Clinical management methods for out-patients with alcohol dependence.

BACKGROUND: In France outpatient centres for the care of alcoholics are healthcare establishments providing medical, psychological and social support. Although they meet the practical needs of these patients, their degree of use in each of these domains and the respective mobilisation of different skills by the care team are not well understood. Our aim was therefore to determine in detail the management involved as a function of the severity of alcohol dependence. For this purpose, all the procedures involved were compiled in a thesaurus describing its type (psychological, medical, social, reception), its scheduled or unscheduled nature, its method (face-to-face, telephone, letter) and its duration. The severity of dependence was evaluated using the Addiction Severity Index (ASI). RESULTS: 45 patients were included and followed-up during 291 +/- 114 days. The mean initial ASI scores (+/- SD) were: medical (M) = 0.39 +/- 0.3, working-income (ER) = 0.5 +/- 0.3, alcohol (A) = 0.51 +/- 0.2, illicit drugs (D) = 0.07 +/- 0.08, legal (L) = 0.06 +/- 0.13, familial and social environment (FS) = 0.34 +/- 0.26, psychological (P) = 0.39 +/- 0.22. The total number of procedures was 1341 (29.8 per patient) corresponding to 754.4 hours (16.7 per patient). The intensity of management peaked during the first month of treatment, and then declined rapidly; the maximum incidence of abstinence was observed during the 3rd month of management. Interviews with patients, group therapy and staff meetings represented 68.7%, 9.9% and 13.9% of all procedures, respectively. In patients with severe dependence, as compared to moderate, management was twice as intense in the psychological and social domains, but not in the medical domain. The ASI questionnaire was completed a second time by 24 patients, after an average of 3.2 months. The improvement was significant in the M, A, D and P domains only. CONCLUSION: This study provided an overview of the methods employed in managing a sample of patients consulting an alcoholism centre in line with standards for medical, psychological and social establishments. The predominance of the social and psychological domains over the medical domain was clearly established. Relapses were common after the third month of treatment, but a remobilisation of teams made it possible to contain them. These results provide a framework for discussions on the organisation of healthcare systems and highly suggest that staff need to maintain a constant level of care throughout the treatment process.

Variation in AUDIT (Alcohol Use [correction of Used] Disorder Identification Test) scores within the first weeks of imprisonment.

AIMS: Although the prevalence of alcohol problems amongst detainees is suspected to be high, often only more flagrant problems are detected, restricting the possibilities for intervention in alcohol misuse and reducing opportunities for preventive efforts. This study examined the re-test reliability of AUDIT (the Alcohol Use Disorder Identification Test) in screening prisoners METHODS: AUDIT was administered for the first time on the day of entry to prison and again about 15 days later. The results were analysed according to two AUDIT thresholds: a score of 8 or higher and 12 or higher. RESULTS: Of 75 consecutive entrants tested, 47 male prisoners completed the study. At the first administration, 19.1% of these 47 men met criteria for a probable alcohol problem but this percentage rose to 59.6% on the second occasion (P = 0.0001). The proportion of subjects with a score 12 or higher (probably dependent) was 10.6% the first time versus 42.6% the second time (P = 0.0001). In the 19 who scored positive at the second administration only, changes in answers to the 10 items were coherent with a total score growing from 3.0 to 18.1 (P = 0.0001). No prisoner had a lower AUDIT score on the second administration. As alcohol problems are not routinely considered during the medical and biological examination at entry, no confirmation of the AUDIT results could be obtained, although those obtained at the second administration fitted well with the prevalence rates in previous reports. CONCLUSIONS: AUDIT, for the purpose of giving a prevalence estimate or to enter appropriate prisoners into more detailed assessment or interventions, should not be conducted immediately at entry, but some weeks later.

Effect of champagne compared to still white wine on peripheral neurotransmitter concentrations.

To evaluate how the peripheral release of neurotransmitters such as serotonin, dopamine, cholecystokinin, and beta-endorphin is involved in drinking behavior, blood concentrations of these neurotransmitters were followed in 40 healthy young volunteers during the first hour after ingestion of a moderate dose of some common alcoholic beverages (champagne, still white wine) as compared to water. Concerning serotonin levels, two groups of subjects are statistically distinct: one with low basal serotonin levels (< 620 nmol/L) which responded with an increase in serotonin (52% in 10 minutes), and a second group with higher basal serotonin levels (> 620 nmol/L) which responded with a decrease ( 190% in 60 minutes). Variations in serotonin concentrations appear to depend upon the alcoholic content of the beverage. A rapid increase in plasma dopamine concentrations after consumption of champagne seems to be due to the nonalcoholic content of the beverage. Cholecystokinin values were not significantly different between the three beverages: the observed increase can be explained by a moderate gastric distention. Beta-endorphin levels didn't change significantly after drinking. In conclusion, some significant blood variations of serotonin and dopamine appeared even after moderately dose of champagne or still white wine. These changes might be partially responsible for the different drinking behavior.

Relapsing cardial stenosis after laparoscopic nissen treated by esophageal stenting.

Dysphagia after antireflux surgery is often a challenging situation. We report the case of a patient with relapsing cardial stricture and a weight loss of 24 kg following a laparoscopic Nissen procedure. Initial presentation was consistent with the diagnosis of pseudoachalasia and was resistant to endoscopic dilatation. Dysphagia was relieved by surgery, which showed cardial strangulation by tightly sutured diaphragmatic pillars. Symptoms and cardial stricture relapsed after a few months with no significant relief after repeated dilatations. Conservative treatment by endoscopic transcardial prosthesis for six weeks allowed a return to normal diet and a weight gain of 10 kg within a 30-month followup period.

[Effect of assisted ventilation and position on gastro-esophageal acid reflux after laparotomy]. / Effet de la ventilation assistée et de la position sur le reflux gastro-oesophagien acide après laparotomie.

AIMS: Gastro-esophageal reflux disease (GERD) is frequent in mechanically ventilated patients, often source of hemorragic or respiratory complications. The aim of this study was to determine promoting factors for acid reflux and to define the role of methods of ventilation and body position on reflux. METHODS: Fifteen patients with no history of GERD were included, following scheduled abdominal surgery. Reflux was measured in the proximal and distal esophagus by pH-metry. Events associated with reflux were detected by a videocamera linked to a videocassette recorder synchronized to the pH data logger. Position of the patients was randomized between supine and recumbent 30 degrees. Patients were first placed on mechanical ventilation then breathed spontaneously, determining 2 periods of equal duration during which provocative maneuvers were carried out. RESULTS: Acid reflux was absent in recumbent 30 degrees posture. Acid contact time and number of reflux in supine posture were 0.5 +/- 0.4% and 0.3 +/- 0.2/h respectively with mechanical ventilation and 4 +/- 2.5% and 1 +/- 0.5/h respectively with spontaneous breathing (P<0.05 vs position 30 degrees ) in distal esophagus. Twenty-five% of reflux episodes were associated with an event, mainly cough. CONCLUSION: Acid reflux is rare immediately following laparotomy. Seventy-five per cent of reflux occurred without any detectable event. Reflux was absent in semi recumbency. Mechanical ventilation did not facilitate reflux.

[Attitudes and opinions of private practitioners towards alcoholism. A survey in the Languedoc-Roussillon region]. / Attitudes et opinions des médecins libéraux sur l'alcoolisme. Une enquête en région Languedoc-Roussillon.

OBJECTIVE: Information on the position of private practitioners faced with the problem of alcoholism mainly concerns the role of the general practitioner in the follow-up of these patients and there is little information from private specialists, hence the need for new data METHOD: All the general practitioners and specialists in the Languedoc-Roussillon area were interviewed through a mailed questionnaire regarding their opinion on alcohol consumption and public health; their definition of the risks; moderate consumption and health; how they approached the question of drinking during consultations and their involvement in training and prevention. RESULTS: Six hundred sixty-five practitioners (12.4% of those interviewed) returned the questionnaire. The profile of those who replied was identical to that of the whole population surveyed. The medical corps is clearly aware of the need to fight against alcohol abuse, but this is associated with a relative ignorance of the basics of alcoholism, a non-systematic approach of the question of drinking during consultations, little involvement in its management, limited use of the specialised structures and limited training on the question. The specialists are less involved than the general practitioners, but appear more at ease when approaching the question of drinking with their patients and resort more frequently to specialised structures than the general practitioners. Continued medical training on alcoholism only concerned a minority of practitioners and its practical impact was low. CONCLUSION: With regard to alcoholism, the practitioners fulfill their role in providing medical care, within the limits of available therapeutic resources, but their role with regard to the reduction of the risks, i.e., primary or early prevention is more or less disregarded.

Wine consumption is not associated with a decreased risk of alcoholic cirrhosis in heavy drinkers.

AIMS: While it was thought that all alcoholic beverages share a similar liver toxicity when drunk at a high level, recent epidemiological surveys have suggested that wine drinking might decrease the risk of alcoholic cirrhosis in heavy drinkers. Therefore, we performed a study aiming to analyse the type and the intake levels of alcoholic beverages in heavy drinkers according to the severity of the liver disease. METHODS: This is a case-control study enrolling 42 cirrhotic and 60 non-cirrhotic patients. Liver status was assessed using clinical, biological, histological and ultrasonographic procedures. Alcohol consumption was recorded using the Lifetime Drinking History method. RESULTS: We did not find any significant differences in total alcohol consumption between cases and controls and, moreover, in our series, the relative percentage of pure alcohol drunk in wine was significantly higher in cirrhotic, than in non-cirrhotic, patients. CONCLUSIONS: Our results confirm that the absence of a link between the type of alcoholic beverage and the occurrence of cirrhosis is still valid.