Long-term outcome of the Malmö preventive project: mortality and cardiovascular morbidity.

OBJECTIVES: To analyse the effects on mortality and cardiovascular morbidity in a population-based sample, invited to an intervention programme incorporating a baseline screening examination and treatment programmes for subjects with cardiovascular risk factors, high alcohol intake and, in women, suspicion of breast cancer on mammography. SETTING: Section of Preventive Medicine, Department of Medicine, University Hospital, Malmö, Sweden. SUBJECTS: Birth cohorts (aged 32-51 years) invited to screening examination (men = 9. 923; women = 4.422) were compared to birth cohorts not invited (men = 6.655; women = 4.290). Mean participation rate in the invited cohorts was 71% (range 64-78%). SCREENING EXAMINATION: Between 1974 and 1992 a baseline screening including a physical examination, blood pressure, a questionnaire regarding, e.g. family history, lifestyle, and socio-economic factors, laboratory tests of serum cholesterol, triglycerides, gamma-glutamyl-transferase, blood glucose before and after an oral glucose load, as well as a mammography examination in women, was performed. INTERVENTIONS: Subjects with hypertension; hyperlipidaemia; diabetes or glucose intolerance; high alcohol intake; or, in women, suspicion of breast cancer were referred to special outpatient clinics. MAIN OUTCOME MEASURES: Total and cause-specific mortality, nonfatal myocardial infarction, and stroke, from the screening examination until the end of 1995, was followed in both the intervention and control groups, using national and/or local registries. RESULTS: Total mortality did not differ significantly between the intervention group and control group. Cause-specific deaths were also similar except for 'other' deaths amongst men being significantly lower in the intervention group, mainly due to a lower mortality from 'other' causes (suicide, alcohol related deaths) in men under 40 years of age at baseline. Women under 40 years of age had a significantly lower mortality from cancer in the intervention group than in the control group. Nonfatal myocardial infarction and stroke did not differ between intervention and control group in either sex. Within the invited birth cohorts, nonparticipants had a higher total and cause-specific mortality. CONCLUSIONS: Risk factor screening for major diseases such as cardiovascular disease, alcohol abuse, diabetes mellitus and breast cancer, and subsequent treatment of the detected risk factors/diseases - The Malmö Preventive Project - did not reduce total mortality in the intervention group as a whole. In subjects under 40 years of age at entry, total mortality was lower in the intervention group than in the control group. In men, this seemed to be due to a reduction of alcohol-related deaths, whilst in women death from cancer was reduced.

Acupuncture in alcoholism treatment: a randomized out-patient study.

Seventy-two alcoholics were treated with acupuncture to the ear in a randomized single-blind controlled design over 10 weeks. Orthodox points and incorrect points 3-5 mm from orthodox points were used. No initial differences were found regarding social characteristics, the responses to the Swedish version of the Alcohol Use Inventory and the Three-dimensional Personality Questionnaire, indicating a successful randomization. There were non-significant tendencies towards gender differential response after acupuncture treatment (P = 0.07). There was no difference in the number of drinking days or level of craving between treatment and control patients. Among females, those in the treatment group reported reduction of anxiety after 1 month, more often than those in the control group (P < 0.05). Response to acupuncture was not related to personality or drinking pattern. Patients' experience of needle placement was similar in the study and control groups. The effects of acupuncture were less pronounced than those previously reported.

[Drunken driver examinations. CD-transferrin is a valuable marker of alcohol consumption]. / Undersökningar vid en körkortsmottagning. CD-transferrin värdefull markör på alkoholkonsumtion.

The article reports findings in a study of 198 subjects attending a psychiatric out-patient clinic, with known or suspected high alcohol consumption during a 12-month period, about half of whom had had their driving licences revoked. The level of carbohydrate-deficient transferrin (CDT) was found to be a valuable marker of alcohol consumption, and a useful adjunct to the measurement of liver enzymes. Both GGT (gamma-glutamyltransferase) and CDT levels were significantly higher in high alcohol consumers than in low consumers. Alcohol the two markers did not differ from each other in statistical significance, CDT was associated with greater sensitivity and specificity; the sensitivity of CDT was 69% for men and 79% for women, as compared with 62% and 40%, respectively, for GGT; the specificity of CDT was 81% for men and 100% for women, as compared with 82% and 72%, respectively, for GGT. Together, GGT and CDT detected 91% of the male and 93% of the female high consumers. Among younger men, CDT values were higher in the subgroup with a history of traffic offences than in the subgroup without such a history, thus suggesting that CDT levels may be increased by heavy weekend beer consumption. A few cases of false-positive CDT results were found to be attributable to genetic anomalies of the transferrin molecule. Cases characterised by disparity between the CDT level and the clinical picture require further, more specific, analysis. Used in combination with GGT, CDT is thus a feasible marker for use in monitoring alcohol consumption in drivers needing to qualify for the restoration of their licences.

How to get the best out of antabuse.

In the field of alcoholism treatment, disulfiram or calcium carbimide is one part of the treatment package and these deterrent drugs have to be combined with counselling and support to be effective. Besides adequate dosage and formulation of substance, the Antabuse tablet has to be taken under supervision by a therapist to strengthen compliance and motivate the patient to continue long-term treatment. Disulfiram metabolism is very complex and although new metabolites have been identified, clinically useful and practical determination of active substances for routine use has not been developed. In clinical situations, the disulfiram-ethanol reaction (DER) is still of major importance to demonstrate the effectiveness of the drug. This reaction was originally used to induce aversive conditioning. In the course of time, emphasis has focused more on sobriety and the DER has been used as a positive reinforcement during treatment. Antabuse therapy is remarkably free of serious side-effects. The latency time from start of treatment to the manifestation of adverse drug reactions differs according to organ. Hepatotoxicity has special interest in women with nickel dermatitis.

Sex differences in response style to two self-report screening tests on alcoholism.

The revised Malmö modification of the Michigan Alcoholism Screening Test (Mm-MAST) of 10 items including all four CAGE (an acronym for Cut down, Annoyed, Guilty, Eye-opener) items and one item on total sobriety was used in a health screening of a total birth-year cohort in Malmö. Seventy-two percent of the female and 68% of the male population participated. Nine hundred and eleven women and 911 men were included in the study population. The revised Mm-MAST yielded a higher proportion of scores indicative of problem drinking than the CAGE in both sexes; 4% of the women and 17% of the men had positive Mm-MAST scores (> or = 3 yes-answers). Rates of positive CAGE scores (> or = 2 yes-answers) were 1% and 7%, respectively. Frequencies of problem drinking in the Mm-MAST and CAGE positive scorers, respectively were similar for both women and men. The reliability of the revised Mm-MAST was better in the male population producing a Cronbach's alpha coefficient of 0.69 compared with 0.58 in the female population. In men the four CAGE items had the highest item-total scale correlations, which was found in only one CAGE item in women. We suggest that the revised Mm-MAST is a better screening instrument than the CAGE in both sexes. Nevertheless the reliability of the total revised Mm-MAST was poorer in women and the need for a female oriented alcohol questionnaire is promoted.

Sex differences in problem drinking among 42-year-old residents of Malmö, Sweden.

The main objective was to describe sex-related differences in rates of nonidentified vs identified problem drinking in 42-year-old Malmö residents. All 1264 women and 1368 men born in 1941 were invited to a health screening at the Preventive Medicine Section, Malmö General Hospital. Individuals registered at the Department of Alcohol Diseases because of problem drinking prior to screening (identified problem drinkers) were excluded and analyzed separately. Intervention in the remaining subjects was made if any of 3 sets of inclusion criteria was met. The sex ratios (female:male) of identified and nonidentified problem drinking were 1:4.1 and 1:2.8 respectively. Thus, nonidentified problem drinking is by and large proportional to identified problem drinking in both sexes, arguing against hidden drinking being and exclusively female phenomenon.

Long-term Antabuse treatment of alcohol-dependent patients.

Antabuse taken under supervision is effective and useful in the treatment of selected patients in the very long term. Relapses during treatment are the rule rather than the exception as is also illustrated in five case reports, but Antabuse treatment contributes to longer periods of sobriety. Continued support by nurses is necessary in the treatment of alcohol dependent patients and appointments with a psychiatrist are important for patients with alcohol dependence and psychiatric disorders. The personal perception of the severity of the drinking problem seems to be of decisive importance for compliance with the treatment. A high degree of motivation to stop drinking leads to long-term use of Antabuse, a stronger internal locus of control and a favourable outcome. Measurements of liver enzymes are useful for monitoring the treatment outcome as well as for detecting toxic effects on the liver.

[The treatment of drunk drivers]. / Behandling vid rattfylleri.

Conviction for a drunk driving offence entails automatic disqualification. A doctor's certificate recommending the approval or disapproval of driver's license renewal would seem to be a crucial prerequisite in the rehabilitation of an offender. Together with educational programmes, fines and imprisonment, such actions vis-à-vis driving licenses would seem to be feasible adjuncts to rehabilitation, though their implementation would naturally need to be varied according to the severity of alcohol dependence and the risk of recurrent drunk driving.

Methods of intervention to modify drinking patterns in heavy drinkers.

More than 30,000 individuals have been investigated in the continuous screening and intervention study in Malmö. Large subsamples of individuals with different levels of serum gamma-glutamyltransferase (GGT) have been characterized and followed up; GGT has proved to be a useful and simple tool in identifying and treating heavy drinkers and monitoring their outcome. In the intervention study, counseling and repeated feedback of GGT results in a group of middle-aged heavy drinkers led to a significant reduction in sick absence, hospitalization, and mortality compared with those in a control group over a period of 6 to 8 years. At follow-up, about 15% of middle-aged men in the general population had serious alcohol problems. Assessment and treatment of heavy drinkers within general medicine would provide a very considerable impact on the total problem of alcohol-related disease.

Alcohol dependence and problem drinking in urban middle aged men.

UNLABELLED: In the total population of 11.643 men born 1926-1933 and living in Malmoe all individuals registered at the Department of Alcohol Diseases (RAD) from 1968-1984 were calculated and 10% of the records were analyzed. All men were invited to screening investigations and 75% participated. Data on sick leave days were available for as long as 21 years before screening and during follow up. Screening GGT levels and affirmative answers to the Mm-Mast were analyzed. Drinking problems were categorized in Alcohol Dependence Syndrome or Alcohol Related Disabilities. The later category included: a) individuals RAD who were non-alcohol dependent, b) 75% of men with screening GGT in the tenth decentile of the GGT distribution, c) men with high sick leave caused by complications due to drinking. RESULTS: Alcohol dependence was found in 5.4%, problem drinking in another 9.4% of the men in the general population. The yearly incidence of alcohol dependence was 1.5 per thousand in these age year cohorts.

Orthopedic disorders, morbidity, and sick absenteeism in men with different levels of serum gamma-glutamyltransferase.

All orthopedic treatment administered between 1970 and 1982 was analyzed in random subsamples of men 28, 38, and 48 years old being screened for serum gamma-glutamyltransferase (GGT) levels. Of 1,151 screened participants, 631 men had been treated for fracture, distortion, contusion, low-back pain with or without sciatica, or radial epicondylitis. The extent of care and incidence of the different diagnoses over the 13 years, as well as the number of sick days incurred by these men during 1981, were investigated for different GGT brackets. Those men with the highest GGT values (greater than or equal to 1.34 mu kat/liter approximately 80 IU) had 4-6 times more fractures and consulted surgeons 6-13 times more often than those men with the lowest GGT values (less than 0.35 mu kat/liter approximately 20 IU). Epicondylitis and distortion showed the opposite frequency distribution, with the highest incidence occurring in the lowest GGT brackets. Increasing GGT values were also correlated with sick leave days. Men in the highest decile for sick leave had 25 times more fractures than those men with no sick absenteeism. We conclude that an accumulation of alcohol-related orthopedic disorders occurs among men with high GGT values.

Prevention of alcohol-related problems in urban middle-aged males.

More than 30,000 individuals have been investigated in the continuous screening and intervention study in Malmö. Large subsamples of individuals with different levels of GGT (gamma-glutamyltransferase) have been characterized. GGT has proven to be a useful and simple tool in tracing, identifying, treating and controlling heavy drinkers. Furthermore, GGT seems to be a new and strong indicator of alcohol-related disabilities and short term mortality in the male population. Individuals with GGT in the tenth deecentile of the GGT distribution have been randomly selected for treatment or control. Results and follow-up for 60 months in the intervention study with randomized controls in middle-aged heavy drinkers indicate a significant reduction in alcohol consumption, sick absence, hospitalization and mortality. Thus, the intervention program seems to be effective in preventing complications of alcoholism on an individual basis.

Screening and intervention for alcohol-related disease in middle-aged men: the Malmö Preventive Programme.

In the Malmö Preventive Programme the tracing and prevention of alcohol-related disease was attempted by means of the enzyme serum gamma-glutamyltransferase (GGT) in a large unselected population of middle-aged men. Alcohol was considered to be the underlying factor in 70% of subjects with raised GGT values. In a prospective analysis, alcohol-related death turned out to be a major contributor to death in men who died within five years of the screening. GGT was the variable that was most predictive for premature death in this population. There were also statistically significant correlations between alcohol-related death and a questionnaire, the Mm-MAST, positively, and serum creatinine and serum cholesterol, negatively. In the randomized intervention programme, reductions in sickness benefit days, hospital admissions and mortality were seen in the intervention group in comparison with the control group, after four years of follow-up. The intervention programme was therefore effective in preventing the consequences of heavy drinking, and a risk factor approach to alcohol-related diseases seems feasible. This approach, however, encounters several problems, such as the recruitment of the non-participants in the screening, the investigation of the GGT-high/non-alcoholic subjects, and the identification of the GGT-normal/alcoholic subjects.