hourly elimination rates were 5.008+/-0.678 g/kg liver/h for women and 4.854+/-0.659 g/kg liver/h for men, and were not statistically significant. The different liver masses as calculated in relation to the distribution volume account for the differing ethanol elimination rates between men and women.

Skeletal muscle protein synthesis and degradation exhibit sexual dimorphism after chronic alcohol consumption but not acute intoxication

Epidemiological evidence suggests alcoholic myopathy is more severe in females than males, but comparable animal studies are lacking that make elucidating the biochemical locus for this defect problematic. The present study determined whether skeletal muscle protein synthesis and markers of degradation exhibit a sexual dimorphic response to either chronic alcohol consumption or acute intoxication. Male and female rats were fed an alcohol-containing diet, pair-fed for 26 wk (chronic), or received an intraperitoneal injection of alcohol (acute). In males, chronic alcohol decreased gastrocnemius protein synthesis by 20%. This reduction was associated with a twofold increase in the inactive eukaryotic initiation factor (eIF) 4E.4E-binding protein 1 (4E-BP1) complex and a 60% reduction in the active eIF4E.eIF4G complex. This redistribution of eIF4E was associated with decreased phosphorylation of both 4E-BP1 and eIF4G (50-55%). The phosphorylation of ribosomal protein S6 was also reduced 60% in alcohol-consuming male rats. In contrast, neither rates of protein synthesis nor indexes of translation initiation in muscle were altered in alcohol-fed female rats despite blood alcohol levels comparable to males. Chronic alcohol ingestion did not alter atrogin-1 or muscle RING finger-1 mRNA content (biomarkers of muscle proteolysis) in males but increased their expression in females 50-100%. Acute alcohol intoxication produced a comparable decrease in muscle protein synthesis and translation initiation in both male and female rats. Our data demonstrate a sexual dimorphism for muscle protein synthesis, translation initiation, and proteolysis in response to chronic, but not acute, alcohol intoxication; however, they do not support evidence indicating females are more sensitive toward the development of alcoholic skeletal muscle myopathy.

Liver, alcohol and gender

Gender differences in alcohol-induced liver injury have been well described. Females develop alcoholic liver injury more rapidly and have a lower alcohol toxic threshold than men. The mechanism for this difference is poorly characterized, differences in first-pass metabolism in the stomach, or elimination rate, or alcohol distribution volume in the body have been suggested. In addition, estrogen has a major influence on the susceptibility of Kupffer cells to gut-derived LPS resulting in increased proinflammatory cytokine production, which could be a major contributing factor to the increased risk of women to alcohol-induced liver disease.

Review article: alcoholic liver disease--pathophysiological aspects and risk factors

BACKGROUND

Alcoholic liver disease has a known aetiology but a complex and incompletely known pathogenesis. It is an extremely common disease with significant morbidity and mortality, but the reason why only a relatively small proportion of heavy drinkers progress to advanced disease remains elusive.

AIM

To recognize the factors responsible for the development and progression of alcoholic liver disease, in the light of current knowledge on this matter.

METHODS

We performed a structured literature review identifying studies focusing on the complex pathogenetic pathway and risk factors of alcoholic liver disease. Results In addition to the cumulative amount of alcohol intake and alcohol consumption patterns, factors such as gender and ethnicity, genetic background, nutritional factors, energy metabolism abnormalities, oxidative stress, immunological mechanisms and hepatic co-morbid conditions play a key role in the genesis and progression of alcoholic liver injury.

CONCLUSIONS

Understanding the pathogenesis and risk factors of alcoholic liver disease should provide insight into the development of therapeutic strategies.

The medical complications of alcohol use: understanding mechanisms to improve management

The use of alcohol in a dependent or even a regular heavy pattern predisposes the drinker to a range of adverse consequences. These include a risk of direct harm from alcohol, including organ damage, mental health disorders and a range of social and legal problems associated with behaviours due to alcohol's effects. The range of organ damage associated with regular heavy alcohol consumption is well described. Much new information on the mechanisms by which damage occurs is available and is reviewed in this paper. New knowledge can assist in the development of more appropriate management strategies for those affected by the medical complications of alcohol use. Genetic susceptibility to tissue injury is explored and the reasons why many heavy drinkers do not appear to experience organ damage are considered. Approaches to the management of certain alcohol-related disorders are outlined.

Nonalcoholic fatty liver disease: from steatosis to cirrhosis

Nonalcoholic steatohepatitis (NASH), the lynchpin between steatosis and cirrhosis in the spectrum of nonalcoholic fatty liver disorders (NAFLD), was barely recognized in 1981. NAFLD is now present in 17% to 33% of Americans, has a worldwide distribution, and parallels the frequency of central adiposity, obesity, insulin resistance, metabolic syndrome and type 2 diabetes. NASH could be present in one third of NAFLD cases. Age, activity of steatohepatitis, and established fibrosis predispose to cirrhosis, which has a 7- to 10-year liver-related mortality of 12% to 25%. Many cases of cryptogenic cirrhosis are likely endstage NASH. While endstage NAFLD currently accounts for 4% to 10% of liver transplants, this may soon rise. Pathogenic concepts for NAFLD/NASH must account for the strong links with overnutrition and underactivity, insulin resistance, and genetic factors. Lipotoxicity, oxidative stress, cytokines, and other proinflammatory mediators may each play a role in transition of steatosis to NASH. The present "gold standard" management of NASH is modest weight reduction, particularly correction of central obesity achieved by combining dietary measures with increased physical activity. Whether achieved by "lifestyle adjustment" or anti-obesity surgery, this improves insulin resistance and reverses steatosis, hepatocellular injury, inflammation, and fibrosis. The same potential for "unwinding" fibrotic NASH is indicated by studies of the peroxisome proliferation activator receptor (PPAR)-gamma agonist "glitazones," but these agents may improve liver disease at the expense of worsening obesity. Future challenges are to approach NAFLD as a preventive public health initiative and to motivate affected persons to adopt a healthier lifestyle.

Smoking and alcohol consumption among the elderly: trends and associations, 1985-2001

BACKGROUND

Despite their clear association with health, smoking and alcohol consumption among elderly people have not been extensively researched. This study examined changes in smoking and alcohol consumption and their sociodemographic patterning among the Finnish population aged 65-79 years over the period 1985-2001.

METHODS

Population-based monitoring surveys conducted biennially from 1985 to 2001 were pooled into three time periods. Trends in smoking and alcohol consumption and their sociodemographic variations among 5870 men and 5923 women were calculated. Logistic regression was used as the main method of analysis.

RESULTS

Smoking declined slightly among men, and consumption of higher levels of alcohol rose in both genders from the mid-1980s to the early 2000s. Smoking among women remained at a very low level throughout the study period. Smoking and higher level of alcohol consumption were more prevalent among the younger elderly and among the men than among their counterparts. Higher alcohol use was more common among retired office workers than other former employees. Smoking was clearly more prevalent among unmarried than married people.

CONCLUSIONS

Declining numbers of male smokers and remarkably few female smokers, together with positive changes already noted in diet and functional ability, suggest healthier senior years ahead. On the other hand, the rising trend of alcohol use poses a challenge to future public health.

Alcohol and cirrhosis: dose--response or threshold effect?

BACKGROUND/AIMS

General population studies have shown a strong association between alcohol intake and death from alcoholic cirrhosis, but whether this is a dose-response or a threshold effect remains unknown, and the relation among alcohol misusers has not been studied.

METHODS

A cohort of 6152 alcohol misusing men and women aged 15-83 were interviewed about drinking pattern and social issues and followed for 84,257 person-years. Outcome was alcoholic cirrhosis mortality. Data was analyzed by means of Cox-regression models.

RESULTS

In this large prospective cohort study of alcohol misusers there was a 27 fold increased mortality from alcoholic cirrhosis in men and a 35 fold increased mortality from alcoholic cirrhosis in women compared to the Danish population. Number of drinks per day was not significantly associated with death from alcoholic cirrhosis, since there was no additional risk of death from alcoholic cirrhosis when exceeding an average daily number of five drinks (>60 g/alcohol) in neither men nor women.

CONCLUSIONS

The results indicate that alcohol has a threshold effect rather than a dose-response effect on mortality from alcoholic cirrhosis in alcohol misusers.

Pathogenesis and management of alcoholic hepatitis

Alcoholic hepatitis is a potentially life-threatening complication of alcoholic abuse, typically presenting with symptoms and signs of hepatitis in the presence of an alcohol use disorder. The definitive diagnosis requires liver biopsy, but this is not generally required. The pathogenesis is uncertain, but relevant factors include metabolism of alcohol to toxic products, oxidant stress, acetaldehyde adducts, the action of endotoxin on Kupffer cells, and impaired hepatic regeneration. Mild alcoholic hepatitis recovers with abstinence and the long-term prognosis is determined by the underlying disorder of alcohol use. Severe alcoholic hepatitis is recognized by a Maddrey discriminant function >32 and is associated with a short-term mortality rate of almost 50%. Primary therapy is abstinence from alcohol and supportive care. Corticosteroids have been shown to be beneficial in a subset of severely ill patients with concomitant hepatic encephalopathy, but their use remains controversial. Pentoxifylline has been shown in one study to improve short-term survival rates. Other pharmacological interventions, including colchicine, propylthiouracil, calcium channel antagonists, and insulin with glucagon infusions, have not been proven to be beneficial. Nutritional supplementation with available high-calorie, high-protein diets is beneficial, but does not improve mortality. Orthotopic liver transplantation is not indicated for patients presenting with alcoholic hepatitis who have been drinking until the time of admission, but may be considered in those who achieve stable abstinence if liver function fails to recover.

[Bacterial infection in cirrhotic patient]

BACKGROUND

Bacterial infections at admission or during hospitalization are frequent complication of cirrhosis that occurs in about 30% of the cases. Furthermore they are responsible for 25% of deaths in this population.

AIM

Evaluate the prevalence of bacterial infections in cirrhotic patients at a general hospital and determine its correlation with alcoholic etiology of liver disease; degree of hepatic dysfunction and upper gastrointestinal bleeding.

PATIENTS/METHODS

Five hundred and forty one admissions were retrospectively evaluated in 426 cirrhotic patients at years 1992 to 2000. The mean age was 50.5 years (15-95), being 71.2% male. The alcoholic etiology of cirrhosis was 35.4%. The main outcome considered was discharge or death during admission.

RESULTS

One hundred and thirty five episodes of bacterial infections (25%) were diagnosed. The most frequent are urinary tract infection (31.1%), spontaneous bacterial peritonitis (25.9%) and pneumonia (25.2%). The association between urinary tract infection and pneumonia occurred in 3.7% and erysipelas or cellulites in 11.1%. Bacteremia occurred in 2.9%. There was a correlation between bacterial infection and alcoholic etiology of liver disease, hepatic dysfunction and upper gastrointestinal bleeding. The mortality was higher in the infected patients (8.9%) and in those with a poor hepatic function.

CONCLUSIONS

Bacterial infections are common complications in cirrhotic patients and are correlated with alcoholic etiology, Child Pugh classification and upper gastrointestinal bleeding. Furthermore, bacterial infections are correlated with poor prognosis.

Sex differences in ethanol-related behaviors in genetically defined murine stocks

Over the past 30 years, there have been a number of important developments in our understanding of the etiology and consequences of excessive drinking among humans. Probably one of the most important findings to date is that there are large individual differences among humans in appetite for alcohol and age of onset of problem drinking. We recognize this finding in at least two different alcoholic types, each with its own estimate of genetic influence. We have also come to realize that there are important differences between men and women, both in etiology of problem drinking and in the consequences of chronic alcohol use. In this chapter, the advantages and limitations of applying genetically defined animal models, primarily, selected lines and inbred strains of mice, are evaluated with examples from the literature.

Gender affects reperfusion injury in rat liver

Sex mismatch is a well-known risk factor for chronic rejection of liver allografts, but the mechanisms involved remain unclear. Since experimental observations suggest that female liver is more sensitive to reperfusion injury than male liver, we assessed the influence of gender on oxidative stress. Livers from male and female rats were exposed to warm ischemia and reperfused by an oxygenated buffer. Chemiluminescence was continuously recorded. Reduced and oxidized glutathione and malondialdehyde lactic dehydrogenase values were also determined. Chemiluminescence increased during reperfusion in both groups, but was significantly greater in livers from female rats. Malondyaldehyde and lactic dehydrogenase progressively increased in all animals, reaching significantly greater values in female rats. Livers from female rats showed an increase in all the parameters of oxidative stress compared to male animals. A greater susceptibility to reperfusion injury may be evoked as an alternative mechanism to explain the poor outcome of female organ after liver transplantation.

The health effects of moderate alcohol intake in humans: an epidemiologic review

A large body of scientific evidence associates the moderate intake of alcohol with reduced mortality among middle-aged and older people in industrialized societies. This association is due largely to a reduced risk of death from coronary heart disease, which appears to outweigh any possible adverse effects of moderate drinking. The regular consumption of small amounts of alcohol is more healthful than the sporadic consumption of larger amounts. No beneficial effect of moderate drinking on mortality has been demonstrated in young adults (premenopausal women and men who have not reached their forties). It is theoretically possible that moderate drinking in young adulthood might reduce the risk of later heart disease; however, this has not been clearly demonstrated. For some individuals (e.g., those who cannot keep their drinking moderate, pregnant women, and those who are taking medications that may interact adversely with alcoholic beverages), the risks of alcohol consumption, even in moderation, outweigh any potential benefits. Because even small amounts of alcohol can impair judgment and coordination, no one should drink alcoholic beverages, even in moderation, before driving a motor vehicle or performing other activities that involve attention and skill.

Human variability and susceptibility to trichloroethylene

Although humans vary in their response to chemicals, comprehensive measures of susceptibility have generally not been incorporated into human risk assessment. The U.S. EPA dose-response-based risk assessments for cancer and the RfD/RfC (reference dose-reference concentration) approach for noncancer risk assessments are assumed to protect vulnerable human subgroups. However, these approaches generally rely on default assumptions and do not consider the specific biological basis for potential susceptibility to a given toxicant. In an effort to focus more explicitly on this issue, this article addresses biological factors that may affect human variability and susceptibility to trichloroethylene (TCE), a widely used halogenated industrial solvent. In response to Executive Order 13045, which requires federal agencies to make protection of children a high priority in implementing their policies and to take special risks to children into account when developing standards, this article examines factors that may affect risk of exposure to TCE in children. The influence of genetics, sex, altered health state, coexposure to alcohol, and enzyme induction on TCE toxicity are also examined.

Light-to-moderate alcohol consumption and mortality in the Physicians' Health Study enrollment cohort

OBJECTIVES

This study examined the relationship between light-to-moderate alcohol consumption and cause-specific mortality.

BACKGROUND

Previous studies suggest a J-shaped relation between alcohol and total mortality in men. A decrease in cardiovascular disease (CVD) mortality without a significant increase in other causes of mortality may explain the overall risk reduction at light-to-moderate levels.

METHODS

We conducted a prospective cohort study of 89,299 U.S. men from the Physicians' Health Study enrollment cohort who were 40 to 84 years old in 1982 and free of known myocardial infarction, stroke, cancer or liver disease at baseline. Usual alcohol consumption was estimated by a limited food frequency questionnaire.

RESULTS

There were 3,216 deaths over 5.5 years of follow-up. We observed a U-shaped relationship between alcohol consumption and total mortality. Compared with rarely/never drinkers, consumers of 1, 2 to 4 and 5 to 6 drinks per week and 1 drink per day had significant reductions in risk of death (multivariate relative risks [RRs] of 0.74, 0.77, 0.78 and 0.82, respectively) with no overall benefit or harm detected at the > or =2 drinks per day level (RR = 0.95; 95% confidence interval (CI), 0.79 to 1.14). The relationship with CVD mortality was inverse or L-shaped with apparent risk reductions even in the highest category of > or =2 drinks per day (RR = 0.76; 95% CI, 0.57 to 1.01). We found no clear harm or benefit for total or common site-specific cancers. For remaining other cancers, there was a nonsignificant 28% increased risk for those consuming > or =2 drinks per day.

CONCLUSIONS

These data support a U-shaped relation between alcohol and total mortality among light-to-moderate drinking men. The U-shaped curve may reflect an inverse association for CVD mortality, no association for common site-specific cancers and a possible positive association for less common cancers.

Alcohol problems in a general hospital

Alcohol is a ubiquitous drug which is responsible for a substantial amount of ill health and approximately 20% of patients in a general hospital will have alcohol-related problems, although only 4% will be admitted with alcohol-caused conditions. Eight per cent of patients, however, can be expected to have sufficient neuroadaptation to be at risk of withdrawal. This level of prevalence of alcoholism in general hospital patients requires that hospitals must become expert at providing good quality care for alcohol-related problems in all areas including obstetrics, but particularly in the management of intoxication, withdrawal and the various alcohol-related diseases. This paper provides some suggested benchmarks for acceptable standards of care for alcohol problems in the acute hospital.

The use of alcohol by lesbians: a review and research agenda

This article reviews the literature on alcohol use by lesbians. Comparisons of data on lesbians and women from the general population show that lesbians tend to drink more than other women; that rates of drinking do not decline with age as is true for general population women; and that even when levels of drinking are equivalent between lesbians and general population women, lesbians report greater difficulties related to alcohol consumption. Differences in sampling techniques and differences in definitions of drinking among the papers made comparisons of results difficult. These issues are discussed and recommendations are made concerning standardization of data collection.

Medical risks for women who drink alcohol

OBJECTIVE

To summarize for clinicians recent epidemiologic evidence regarding medical risks of alcohol use for women.

METHODS

MEDLINE and PsychINFO, 1990 through 1996, were searched using key words "women" or "woman," and "alcohol." MEDLINE was also searched for other specific topics and authors from 1980 through 1996. Data were extracted and reviewed regarding levels of alcohol consumption associated with mortality, cardiovascular disease, alcohol-related liver disease, injury, osteoporosis, neurologic symptoms, psychiatric comorbidity, fetal alcohol syndrome, spontaneous abortion, infertility, menstrual symptoms, breast cancer, and gynecologic malignancies. Gender-specific data from cohort studies of general population or large clinical samples are primarily reviewed.

MAIN RESULTS

Women develop many alcohol-related medical problems at lower levels of consumption than men, probably reflecting women's lower total body water, gender differences in alcohol metabolism, and effects of alcohol on postmenopausal estrogen levels. Mortality and breast cancer are increased in women who report drinking more than two drinks daily. Higher levels of alcohol consumption by women are associated with increased menstrual symptoms, hypertension, and stroke. Women who drink heavily also appear to have increased infertility and spontaneous abortion. Adverse fetal effects occur after variable amounts of alcohol consumption, making any alcohol use during pregnancy potentially harmful.

CONCLUSIONS

In general, advising nonpregnant women who drink alcohol to have fewer than two drinks daily is strongly supported by the epidemiologic literature, although specific recommendations for a particular woman should depend on her medical history and risk factors.

Gender differences in ethanol preference and ingestion in rats. The role of the gonadal steroid environment

An ethanol oral self administration paradigm showed the existence of gender differences in alcohol preference in rats: whereas males and females initiated alcohol drinking at similar rates, females maintained their preference for ethanol over a longer duration. Neonatal estrogenization of females, which effectively confers a male phenotype on a genetically female brain, resulted in patterns of drinking that were similar to those displayed by intact male rats, indicating that gender differences in alcohol drinking patterns may be, at least partially, accounted for by sexual differentiation of the brain. To test whether gonadal steroids also exert activational effects on ethanol-seeking behavior, we also examined the effects of gonadectomy alone, or in combination with gonadal steroid replacement therapy. Castration did not significantly alter ethanol consumption in males, although treatment of castrated rats with dihydrotestosterone resulted in a significant inhibition of this parameter. As compared with the situation in intact female rats, ethanol ingestion was significantly reduced in ovariectomized female rats receiving estradiol (E2) and in ovariectomized female rats receiving combined E2 and progesterone replacement therapy. However, neither ovariectomy nor progesterone replacement in ovariectomized rats resulted in ethanol drinking patterns that were different compared to those observed in intact female controls. Thus, dihydrotestosterone and E2, respectively, appear to exert modulatory influences on the male and female rats' preference for ethanol, but further investigations are necessary to determine to what extent these effects result from activational actions on the brain.

Tobacco, alcohol, and drug use in a primary care sample: 90-day prevalence and associated factors

BACKGROUND

Primary care settings are an ideal system in which to identify and treat substance use disorders.

OBJECTIVE

To ascertain the prevalence of tobacco, alcohol, and drug use in the office of 88 primary care clinicians by gender, age and ethnicity.

METHOD

21,282 adults ages 18-65 completed a self-administered Health Screening Survey while participating in a trial for early alcohol treatment.

RESULTS

The period prevalence of tobacco use was 27%. For alcohol: abstainers 40%, low risk drinkers 38%, at-risk drinkers 9%, problem drinkers 8%, and dependent drinkers 5%. Twenty percent of the sample reported using illicit drugs five or more times in their lifetime and 5% reported current illicit drug use. There were marked differences in alcohol use disorders by age and ethnicity. The majority of persons who smoked reported the desire to cut down or stop using tobacco.

SIGNIFICANCE

This is the first report on the combined prevalence of tobacco, alcohol and drug disorders in a large sample of persons attending community-based non-academic primary care clinics. This report confirms the high prevalence of these problems and suggests that patients will accurately complete a self-administered screening test such as the Health Screening Survey. The office procedures developed for this study provide Managed Care Organizations with a system of care that can be used to screen all persons for tobacco, alcohol and drug use disorders.

Independent and combined action of hepatitis C virus infection and alcohol consumption on the risk of symptomatic liver cirrhosis

Although alcohol intake and hepatitis C virus (HCV) infection are the major determinants of liver cirrhosis (LC) in Western countries, the joint effect of these two factors on LC risk has not yet been adequately studied. We used data from two hospital-based case-control studies performed in Italy. Cases were 285 cirrhotic patients admitted for the first time to district hospitals for liver decompensation. Controls were 417 patients admitted during the same period, and in the same hospitals as the cases, for acute diseases unrelated to alcohol. Alcohol consumption was expressed as lifetime daily alcohol intake (LDAI). Serum HCV antibodies (anti-HCV) were detected using a second-generation test and recombinant immunoblotting assay. We found a dose-effect relationship between LDAI and the risk of LC in both anti-HCV-negative and -positive subjects. Considering the extreme LDAI categories (LDAI = 0 g, lifetime teetotalers, and LDAI = 175 g), the LC odds ratios increased from 1.0 (reference category) to 15.0 (95% CI, 7.1-31.7) and from 9.2 (95% CI, 2.0-43.2) to 147.2 (95% CI, 42.1-514.3) in anti-HCV-negative and -positive patients respectively. The interaction between LDAI and HCV showed an additive structure for LDAI < 50 g/day and a multiplicative structure for consumption > 125 g/day. Alcohol intake and HCV infection are independent risk factors for symptomatic liver cirrhosis, each being sufficient to induce the disease. In subjects with high alcohol intake, the coexistence of HCV infection multiplies the alcohol-associated risk of cirrhosis. In subjects with low alcohol intake, other factors could be involved.

At-risk drinking in an HMO primary care sample: prevalence and health policy implications

OBJECTIVES

This study was designed to determine the prevalence of at-risk drinking using varying alcohol use criteria.

METHODS

A period prevalence survey was conducted in 22 primary care practices (n = 19372 adults).

RESULTS

The frequency of at-risk alcohol use varied from 7.5% (World Health Organization criteria) to 19.7% (National Institute on Alcohol Abuse and Alcoholism criteria). A stepwise logistic model using National Institute on Alcohol Abuse and Alcoholism criteria found male gender, current tobacco use, never married status, retirement, and unemployment to be significant predictors of at-risk alcohol use.

CONCLUSIONS

Public health policy needs to move to a primary care paradigm focusing on identification and treatment of at-risk drinkers.