John P. Allen, PhD, MPA; Stephen A. Maisto, PhD; Gerard J. Connors, PhD
Considering the prevalence of excessive alcohol use, its adverse consequences on physical and emotional well-being, and the high degree of responsivity of early-stage drinking problems to brief intervention, screening for alcohol abuse is warranted in medical practice. We describe several practical self-report tests that can help primary care physicians screen their patients for alcohol abuse. Two of the more popular tests, the Michigan Alcoholism Screening Test and the CAGE (an acronym for questions about cutting down on drinking, annoyance at others' concern about drinking, feeling guilty about drinking, and using alcohol as an eye-opener in the morning), are comparable in sensitivity and specificity. Either test is appropriate, but the brevity of CAGE generally gives it an advantage in a busy medical office. Three new tests, the Alcohol Use Disorders Identification Test, the Adolescent Drinking Index, and the TWEAK also are promising. We offer guidelines for selection of screening tests for primary care practice.
(Arch Intern Med. 1995;155:1726-1730)
Mordechai R. Kramer, MD, Charles L. Sprung, MD
Lung transplantation has become an established rescue therapy for patients with end-stage disease. The major problem, however, is the shortage of organ donors. Living related donation has been successful in kidney and liver transplantation and, recently, in lobar lung transplantation as well. The main ethical dilemma is whether we should risk a parent family member in order to save a child or relative. This dilemma can be taken to the extreme in a case in which pneumonectomy from a live donor can save a patient who is in need of single lung transplantation, a procedure that has not yet been performed, although technically feasible. We discuss the ethical aspects of such a procedure from the perspectives of the donor, the recipient, and the medical team.
(Arch Intern Med. 1995;155:1734-1738)
Astrid D. Mueller, MD, MS, Amnon Sonnenberg, MD, MSc
Background: Although several clinical and epidemiologic studies suggest that timely diagnostic procedures of the large bowel may reduce mortality from colorectal cancer, the evidence for this relationship is primarily circumstantial.
Methods: A case-control study was conducted among hospitalized US military veterans to investigate whether diagnostic procedures of the large bowel were performed in the period preceding the diagnosis of colorectal cancer less frequently in patients dying of colorectal cancer than in control patients. Data files of a total of 4411 veterans dying of colorectal cancer between 1988 and 1992 were extracted from the records of the US Department of Veterans Affairs, Washington, DC. Data of four living control patients and four dead control patients without colorectal cancer were matched by age, sex, and race to each case patient. The case and the two control popula- tions were compared by conditional logistic regression, calculating odds ratios, and their 95% confidence interval.
Results: Diagnostic procedures of the large bowel reduced mortality from colorectal cancer, the odds ratio being 0.41 (range, 0.33 to 0.50) for the comparison with living control patients. The protective effects of proctosigmoidoscopy, colonoscopy, and polypectomy lasted for 5 years. The procedures were protective against death from cancer of the colon, as well as cancer of the rectum. The most protective influence was associated with removal of tissue through biopsy, fulguration, and polypectomy. Similar influences were found comparing case patients with dead control patients.
Conclusion: Removal of tissue represents the most effective means to reduce mortality from cancers of the large bowel. It retains its efficacy over a time period of 5 years.
(Arch Intern Med. 1995;155:1741-1748)
Stephen F. Kemp, MD; Richard F. Lockey, MD; Bruce L. Wolf, MD; Phil Lieberman, MD
Background: A presentation of findings from a large population of anaphylaxis cases.
Methods: Retrospective chart review and follow-up questionnaire provided data on 266 subjects (113 males and 153 females) aged 12 to 75 years (mean age, 38 years) who were referred to a university-affiliated private allergy-immunology practice in Memphis, Tenn, for evaluation and management of anaphylaxis from January 1978 through March 1992.
Results: Of 266 subjects, 162 (61%) had three or more anaphylactic episodes, 41 (15%) had two episodes, and 63 (24%) had one episode. Atopy was present in 98 individuals (37%). Physicians thought foods, spices, and food additives caused anaphylaxis in 89 individuals (34%); crustaceans and peanut accounted for about half of these cases. Medications were thought to have caused the anaphylactic episodes in 52 individuals (20%); nonsteroidal anti-inflammatory drugs in about half of these cases. Other probable causes included exercise (n=19), latex (n=2), hormonal changes (n=2), and insect bites (n=4). A suspected cause could not be determined in 98 individuals (37%). These subjects were diagnosed as having idiopathic anaphylaxis. Of the 266 subjects, 102 responded to a follow-up survey; 68 (67%) of the 102 were thought to have identifiable causes of anaphylaxis (32 of whom [47%] failed to carry epinephrine syringes for self-administration despite instructions to do so). In contrast, of 34 subjects with idiopathic anaphylaxis who responded to the survey, only three (9%) did not carry epinephrine.
Conclusions: (1) Atopy is common in subjects who experience anaphylaxis, regardless of its origin; (2) crustaceans and nonsteroidal anti-inflammatory drugs are the most common food and medication groups, respectively, thought to cause anaphylaxis; (3) causative agents can be identified for two thirds of the subjects, and recurrent attacks are the rule; and (4) subjects with idiopathic anaphylaxis are more likely to carry epinephrine for self-administration than those with identifiable causes.
(Arch Intern Med. 1995;155:1749-1754)
Barry J. Materson, MD, MBA; Domenic J. Reda, MS; Richard A. Preston, MD; William C. Cushman, MD; Barry M. Massie, MD; Edward D. Freis, MD; Mahendr S. Kochar, MD; Robert J. Hamburger, MD; Carol Fye, RPh, MS; Raj Lakshman, PhD; John Gottdiener, MD; Eli A. Ramirez, MD; William G. Henderson, PhD; for the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents
Background: An important issue in clinical practice is how to treat patients whose blood pressure does not respond to the first antihypertensive drug selected.
Objective: To analyze the antihypertensive response of patients who had failed to achieve their diastolic blood pressure goal (<90 mm Hg at the end of 8 to 12 weeks of titration) with one of six randomly allocated drugs or placebo to the random allocation of an alternate drug.
Methods: We initially randomized 1292 men with diastolic blood pressure of 95 to 109 mm Hg to treatment with hydrochlorothiazide, atenolol, captopril, clonidine hydrochloride, diltiazem hydrochloride (sustained release), prazosin hydrochloride, or placebo. Of 410 men in whom initial treatment failed, 352 qualified for randomization to the alternate drug.
Results: Of the 352 patients, 173 (49.1%) achieved their goal diastolic blood pressure, in 133 (37.8%) the alternate drug failed, and 46 (13.1%) left the study for various reasons. Overall response rates were as follows: diltiazem, 63%; clonidine, 59%; prazosin, 47%; hydrochlorothiazide, 46%; atenolol, 41%; and captopril, 37%. The best response rate for patients in whom hydrochlorothiazide failed was achieved with diltiazem (70%); after atenolol failure, clonidine (86%); after captopril failure, prazosin (54%); after clonidine failure, diltiazem (100%); after diltiazem failure, captopril (67%); and after prazosin failure, clonidine (53%). The combined response rate for patients initially randomized to an active treatment was 76.0%, which is similar to that achieved by the combination of two drugs in previous studies.
Conclusions: We conclude that sequential single-drug therapy is a rational approach for treatment of hypertension in patients in whom initial drug therapy has failed.
(Arch Intern Med. 1995;155:1757-1762)
Piero G. Antuono, MD, for The Mentane Study Group
Background: Alzheimer's disease is characterized by cognitive and behavioral disturbances that are mediated in part by cholinergic brain deficits.
Objective: To evaluate the long-term effectiveness and safety of an investigational cholinesterase inhibitor, that is, velnacrine maleate, in treating patients with clinically probable Alzheimer's disease (according to the criteria of the National Institute of Neurological Disorders and Stroke [Washington, DC]-Alzheimer Disease and Related Disorders Association [Chicago, Ill]).
Methods: This was a double-blind, placebo-controlled study. After a single-blind washout period, patients were randomized to receive placebo (n=152), velnacrine maleate, 150 mg/d (n=149), or velnacrine maleate, 225 mg/d (n=148) for 24 weeks. Primary end points were cognitive behavior and memory components of the Alzheimer's Disease Assessment Scale and the Clinical Global Impression of Change scale. Secondary end points were caregiver-rated scales.
Results: The scores for the cognitive behavior and memory components of the Alzheimer's Disease Assessment Scale deteriorated in the placebo-treated group (P<.05) but not in the velnacrine-treated groups. Between-group comparisons favored velnacrine maleate, 225 mg over 150 mg (P<.05). Findings were similar for the Clinical Global Impression of Change scale and three of the four caregiver-rated scales. Treatment-related adverse clinical events occurred in 36%, 28%, and 30% of patients in the groups that received placebo, velnacrine maleate (150 mg), and velnacrine maleate (225 mg), respectively. The most common adverse clinical event was diarrhea, which rarely interrupted therapy. Treatment was stopped because of reversible abnormal liver function test results (five or more times the upper limits of normal) in 3%, 30%, and 24% of the patients who received placebo, velnacrine maleate (150 mg), and velnacrine maleate (225 mg), respectively.
Conclusions: Velnacrine produces modest but significant benefits in patients with Alzheimer's disease. Velnacrine maleate (225 mg) is more effective than 150 mg of velnacrine. Both dosages have acceptable safety profiles.
(Arch Intern Med. 1995;155:1766-1772)
Steven D. Pearson, MD, MSc; Joseph L. Polak, MD; Scyrus Cartwright, MD, MPH; Sheila McCabe-Hassan, RN; Thomas H. Lee, MD, SM; Samuel Z. Goldhaber, MD
Uncertainty regarding the optimal evaluation of suspected deep vein thrombosis (DVT) results in wide variations in practice, even within the same institution. To address variation in practice while maximizing the efficiency and quality of care, our institution developed a critical pathway guideline for the emergency department evaluation of patients suspected of having DVT. We present the critical pathway and the clinical rationale underlying its recommendations. The critical pathway was developed by a multidisciplinary team using chart review of practice at our institution, benchmarking at other institutions, and review and discussion of the medical literature. Consensus was achieved for the selection of ultrasound as the primary imaging test for all patients and for recommending initial doses of heparin sodium that are higher than the current norm at our institution to reduce the length of time required to achieve therapeutic anticoagulation. A total time for patient evaluation of 5 hours or less was established as the target. Controversy arose in two key areas: (1) the treatment of patients with normal ultrasound scans when high clinical suspicion for DVT exists and (2) the evaluation and treatment of suspected isolated calf-vein DVT. In its final form, the critical pathway recommendations seek to balance the benefits of standardization with the prerogatives of physicians to make decisions tailored to individual patients.
(Arch Intern Med. 1995;155:1773-1778)
Arthur J. Barsky, MD; Paul D. Cleary, PhD; Remy R. Coeytaux; Jeremy N. Ruskin, MD
Objective: The aim of this study was to describe the longitudinal course of patients who were referred for ambulatory electrocardiographic monitoring because of palpitations.
Methods: A prospective, follow-up examination was conducted of patients who had been studied 6 months previously when referred for monitoring. The inception cohort consisted of 145 consecutive patients with palpitations and 70 asymptomatic, nonpatient volunteers. At follow-up, the patients completed the same research battery as at inception, consisting of structured interviews and self-report questionnaires. These assessed cardiac symptoms, medical care use, role impairment, somatization, hypochondriacal fears and beliefs, and psychiatric disorder.
Results: At 6 months' follow-up, 130 patients with palpitations (89.7% of the original cohort) and 69 nonpatients (98.6%) were reinterviewed. Eighty-four percent of the patients had recurrent palpitations during the 6-month follow-up period. At follow-up, patients with palpitations scored significantly higher than the comparison group on measures of cardiac symptoms and role impairment, and had made more physician visits in the preceding 6 months. They had a higher prevalence of panic disorder and more psychopathologic symptoms, somatized more, and were more hypochondriacal. Psychiatric symptoms and the tendency to amplify bodily sensation, measured at inception, were significant but modest predictors of subsequent palpitations. There was considerable confusion and misunderstanding among patients as to the findings of their ambulatory elec- trocardiogram and the presence or absence of panic disorder.
Conclusions: Patients with palpitations remain symptomatic and functionally impaired and have increased rates of physician visits in the 6 months following Holter monitoring. They also continue to have elevated rates of panic disorder and to evidence some confusion about the cause of their symptoms.
(Arch Intern Med. 1995;155:1782-1788)
Edward H. Wagner, MD, MPH; Susan J. Curry, PhD; Louis Grothaus, MA; Kathleen W. Saunders; Colleen M. McBride, PhD
Background: The magnitude and timing of the impact of effects of smoking cessation on inpatient and outpatient health care use are uncertain.
Methods: Comparison of the use of outpatient and hospital services over time of 2440 persistent smokers and 244 biochemically verified quitters, all of whom were participants in two independent randomized trials of smoking cessation interventions.
Results: Continued smokers in both trials experienced a 7% to 15% increase in outpatient visits and a 30% to 45% increase in hospital admissions over 5 to 6 years of follow-up. The positive slopes approached or reached statistical significance for all use variables in both trial populations. Among quitters, all health care use rates significantly increased during the year in which they quit; after that, the rates declined progressively. By the fourth year after quitting, all use rates among quitters were lower than those for smokers. The increase in hospitalizations during the year of quitting was more often a cause rather than a consequence of successful smoking cessation.
Conclusion: Successful smoking cessation appears to halt the progressive increase in the use of health services associated with continued smoking within a 4-year period.
(Arch Intern Med. 1995;155:1789-1795)
Russell Dodge, MD; Martha G. Cline, MS; Stuart F. Quan, MD
Background: Although insomnia is a frequent complaint among patients, epidemiologic study has been limited. Researchers have reported a wide range in the prevalence of this complaint in a variety of selected populations. Other parameters, such as incidence and remission rates, have not been reported.
Methods: Subjects of the Tucson (Ariz) Epidemiologic Study of Obstructive Lung Disease were asked questions about trouble sleeping in the 1984-1985 (survey I) and 1990-1992 (survey II) surveys. Answers were analyzed along with responses to questions about age, sex, respiratory symptoms, and drug and alcohol use for sleep.
Results: The prevalence of insomnia was similar in both surveys, 34.4% in survey I and 34.1% in survey II. Women had a higher prevalence of insomnia than men in both surveys, and insomnia was more common among older subjects (50.6% of the women aged 65 years or older had insomnia in survey II). In addition, the incidence of new insomnia in survey II was higher in the same groups. Grouping subjects by respiratory symptoms, we found that the prevalence of insomnia was significantly related to cough, dyspnea, or wheeze. Furthermore, subjects with persistent or new respiratory symptoms at survey II were less likely to have remission of insomnia by that survey (31.6% vs 51.5%; P<.05; odds ratio, 0.43) and more likely to develop new insomnia (28.6% vs 14.5%; P<05; odds ratio, 2.36) than subjects with either no symptoms or disappearance of their symptoms by survey II.
Conclusions: In our population, insomnia is a common dynamic complaint whose frequency waxes and wanes in association with respiratory symptoms.
(Arch Intern Med. 1995;155:1797-1800)
Ron M. C. Herings, PhD; Bruno H. Ch. Stricker, PhD; Anthonius de Boer, PhD; Albert Bakker, PhD; Ferd Sturmans, PhD
Background: In the past decade, the use of benzodiazepines has been identified as a major independent risk factor for accidental falls.
Objective: To study the role of dosing, timing, elimination half-life, and type of benzodiazepine in relation to the occurrence of accidental falls leading to hospitalization for femur fractures.
Methods: A 1:3 age-, sex-, and pharmacy-matched case-control study was performed using data from a Dutch record linkage system (PHARMO) (N=300 000). Cases included 493 patients (55 years and older), newly admitted to the hospital for a femur fracture resulting from an accidental fall (between 1986 and 1992). Relative risk estimates were calculated using conditional logistic regression analyses to control for the potential confounding effects of concomitant drug use and presence of a wide range of underlying diseases.Results: Falls were significantly associated with current use of benzodiazepines (odds ratio, 1.6; 95% confidence interval, 1.2 to 2.1) and in particular with short half-life benzodiazepines (odds ratio, 1.5; 95% confidence interval, 1.1 to 2.0), sudden dose increases (odds ratio, 3.4; 95% confidence interval, 1.0 to 11.5), and concomitant use of several benzodiazepines (odds ratio, 2.5; 95% confidence interval, 1.3 to 4.9). A strong dose-response relationship (P<.0001) and dose-response relations among users of either short or long half-life benzodiazepines suggests that these increased risks are explained primarily by dose.
Conclusions: Benzodiazepines are a major, independent risk factor for falls leading to femur fractures, and the increased risk is probably explained by prescribing too-high doses to the elderly.
(Arch Intern Med. 1995;155:1801-1807)
Norbert E. Schindlbeck, MD; Andreas G. Klauser, MD; Winfried A. Voderholzer, MD; Stefan A. Mueller-Lissner, MD
Background: In the absence of highly specific symptoms and without esophageal erosions, long-term pH monitoring is necessary for diagnosing gastroesophageal reflux disease. This method, however, is not generally available.
Objective: To determine whether gastroesophageal reflux disease can be diagnosed empirically by acid suppression in patients with normal results of endoscopy.
Methods: We studied 33 consecutive outpatients with pathologic findings on pH monitoring who had symptoms compatible with gastroesophageal reflux disease and normal results of esophagogastroduodenoscopy, particularly a normal appearance of the esophageal mucosa. The severity of symptoms was graded on a visual analog scale from 1 to 10 by the patient. The patients were treated for at least 7 days with either ranitidine, 150 mg twice daily (patients 1 through 10), omeprazole, 40 mg/d (patients 11 through 21), or omeprazole, 40 mg twice daily (patients 22 through 33). A reassessment of symptoms and second pH monitoring were performed during the last day of treatment.
Results: Omeprazole, 40 mg/d, significantly reduced the severity of symptoms from 7.1 (range, 4 to 9) to 3.7 (0 to 8) and the reflux measure mean acidity from 0.98 mmol/L (0.21 to 76 mmol/L) to 0.02 mmol/L (0 to 0.47 mmol/L). Omeprazole, 40 mg twice daily, significantly reduced the severity of symptoms from 6.8 (3 to 10) to 0.6 (0 to 2) and the mean acidity from 0.38 mmol/L (0.13 to 8.5 mmol/L) to 0.01 mmol/L (0 to 0.14 mmol/L). Both doses of omeprazole were superior to ranitidine, 150 mg twice daily. When a 75% reduction of symptoms was defined as positive, the "omeprazole test" with 40 mg twice daily had a sensitivity of 83.3%, whereas the sensitivity with 40 mg/d was only 27.2%.
Conclusion: In practice, the diagnosis of gastroesophageal reflux disease can be ruled out if symptoms do not improve with a limited course of high-dose proton pump inhibitors.
(Arch Intern Med. 1995;155:1808-1812)
Elizabeth Wallace, MBChB; Jencia Wong, MBChB; Ian R. Reid, MD
Spinal stenosis is a serious complication of Paget's disease of bone. Surgical decompression has a high complication rate and is not always effective. Medical therapy with bisphosphonates is established treatment in other forms of Paget's disease. To our knowledge, this is the first report of the use of intravenous pamidronate disodium as the sole treatment of lower limb weakness attributable to pagetic spinal stenosis. Our patient has been restored to independent living and has maintained his remission, with repeated treatment, for more than 5 years.
(Arch Intern Med. 1995;155:1813-1815)