Atypical mycobacteria in extrapulmonary disease among children. Incidence in Sweden from 1969 to 1990, related to changing BCG-vaccination coverage.

SETTING: In April 1975, the general BCG vaccination of newborns in Sweden was replaced by selective vaccination of groups at increased risk of tuberculosis. OBJECTIVE: To relate the incidence of atypical mycobacterial disease in children to BCG vaccination. DESIGN: A nationwide survey in Sweden during the period 1969-90 disclosed 390 children under 15 years of age with bacteriologically confirmed atypical mycobacteria from extrapulmonary lesions. RESULTS: The average, annual incidence of atypical mycobacterial disease per 100,000 children under 5 years of age increased from 0.06 during the period 1969-74 to a maximum level of 5.7 during 1981-85. Among the cohorts born in Sweden in the period 1975-85, the cumulative incidence rate before 5 years of age was estimated at 26.8 per 100,000 non-BCG-vaccinated children and at 4.6 among those BCG-vaccinated, ratio 5.9 (95% confidence limits 1.6, 48.5). Mycobacterium avium-intracellulare was found in 83%. Disseminated, fatal disease developed in 3 children. The remaining ones suffered from local infections, most often lymph-node or soft-tissue lesions. The observed incidence of bacteriologically confirmed diagnosis was estimated to represent approximately 40% of the 'true' number, if patients with diagnosis based on histological, clinical and epidemiological findings only were included. CONCLUSION: The present study indicates that BCG vaccination plays a role in protection against localized disease caused by atypical mycobacteria in children.

Serum gamma-glutamyl transferase (GGT) in a group of organized teetotallers.

Organized teetotalers were examined with regard to gamma-glutamyl transferase (GGT) in the serum. The mean values for GGT in the group of teetotalers (0.32 mukat/l +/- 0.23) was considerably lower compared with a group of the general population (0.50 mukat/l +/- 0.48), p less than 0.001. Only a few teetotalers had GGT values more than 1.0 mukat/l. A certain tendency to higher values was found among middle-aged men compared to women. No statistically significant correlation between GGT and age was found.

Morphologic changes in the small intestine after chronic alcohol consumption.

The morphology of the small-intestinal mucosa was studied in 11 alcoholic patients admitted to hospital for detoxification. A first biopsy specimen from the small intestine was taken as soon as possible after admission and a second specimen after about 6 weeks of abstinence. The specimens were studied in the light microscope, in the scanning electron microscope, and by immunohistochemistry. Morphometrically, a slight reduction in villus height in relation to crypt depth was observed. One patient had a subtotal villus atrophy. After abstinence the villus height was increased in five of the six patients who accepted a second biopsy. No obvious changes were seen in the frequency and appearance of peptidergic nerves or endocrine cells. Ultrastructurally, pronounced alterations were seen in the surface ultrastructure of the enterocytes. In two specimens bacterial adhesion to the mucosal surface was also found. The ultrastructural changes were unaltered after abstinence. In serum the concentrations of zinc were reduced, and the levels of copper were elevated compared with a group of teetotallers. A recently developed marker of high alcohol consumption, carbohydrate-deficient transferrin, was as good an indicator as the other conventional biochemical markers.

Sickness absenteeism and mortality in patients with excessive drinking in somatic out-patient care.

In a study of 2114 patients attending somatic outpatient clinics, 208 were classified as excessive drinkers. Sickness benefit days and sickness periods per year, disability pension, and mortality were studied for the years 1981 to 1985. The excessive drinkers as a group had 13 to 27 more sickness days per year than the other patients. They also had more sickness periods and a higher rate of disability pension than patients without alcohol overconsumption. The study thus showed that a group with varying degrees of excessive drinking had an increased need for sickness benefits. The mortality was considerably increased among the excessive drinkers. The patients who had undergone treatment or were registered because of alcohol problems had most sickness benefit days. The excessive drinking patients without advanced alcohol problems did not have more sickness days than the other patients. Most of these patients (75%) were sick-listed without recognition of their excessive drinking by their doctor. This emphasizes the importance, in terms of sickness benefits and mortality, of better identification of patients with excessive drinking.

Early intervention in patients with excessive consumption of alcohol: a controlled study.

From a population of 2,114 patients attending somatic outpatient clinics, 78 patients were selected who had either an excessive consumption of alcohol according to questionnaires or a raised gamma glutamyltransferase (GGT) value (above 0.6 mu kat/l) due to alcohol. They had not undergone treatment for problem drinking previously, and had no serious alcohol dependence. They were thereby classified as excessive consumers of alcohol, and randomly allocated to an intervention (n = 36) or to a control group (n = 42). Those in the intervention group were followed up by a nurse once a month and by a doctor every third month for a total of 12 months. Laboratory tests were taken monthly. Consumption of alcohol, GGT and triglyceride levels, and sickness allowance days were decreased in the intervention group compared to the time before intervention. In contrast, the number of sickness allowance days in the control group increased. There was also a tendency towards a positive effect of intervention on the number of consultations made with a statistically not significant decrease of consultations after intervention. The study thus indicates that an early and relatively simple intervention programme for problem drinkers may be effective and can be carried out at a low cost and with a positive response from the patients.

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

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

Prevalence of excessive or problem drinkers among patients attending somatic outpatient clinics: a study of alcohol related medical care.

The prevalence of alcohol related morbidity was studied among 2038 patients attending somatic outpatient clinics. A further 76 patients had refused the study, giving an overall drop out rate of 3.6%. Several methods were combined so as to detect as many patients with problem drinking as possible. According to the criteria and definitions employed 17% of men (confidence interval 15% to 19%) and 4% of women (confidence interval 3% to 5%) were excessive consumers of alcohol or problem drinkers. The highest proportion of such patients--that is, 17%--was noted in the emergency rooms (27% of men, 8% of women). At other clinics the proportions varied from 11% to 17% of men and from 2% to 4% of women. The strongest relations between overconsumption of alcohol and consultation at the clinic were among patients attending the medical outpatient clinic and the emergency rooms; in 86% (confidence interval 75% to 97%) and 88% (confidence interval 81% to 95%) of problem drinkers attending these clinics, respectively, alcohol was related to the consultation. Consultations were related to alcohol in 82% of women with excessive or problem drinking and 73% of men defined in this way. There was a tendency to a higher proportion of men with excessive or problem drinking in the age group 40-49 years. These findings show that among patients classified as excessive or problem drinkers attending somatic outpatient clinics there was a close relation between alcohol consumption and utilisation of medical resources, especially in women.

Causes of elevated serum gamma-glutamyl transferase in patients attending outpatient somatic clinics and district health centres.

In this study of 1985 patients in somatic outpatient care (medicine, surgery, orthopedics, emergency and primary health care clinics), 231, or 11.6%, were found to have an elevated serum GT value (above 0.9 mukat/l). Alcohol was the cause of this in approximately one third of the cases, while diseases and drugs were the underlying cause in the other cases. In the population, there were 208 alcohol-overconsuming patients (163 men and 45 women) and 28 patients had a serum GT elevation which led to detection of a previous unknown alcohol problem or excessive consumption. The mean and median value for serum GT for the alcohol patients was markedly higher than in the non-alcohol-overconsuming group. The sensitivity for serum GT (with a value of 0.9) as regards alcohol consumption was 40%. The GT test screened 4.2% of patients with excessive alcohol consumption of which one third were "hidden".