Methadone treatment of chronic non-malignant pain and opioid dependence--a long-term follow-up.

UNLABELLED: Iatrogenic opioid addiction among chronic pain patients was the initiative for starting a methadone programme for pain patients at the University Hospital of Uppsala. The aims were to improve pain relief and quality of life in pain patients with problematic opioid use and to investigate background factors explaining problems with opioid use. METHODS: Records of all 60 patients included in the methadone programme 1994-2002 were studied. An interview was done after a mean of 34 months of methadone treatment regarding pain relief, quality of life and side effects on 48 patients. RESULTS: Titration of oral methadone mixture in daily doses ranging from 10 to 350 mg (mean 99.5 mg) was done on all patients. Background factors were low back and musculoskeletal pain in 40%, psychiatric disease in 68%, and substance use disorder in 32% of the patients. Before methadone treatment all patients were on sick leave. After treatment five patients returned to work. Ten patients failed treatment, 4 due to intractable nausea, 4 to drug diversion, 1 because of methadone related arrhythmia and 1 because of insufficient analgesia. Pain relief was rated good by 75% and moderate by 25% of the patients. Global quality of life was rated at mean of 50(0-100), which favourably compares with Swedish chronic pain patients mean 33(0-100). CONCLUSION: A structured methadone programme can be used for treating chronic pain patients with opioid dependence improving pain relief and quality of life. However, side effects and serious adverse events may limit the beneficial effects of the method.

A 6-month controlled naltrexone study: combined effect with cognitive behavioral therapy in outpatient treatment of alcohol dependence.

BACKGROUND: In several studies, patients with alcohol dependence treated with the opioid antagonist naltrexone have shown fewer relapses to heavy drinking than those receiving placebo. An interaction between the naltrexone effect and the type of psychological therapy has been observed. METHODS: A 6-month, double-blind, placebo-controlled, parallel-group study was performed at 10 different investigation sites. After a placebo run-in period of 1 week, 118 patients were randomized into 4 treatment groups-50 mg of naltrexone daily or placebo in combination with either cognitive behavioral therapy (CBT) or supportive therapy. The CBT was performed over nine sessions according to the manual of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity). The supportive therapy was defined as "the treatment as usual." Alcohol consumption, craving, carbohydrate-deficient transferrin, medication compliance by tablet count, and adverse clinical events were assessed at all visits. Other liver enzymes and psychiatric symptoms were also determined. RESULTS: Ninety-one (77%) patients completed the study, and 92 (78%) were 80% compliant with the medication regimen. A lower percentage of heavy-drinking days was shown in the naltrexone group (p = 0.045) compared with the placebo group, as was a lower craving score (p = 0.029). These results are supported by the lower levels of liver enzyme activities (p < 0.010 for aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyltransferase), but not by the carbohydrate-deficient transferrin levels, in the naltrexone group. The mean time period before the first day of heavy drinking was longer for the group treated with CBT (p = 0.010), especially in combination with naltrexone (p = 0.007). Naltrexone was well tolerated, and no patients discontinued the study due to side effects. CONCLUSIONS: This study supports the effect of naltrexone in outpatient treatment of alcohol dependence and suggests that a beneficial interaction effect with CBT can be expected.

Clinical value of symptom assessment in patients with constipation.

PURPOSE: This study was designed to evaluate symptoms and clinical findings in a prospective series of patients with chronic constipation. METHODS: A total of 155 consecutive patients with intractable constipation underwent detailed symptom registration, anorectal manometry, electromyography, colonic transit time measurement, and defecography. RESULTS: All investigations were completed by 134 patients (112 females) with a median age of 52 (range, 17-79) years. Whole-gut transit time was delayed in 55 patients (41 percent), pelvic floor dysfunction was diagnosed in 59 patients (44 percent), but in 35 percent of patients both transit time and pelvic floor function were found to be normal. Three symptoms were shown to have an independent value for the diagnosis of slow-transit constipation. Patients with slow transit more often reported two or fewer stools per week (84 vs. 46 percent), laxative dependence (87 vs. 44 percent), and a history of constipation since childhood (58 vs. 22 percent) than did those with normal transit. Pelvic floor dysfunction was associated with a higher prevalence of backache (53 vs. 33 percent) and a lower prevalence of normal stool frequency (19 vs. 36 percent), heartburn (12 vs. 27 percent), and a history of anorectal surgery (7 vs. 21 percent) compared with those with normal pelvic floor function. All four symptoms retained an independent value in the logistic regression analysis for pelvic floor dysfunction. Two symptoms characterized the group with normal transit and normal pelvic floor function: normal stool frequency and alternating diarrhea and constipation. CONCLUSIONS: Symptoms are good predictors of transit time but poorer predictors of pelvic floor function in patients with constipation.

Symptom criteria do not distinguish between functional and organic dyspepsia.

DESIGN: Retrospective study. SETTING: Teaching hospital, Sweden. OBJECTIVE: To find out if various diagnostic criteria could distinguish organic from non-organic causes of dyspepsia. SUBJECTS: 635 patients previously interviewed by computer questionnaire. INTERVENTIONS: Upper gastrointestinal endoscopy, laboratory tests, clinical examination. MAIN OUTCOME MEASURE: Differentiation between organic and functional dyspepsia. RESULTS: 106 patients had functional dyspepsia. Of these 83 had ulcer-like dyspepsia, 76 motility-like dyspepsia, and 50 reflux-like dyspepsia. Eight patients had unspecified dyspepsia. CONCLUSIONS: There was a considerable overlap between different subgroups, and the criteria did not differentiate between organic and non-organic causes of dyspepsia though the symptom criteria in most cases showed an independent value in discriminating between different subgroups. The clinical usefulness of the criteria remains to be shown.

Constipation assessed on the basis of colorectal physiology.

BACKGROUND: Constipation is a collective term for symptoms of different aetiologies and pathophysiologies. Our aim was to determine the prevalence of colorectal pathophysiology findings in a prospective series of patients with chronic constipation. METHODS: A total of 155 consecutive patients with chronic constipation underwent anorectal manometry, electromyography (EMG), the balloon expulsion test, colonic transit-time study, and defecography. RESULTS: All investigations were completed by 134 patients (112 females) with a median age 52 (range, 17-79) years. Patients were categorized on the basis of transit time and pelvic-floor function as belonging to 1 of 4 groups: slow-transit constipation (STC) (delayed transit time but normal pelvic-floor function, n = 28), pelvic-floor dysfunction (PFD) (pelvic-floor dysfunction and normal transit time, n = 32), combined slow transit and pelvic-floor dysfunction (STC + PFD) (n = 27), and normal-transit constipation (NTC) (normal transit time and normal pelvic-floor function, n = 47). There was no difference between diagnostic groups in anal sphincter pressures. However, rectal sensitivity to balloon distension was lower (P < 0.05) in patients with delayed transit. Paradoxical puborectalis contraction (PPC) was found on EMG in 42 patients (31%). The prevalence of PPC was higher (P < 0.001) in patients with pelvic-floor dysfunction. Inability to evacuate the rectal balloon was reported by 37% of patients with pelvic-floor dysfunction and 12% of patients with normal pelvic-floor function (P < 0.001). Rectocele was the only anatomic abnormality at defecography which was associated with poor rectal emptying. CONCLUSIONS: About two-thirds of our patients with constipation had objective evidence of delayed transit or pelvic-floor dysfunction. No single test could reliably identify any of the pathophysiologic subgroups of constipation.

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.

The effect of omeprazole and ranitidine on ulcer healing, relief of symptoms, and incidence of adverse events in the treatment of duodenal ulcer patients.

In a Swedish double-blind multicenter study involving 143 patients, the new proton pump inhibitor omeprazole (30 mg taken as a single morning dose) was compared with ranitidine (400 mg b.i.d.). Clinical assessment and laboratory investigations were carried out at 2 and 4 weeks, and again at 6 weeks if patients had not healed earlier. Endoscopy was repeated at two-weekly intervals until the ulcer was healed. The patients in the two treatment groups were well matched prior to treatment. There was a higher ulcer healing rate in the omeprazole group (70%) than in the ranitidine group (55%) after two weeks of treatment. This difference reached statistical significance in 128 patients adhering to the protocol as shown by a logit model analysis with drug, ulcer size and smoking as the prognostic factors (p = 0.04). There were no major differences between the two treatment groups in terms of symptomatic relief. Both drugs were generally well tolerated, and the number of adverse events in the two treatment groups were similar. After healing, 127 patients entered a follow-up study, with endoscopy either after 6 months or on recurrence of symptoms. There was no significant difference between the two treatment groups, with the relapse frequency within 6 months being 39% in the omeprazole group and 47% in the ranitidine group. These results, with a 15 percentage points higher ulcer healing rate for omeprazole as compared with H2-receptor antagonists after two weeks, are in accordance with results reported in other studies.

Minor role of hepatitis B virus in the causation of chronic liver disease in Somalia indicated by a case-control study.

Chronic liver disease (CLD) is frequent in Somalia. In a case-control study, 116 in-patients with CLD were compared with the same number of age and sex matched controls. Demographic variables, use of drugs, symptoms and signs, serological markers for hepatitis B virus (HBV) and serum alpha-foetoprotein (AFP) were assessed. Hepatitis B surface antigen (HBsAg) was found in 44 cases of which 17 had antibodies to hepatitis D virus (anti-HD) and 7 had hepatitis B e antigen (HBeAg). Twenty-three controls were HBsAg-positive, of whom 3 had anti-HD and one HBeAg. Increased relative risks (95% confidence intervals in parentheses) were 2.5 (1.3-4.5) for HBsAg, 6.5 (1.7-21.5) for anti-HD, and 7.4 (0.9-66.5) for HBeAg. Despite the association between the presence of HBV markers and CLD, 62% of the cases had no markers indicating current HBV infection. This was reflected in the low risk attributable to chronic HBV infection (22.6%), which was lower than that in patients with CLD in other African populations with a high HBsAg carrier rate. The prevalence of HBV markers did not differ between cases with AFP greater than 100 ng/ml and those with AFP less than 100 ng/ml. The former were characterized by male predominance, shorter duration of symptoms, and larger mean liver size, indicative of malignancy. The mean age of HBsAg-positive cases with AFP greater than 100 ng/ml was significantly lower (by 7.7 years) than that of HBsAg-negative cases with AFP greater than 100 ng/ml. Among the CLD patients with AFP less than 100 ng/ml, 48 were HBsAg-negative. These cases differed significantly from the other 68 cases in that more were females (35% against 16%), more originated from an agricultural area (56% against 30%), and more were regular consumers of drugs (48% against 28%). In conclusion, factors as yet undefined play a considerable role in the causation of CLD in Somalia. The possibility of determining the role of hepatitis C virus (HCV) awaits the development of more specific assays for anti-HCV antibodies.

Transferability of a computer system for medical history taking and decision support in dyspepsia. A comparison of indicants for peptic ulcer disease.

The transferability of a British data base for differential diagnosis of dyspepsia using data obtained by computer interrogation was tested in 467 Swedish patients. The diagnostic value for peptic ulcer disease of symptoms such as frequent night pain relieved by food or antacids, smoking, family history of ulcer, food relief pain, male sex, and episodic pain was shown to be reproducible. However, for a number of symptoms their value for the diagnosis of peptic ulcer disease could not be reproduced in Swedish patients. The combined value of indicants was tested using a computer based algorithm for calculating diagnostic probabilities. The performance of this algorithm was poor when British data were applied to Swedish patients but reclassification of the Swedish patients on their own data base showed promising results. Crean and colleagues in Glasgow have developed a computer system for automated interrogation of patients with dyspepsia. The system utilises a large number of questions to obtain information regarding a maximum of 160 diagnostic indicants. The symptoms elicited from a patient can be compared with those of a large number of previously examined patients and the probabilities of ten different diagnoses can be calculated. The calculation of diagnostic probabilities is based on scores reflecting the diagnostic value of different symptoms in different diseases. After careful translation of questions the system has been transferred for use in Sweden. The present report is based on data from patients seen during the first two years with the system at a Swedish hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

Liver investigation in 149 asymptomatic patients with moderately elevated activities of serum aminotransferases.

The accidental finding of raised levels of serum aminotransferase levels may lead to extensive investigations of the liver in apparently healthy people. To identify diagnostic groups and their need for investigations, we have evaluated the results of all investigative procedures carried out in 149 asymptomatic patients with persistently raised serum levels of aminotransferases. Fatty liver was found in 64%. These patients often had a high body weight. A high alcohol intake and diabetes mellitus were also noted. Chronic active or persistent hepatitis was found in 20% of the patients. Six per cent had cirrhosis, 4% had alpha 1-antitrypsin deficiency, and 3.5% had hemochromatosis. Apart from ferritin, alpha 1-antitrypsin, and markers for hepatitis B, blood tests were of little value for distinguishing among different diagnostic groups. This was the case also for the imaging procedures, and neither liver scintigraphy nor ultrasonography was a reliable source of diagnostic information. The results of our study indicate that diagnosis in this group of patients cannot be made without liver biopsy.

Alcohol withdrawal: effects of clonidine treatment on sympathetic activity, the renin-aldosterone system, and clinical symptoms.

Twenty male alcoholics with alcohol withdrawal syndrome were randomized to receive either oral clonidine (3-600 micrograms, six hourly) or oral chlormethiazole (500-1000 mg, six hourly) for 4 days. All subjects were also given oral carbamazepine (200 mg, 12 hourly) throughout the study. Nine subjects given clonidine and eight given chlormethiazole completed the study. Clonidine was as effective as chlormethiazole in suppressing the symptoms and signs of alcohol withdrawal. However, plasma catecholamines, blood pressure, and pulse rate fell more rapidly and to a greater extent during clonidine than following chlormethiazole, findings which could have therapeutic implications. It is suggested that activation of brain noradrenergic neurons constitutes a common denominator in the pathophysiology of several withdrawal syndromes.

Minimal liver disease in young persons with homozygous and heterozygous alpha-1-antitrypsin deficiency.

Of 120 patients who were investigated for moderately elevated liver function tests as the only sign of liver disease, 6 young persons had alpha-1-antitrypsin (AAT) deficiency. Three had a homozygous (Pi ZZ) and three had a heterozygous (Pi MZ) AAT deficiency as measured with isoelectric focusing. An extensive investigation ruled out all other causes of liver disease. The three homozygous patients showed typical periodic acid-Schiff (PAS)-positive globules in their liver biopsies and slight fibrosis, whereas none of the heterozygous patients showed these features. Electron microscopical investigation also showed typical findings in the homozygous but not in the heterozygous patients. Further development of liver disease in these young and apparently healthy AAT-deficient patients with early signs of liver damage is not known. It is possible that these patients will develop severe liver disease later in life. It was possible to detect only the three homozygous patients by histochemical examination of liver tissue, since the heterozygous patients did not show PAS-positive globules in their liver.

A case of haemobilia following percutaneous liver biopsy treated by selective arterial embolization.

A case is reported of severe hemobilia following a percutaneous liver biopsy. Hepatic ultrasound and computed tomography showed evidence of blood in the bile ducts and gall bladder. A selective arteriography revealed extravasation of blood in the liver. The bleeding ceased following selective embolization of the damaged artery after embolization with spongostan through the catheter used for the arteriogram. Following the embolization no further signs of bleeding were noted and the patient recovered completely.