Two-muscle surgical treatment of a compensatory head tilt in an adult with acquired downbeat nystagmus.

Kestenbaum-Anderson-like operations have proven beneficial in treatment of compensatory head tilt in patients with infantile nystagmus. However, their use in acquired vertical nystagmus in adults with head tilt has rarely been reported. Presented here is a case of a 52-year-old woman with acquired downbeat nystagmus with a significant head tilt who responded to a simple two-muscle surgery involving the superior recti. Cyclovertical muscle surgery should be considered a viable option in such patients who are refractory to medical intervention. Additionally, it appears that four-muscle vertical muscle recessions (two muscles per eye) may not be necessary to dampen vertical nystagmus since good results can be obtained with a single muscle recession bilaterally.

Item Responses in Quantity-Frequency Questionnaires: Implications for Data Generalizability.

Alcohol consumption is an important predictor of a variety of negative outcomes. There is an extensive literature that examines the differences in the estimated level of alcohol consumption between types of assessments (e.g., quantity-frequency [QF] questionnaires, daily diaries). However, it is typically assumed that all QF-based measures are nearly identical in their assessment of the volume of alcohol consumption in a population. Using timeline follow-back data and constructing common QF consumption measures, we examined differences among survey instruments to assess alcohol consumption and heavy drinking. Using three data sets, including clinical to community samples, we demonstrate how scale-specific item characteristics (i.e., number of response options and ranges of consumption assessed by each option) can substantially affect the estimated mean level of consumption and estimated prevalence of binge drinking. Our analyses suggest that problems can be mitigated by employing more resolved measures of quantity and frequency in consumption questionnaires.

Patient perceptions of risky drinking: Knowledge of daily and weekly low-risk guidelines and standard drink sizes.

BACKGROUND: Effective intervention for risky drinking requires that clinicians and patients know low-risk daily and weekly guidelines and what constitutes a "standard drink." The authors hypothesized that most patients lack this knowledge, and that education is required. METHODS: Following primary care visits, patients completed anonymous exit questionnaires that included the 3 Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questions, "How many drinks (containing alcohol) can you safely have in one day?" and questions about size, in ounces, of a standard drink of wine, beer, and liquor. Descriptive analyses were done in Stata. RESULTS: Of 1,331 respondents (60% female, mean age: 49.6, SD = 17.5), 21% screened positive on the AUDIT-C for risky drinking. Only 10% of those accurately estimated daily low-risk limits, with 9% accurate on weekly limits, and half estimated low-risk limits at or below guidelines. Fewer than half who checked "Yes" to "Do you know what a 'standard drink' is?" provided accurate answers for beer, wine, or liquor. Patients with a positive screen were twice as likely to say they knew what a standard drink is, but only a third gave accurate estimates. When asked about plans in the next month regarding change in drinking behavior, 23% with a positive AUDIT-C indicated they were at least considering a change. CONCLUSIONS: Most patients in primary care don't know specifics of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines for low-risk drinking. Exploring patient perceptions of low-risk guidelines and current drinking behavior may reveal discrepancies worth discussing. For risky drinkers, most of whom don't know daily and weekly low-risk guidelines or standard drink sizes, education can be vital in intervening. Findings suggest the need for detailed and explicit social marketing and communication on exactly what low-risk drinking entails.

Substance Use in Women of Reproductive Age.

Using anonymous exit questionnaires in a university OB/GYN clinic, of 165 pregnant women reporting on drinking prior to pregnancy, 26% screened positive for hazardous or harmful drinking. Among 153 non-pregnant women age 50 or younger, 39% screened positive. Of those, 85% had no plans to change their alcohol consumption, as most believed their drinking levels were not risky; 80% had a significant risk of becoming pregnant, but 85% believed pregnancy was unlikely.

Patient abusing alcohol or drugs? Help starts with a single question.

Although binge drinking and drug use are rarely discussed during office visits, they're common, costly, and potentially fatal. Help patients stop with these easy-to-use screening tools and effective intervention strategies.

Clinician suspicion of an alcohol problem: an observational study from the AAFP National Research Network.

PURPOSE: In clinical practice, detection of alcohol problems often relies on clinician suspicion instead of using a screening instrument. We assessed the sensitivity, specificity, and predictive values of clinician suspicion compared with screening-detected alcohol problems in patients. METHODS: We undertook a cross-sectional study of 94 primary care clinicians' office visits. Brief questionnaires were completed separately after a visit by both clinicians and eligible patients. The patient's anonymous exit questionnaire screened for hazardous drinking based on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and for harmful drinking (alcohol abuse or dependence) based on 2 questions from the Diagnostic and Statistical Manual of Mental Disorders. After the visit, clinicians responded to the question, "Does this patient have problems with alcohol?" with answer options including "yes, hazardous drinking" and "yes, alcohol abuse or dependence." Analyses assessed the associations between patients' responses to screening questions and clinician's suspicions. RESULTS: Of 2,518 patients with an office visit, 2,173 were eligible, and 1,699 (78%) completed the exit questionnaire. One hundred seventy-one (10.1%) patients had a positive screening test for hazardous drinking (an AUDIT-C score of 5 or greater) and 64 (3.8%) for harmful drinking. Clinicians suspected alcohol problems in 81 patients (hazardous drinking in 37, harmful drinking in 40, and both in 4). The sensitivity of clinician suspicion of either hazardous or harmful drinking was 27% and the specificity was 98%. Positive and negative predictive values were 62% and 92%, respectively. CONCLUSION: Clinician suspicion of alcohol problems had poor sensitivity but high specificity for identifying patients who had a positive screening test for alcohol problems. These data support the routine use of a screening tool to supplement clinicians' suspicions, which already provide reasonable positive predictive value.

Use of AUDIT-based measures to identify unhealthy alcohol use and alcohol dependence in primary care: a validation study.

BACKGROUND: As programs for screening, brief intervention, and referral to treatment (SBIRT) for unhealthy alcohol use disseminate, evidence-based approaches for identifying patients with unhealthy alcohol use and alcohol dependence (AD) are needed. While the National Institute on Alcohol Abuse and Alcoholism Clinician Guide suggests use of a single alcohol screening question (SASQ) for screening and Diagnostic and Statistical Manual checklists for assessment, many SBIRT programs use alcohol use disorders identification test (AUDIT) "zones" for screening and assessment. Validation data for these zones are limited. This study used primary care data from a bi-ethnic southern U.S. population to examine the ability of the AUDIT zones and other AUDIT-based approaches to identify unhealthy alcohol use and dependence. METHODS: Existing data were analyzed from interviews with 625 female and male adult drinkers presenting to 5 southeastern primary care practices. Timeline follow-back was used to identify at-risk drinking, and diagnostic interview schedule was used to identify alcohol abuse and dependence. Validity measures compared performance of AUDIT, AUDIT-C, and AUDIT dependence domains scores, with and without a 30-day binge drinking measure, for detecting unhealthy alcohol use and dependence. RESULTS: Optimal AUDIT scores for detecting unhealthy alcohol use were lower than current commonly used cutoffs (5 for men, 3 for women). Improved performance was obtained by combining AUDIT cutoffs of 6 for men and 4 for women with a 30-day binge drinking measure. AUDIT scores of 15 for men and 13 for women detected AD with 100% specificity but low sensitivity (20 and 18%, respectively). AUDIT dependence subscale scores of 2 or more showed similar specificity (99%) and slightly higher sensitivity (31% for men, 24% for women). CONCLUSIONS: Combining lower AUDIT cutoff scores and binge drinking measures may increase the detection of unhealthy alcohol use in primary care. Use of lower cutoff scores and dependence subscale scores may increase diagnosis of AD; however, better measures for detecting dependence are needed.

Alcohol and sleep problems in primary care patients: a report from the AAFP National Research Network.

PURPOSE: Hazardous and harmful drinking and sleep problems are common, but their associations among patients seen in primary care have not been examined. We hypothesized that greater levels of alcohol consumption would be associated with several self-reported sleep problems. METHODS: In a cross-sectional survey in primary care practices, 94 participating clinicians recruited up to 30 consecutive adult patients, and both clinicians and patients completed anonymous postvisit questionnaires. Patients were asked questions on demographics, alcohol consumption, cardinal symptoms of alcohol use disorders, sleep quality, insomnia, sleep apnea, and symptoms of restless leg syndrome. Multivariate analyses explored the associations of drinking status (none, moderate, or hazardous) and sleep problems, adjusting for demographics and clustering of patients within physician. RESULTS: Of 1,984 patients who responded, 1,699 (85.6%) provided complete data for analysis. Respondents' mean age was 50.4 years (SD 17.4 years), 67% were women, and 72.9% were white. Of these, 22.3% reported hazardous drinking, 47.8% reported fair or poor overall sleep quality, and 7.3% reported a diagnosis or treatment of sleep apnea. Multivariate analyses showed no associations between drinking status and any measure of insomnia, overall sleep quality, or restless legs syndrome symptoms. Moderate drinking was associated with lower adjusted odds of sleep apnea compared with nondrinkers (OR = 0.61; 95% CI, 0.38-1.00). Using alcohol for sleep was strongly associated with hazardous drinking (OR = 4.58; 95% CI, 2.97-7.08, compared with moderate drinking). CONCLUSIONS: Moderate and hazardous drinking were associated with few sleep problems. Using alcohol for sleep, however, was strongly associated with hazardous drinking relative to moderate drinking and may serve as a prompt for physicians to ask about excessive alcohol use.

Differential toxicity of carbon nanomaterials in Drosophila: larval dietary uptake is benign, but adult exposure causes locomotor impairment and mortality.

Rapid growth in nanomaterial manufacturing is raising concerns about potential adverse effects on the environment. Nanoparticle contact with intact organisms in the wild may lead to different biological responses than those observed in laboratory cell-based toxicity assays. In nature, the scale and chemistry of nanoparticles coupled with the surface properties, texture, and behaviors of the organisms will influence biologically significant exposure and ultimate toxicity. We used larval and adult Drosophila melanogaster to study the effects of carbon nanomaterial exposure under several different scenarios. Dietary uptake of fullerene C60, carbon black (CB), or single-walled or multiwalled nanotubes (SWNTs, MWNTs) delivered through the food to the larval stage had no detectable effect on egg to adult survivorship, despite evidence that the nanomaterials are taken up and become sequestered in tissue. However, when these same nanocarbons were exposed in dry form to adults, some materials (CB, SWNTs) adhered extensively to fly surfaces, overwhelmed natural grooming mechanisms, and led to impaired locomotor function and mortality. Others (C60, MWNT arrays) adhered weakly, could be removed by grooming, and did not reduce locomotor function or survivorship. Evidence is presented that these differences are primarily due to differences in nanomaterial superstructure, or aggregation state, and that the combination of adhesion and grooming can lead to active fly borne nanoparticle transport.

Simplifying alcohol assessment: two questions to identify alcohol use disorders.

BACKGROUND: Previous work has validated a single question to screen for hazardous or harmful drinking, but identifying those patients who have an alcohol use disorder (AUD) among those who screen positive is still time consuming. We therefore sought to develop and validate a brief assessment instrument using DSM-IV criteria for use in primary care medical practice. METHODS: Four cross-sectional surveys of past-year drinkers. The developmental sample included patients presenting to emergency departments with an acute injury. The second sample, from the same study, was recruited by random-digit dialing. The third sample was recruited in 5 family medicine practices in Georgia. The fourth sample was the National Epidemiologic Survey on Alcohol and Related Conditions. Interviews with the first 3 samples used the Diagnostic Interview Schedule. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) used the Alcohol Use Disorder and Associated Disabilities Interview Schedule. RESULTS: Two constructs with promising test characteristics were identified: recurrent drinking in hazardous situations and drinking more than intended. Among those who screened positive with the single question in the developmental sample (N=959), if either of the 2 items was positive, the sensitivity for current AUD was 95% and the specificity was 77%. In the second (N=494) and third (N=280) samples, the sensitivity was 94 and 95% and the specificity was 62 and 66%, respectively, among those with a positive screen. In the NESARC sample, including those with at least 1 occasion in the past year of drinking 5 or more drinks (N=7,890), the sensitivity and specificity were 77 and 86%, respectively. CONCLUSIONS: The sensitivity and specificity of these 2 items across 4 samples suggest that they could be formulated into 2 questions, potentially providing busy primary care clinicians with an efficient, reasonably accurate assessment instrument to identify AUD among those patients who screen positive with the single screening question.

Three measures of sleep, sleepiness, and sleep deprivation and the risk of injury: a case-control and case-crossover study.

PURPOSE: Sleepiness and sleep deprivation are associated with injury, but few case-control studies have addressed them. We sought to add to the body of analytic observational studies. METHODS: Case-control and case-crossover study of 2517 injured patients interviewed in person in 3 emergency departments and matched by age, sex, rural versus urban, day of week, and hour of day with 1856 controls. Sleep constructs were measured by the following: (1) self-perceived sleepiness at injury or matched control time using 3 adjectives (tired, sleepy, drowsy); (2) usual sleep quality and quantity, and differences in those in the past 7 days; and (3) hours of sleep in the 24 hours before injury and the 24 hours before that. RESULTS: Better sleep quality in the past 7 days was associated with a lower risk of injury (odds ratio (OR) 0.88, 95% confidence interval (CI) 0.80 to 0.97). Self-reported sleepiness just before injury compared with control time was associated with a lower risk of injury, with ORs of 0.82 per unit on a 0-to-12 scale (95% CI 0.78 to 0.86) in case-control analysis and 0.76 (0.73 to 0.80) in case-crossover analysis. In case-crossover analysis, additional sleep in the 24 hours before injury compared with the 24 hours before that was associated with an increased risk of injury (OR 1.06 per hour, 95% CI 1.03 to 1.09), but this effect disappeared when we controlled for activity, location, and recent alcohol consumption. CONCLUSIONS: Better recent sleep quality was associated with a lower risk of injury, but surprisingly, feeling sleepy was also.

Marijuana and other illicit drug use and the risk of injury: A case-control study.

OBJECTIVES: Assess the associations between marijuana or other illicit drug use and injury risk. METHODS: Case-control study. Cases were emergency department patients with acute injury. Age-sex matched controls were interviewed by telephone. RESULTS: Marijuana use in the past seven days was associated with decreased risk, and use of other illicit drugs was associated with increased risk. Controlling for confounding had little effect. CONCLUSIONS: Marijuana use may be associated with a decreased risk of injury. Other illicit drug use was associated with increased risk.

State anger and the risk of injury: a case-control and case-crossover study.

PURPOSE: Previous studies have examined anger at a given moment (state anger) and proxies for injury, or anger as a trait and injuries per se. Findings have been inconsistent. We sought to define further the relationship between state anger and risk of injury. METHODS: We conducted a case-control and case-crossover study in all 3 emergency departments in 1 county in Missouri. Cases were patients seeking care for an acute injury. They were compared with 2 controls: the patient himself or herself 24 hours before, and an individual recruited by telephone from the community and matched for age-group, sex, and time. Self-reported anger was assessed with 3 Likert scale items. Anger just before the injury was compared in case-crossover analyses with the respondent's own level of anger 24 hours before, and in standard case-control analyses with community participants' level of anger at the same hour the same day of the week in a subsequent week. RESULTS: Of 2,517 patients, 2,446 provided data on anger just before the injury, and 2,117 reported data for 24 hours before injury. Of 1,856 community individuals, 1,533 provided complete data. Anger was prevalent. Of injured patients, 9%, 7%, and 4% reported feeling "quite a bit" or "extremely" "irritable," "angry," and "hostile," respectively, just before injury. Odds ratios for risk of injury were notably higher for greater degrees of anger; for example, for "angry," they were 1.8 (95% confidence interval, 1.1-2.7) for "quite a bit" and 7.2 (3.9-13) for "extremely." Odds ratios in women were substantially lower than those in men. Anger was not associated with fall and traffic injuries, but anger was strongly associated with intentional injuries inflicted by another person in both men and women. CONCLUSIONS: High levels of self-reported state anger increase the risk of injury, especially among men, and specifically the risk of intentional injury in both sexes.

Experiential curriculum improves medical students' ability to answer clinical questions using the internet.

BACKGROUND AND OBJECTIVES: Teaching about evidence-based medicine (EBM) is widespread, yet physicians still use rapid references preferentially over EBM techniques such as literature searching and appraisal of original research. The Internet now provides rapid access to preappraised evidence. We provided clinically integrated teaching of using the Internet to answer clinical questions for third-year medical students and assessed the change in their search skills. METHODS: The curriculum included two 90-minute computer lab sessions with teaching of search skills related to clinical questions. Immediately before the first and after the second session, students recorded sites searched, time needed for searching, and answers found for three standardized questions. Pretest and posttest questions were matched and reversed with each block. RESULTS: Eighty-six students completed pretests and posttests. For two questions about conventional medical care, posttest answer quality was significantly higher, and posttest search times were significantly shorter, by 1.6 minutes for question 1 (mean pretest search time 6.3 minutes, mean posttest search time 4.7 minutes) and 1.9 minutes for question 2 (mean pretest search time 8 minutes, mean posttest search time 6.1 minutes). For a question about herbal medicine, results were similar, but there were smaller differences that did not reach statistical significance. Students used or found significantly fewer sites on the posttest than on the pretest to find answers for all three question types (absolute difference=0.3 sites for each question). CONCLUSIONS Introducing students to useful Web sites, practicing answering clinical questions, and integrating this process with clinical rotation experiences can reduce the effort that students need to find answers and improve the quality of answers they find.

Screening for hazardous or harmful drinking using one or two quantity-frequency questions.

AIMS: To address the accuracy of quantity-frequency (QF) questions in screening for hazardous or harmful drinking. METHODS: Three groups were interviewed: patients presenting to emergency departments for care of an acute injury (n = 1537) or a medical illness (n = 1151), and community controls interviewed by telephone (n = 1112). The first question about alcohol was a single alcohol screening question (SASQ), 'When was the last time you had more than X drinks in one day?', where X = 4 for women and 5 for men, with any time in the past 3 months considered a positive screen (1 drink = 14 g ethanol). The subsequent alcohol questions were a calendar-based review of recent drinking and the alcohol questions from the diagnostic interview schedule (DIS), which included questions about usual frequency and average quantity. Hazardous drinking was defined as drinking >4 drinks in 1 day or >14 drinks in 1 week for men (women 3 and 7) (Guidelines of the US National Institute on Alcohol Abuse and Alcoholism). Current alcohol use disorders were defined using DSM-IV criteria. The areas under the receiver operating characteristic (ROC) curves in identifying hazardous drinking or current alcohol use disorder were compared. RESULTS: The area under the ROC curves in the three samples combined were 0.81 for SASQ (95% confidence interval (CI) 0.79-0.82), 0.80 for a question about average quantity alone (0.79-0.82) and 0.85 for the product of usual frequency times average quantity (0.84-0.86). The QF product and the question about average quantity performed consistently across the three groups. CONCLUSIONS: In clinical settings, one way to put these findings into practice is to screen first with a single question, such as the SASQ, a single question about typical quantity, or a question about the frequency of heavy drinking such as the third item of the alcohol use disorders test (AUDIT).

Alcohol-related injuries: evidence for the prevention paradox.

PURPOSE: The risk of an injury increases exponentially with alcohol consumption on a given occasion, but the conclusion that alcohol-related injuries are attributable primarily to heavy drinking may or may not be correct. The prevention paradox states that a large number of people at small risk may contribute more cases of a particular condition than a smaller number of people who are individually at greater risk. We sought to determine the extent to which the prevention paradox applies in the relationship between alcohol consumption and injury. METHODS: We conducted a population-based case-control and case-crossover study in all 3 emergency departments in Boone County, Mo. Data were collected from 2,517 patients with an acute injury and 1,856 age- and sex-matched controls selected by random digit dialing. RESULTS: The population attributable fraction (PAF) associated with drinking in the 6 hours before injury-the proportion of injuries that would not have occurred in the absence of drinking-was 10.6% in case-crossover analysis and 8.5% in case-control analysis. The PAF that was due to what is usually considered nonhazardous alcohol consumption (fewer than 5 drinks for men, fewer than 4 for women) was 4.5% in case-crossover analysis and 3.1% in case-control analysis. The PAF that was due to alcohol dependence was 4.0%. CONCLUSIONS: Injury is associated more with an occasion of alcohol consumption than with alcohol dependence. A substantial proportion of the PAF that is due to an occasion of alcohol consumption is from what are usually considered low-risk quantities.

Comfortably engaging: which approach to alcohol screening should we use?

PURPOSE: We wanted to compare 2 screening instruments for problem drinking, the CAGE and a single question, assessing frequency of use, patient and clinician comfort, and patient engagement in change. METHODS: The study was a crossover, cluster-randomized clinical trial with 31 clinicians in Missouri and 13 in the American Academy of Family Physicians (AAFP) National Network for Family Practice and Primary Care Research; 2,800 patients provided data. The clinician was the unit of randomization. Clinicians decided whether to screen each patient; if they chose to screen, they used the screening approach assigned for that block of patients. The clinician and patient separately completed questionnaires immediately after the office visit to assess each one's comfort with screening (and any ensuing discussion) and the patient's engagement in change. RESULTS: Missouri clinicians screened more patients when assigned the single question (81%) than the CAGE (69%, P = .001 in weighted analysis). There was no difference among AAFP network clinicians (96% of patients screened with the CAGE, 97% with the single question). Eighty percent to 90% of clinicians and 70% of patients reported being comfortable with screening and the ensuing discussion, with no difference between approaches in either network. About one third of patients who were identified as problem drinkers reported thinking about or planning to change their drinking behavior, with no difference in engagement between screening approaches. CONCLUSIONS: Clinicians and patients reported similar comfort with the CAGE questions and the single-question screening tools for problem drinking, and the 2 instruments were equal in their ability to engage the patient. In Missouri, the single question was more likely to be used.