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1.  Alcohol Screening and Risk of Postoperative Complications in Male VA Patients Undergoing Major Non-cardiac Surgery 
Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed.
To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire—up to a year before surgery—were associated with the risk of postoperative complications.
This is a cohort study.
Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA’s Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery.
One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews.
Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8–6.6%) in patients with AUDIT-C scores 1–4, to 7.9% (6.3–9.7%) in patients with AUDIT-Cs 5–8, 9.7% (6.6–14.1%) in patients with AUDIT-Cs 9–10 and 14.0% (8.9–21.3%) in patients with AUDIT-Cs 11–12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1–5.7%) in patients with AUDIT-C scores 1–4, to 6.9% (5.5–8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0–11.3%) among those with AUDIT-Cs 9–10.
AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1475-x) contains supplementary material, which is available to authorized users.
PMCID: PMC3019325  PMID: 20878363
alcohol screening; surgical outcomes; AUDIT-C
2.  Estimating Risk of Alcohol Dependence Using Alcohol Screening Scores* 
Drug and alcohol dependence  2009;108(1-2):29-36.
Brief alcohol counseling interventions can reduce alcohol consumption and related morbidity among non-dependent risky drinkers, but more intensive alcohol treatment is recommended for persons with alcohol dependence. This study evaluated whether scores on common alcohol screening tests could identify patients likely to have current alcohol dependence so that more appropriate follow-up assessment and/or intervention could be offered. This cross-sectional study used secondary data from 392 male and 927 female adult family medicine outpatients (1993–1994). Likelihood ratios were used to empirically identify and evaluate ranges of scores of the AUDIT, the AUDIT-C, two single-item questions about frequency of binge drinking, and the CAGE questionnaire for detecting DSM-IV past-year alcohol dependence. Based on the prevalence of past-year alcohol dependence in this sample (men: 12.2%; women: 5.8%), zones of the AUDIT and AUDIT-C identified wide variability in the post-screening risk of alcohol dependence in men and women, even among those who screened positive for alcohol misuse. Among men, AUDIT zones 5–10, 11–14 and 15–40 were associated with post-screening probabilities of past-year alcohol dependence ranging from 18–87%, and AUDIT-C zones 5–6, 7–9 and 10–12 were associated with probabilities ranging from 22–75%. Among women, AUDIT zones 3–4, 5–8, 9–12 and 13–40 were associated with post-screening probabilities of past-year alcohol dependence ranging from 6–94%, and AUDIT-C zones 3, 4–6, 7–9 and 10–12 were associated with probabilities ranging from 9–88%. AUDIT or AUDIT-C scores could be used to estimate the probability of past-year alcohol dependence among patients who screen positive for alcohol misuse and inform clinical decision-making.
PMCID: PMC2835806  PMID: 20042299
Alcohol dependence; alcohol screening; stratum specific likelihood ratio; risk stratification; assessment; treatment
3.  Interrelationship of alcohol misuse, HIV sexual risk and HIV screening uptake among emergency department patients 
Emergency department (ED) patients comprise a high-risk population for alcohol misuse and sexual risk for HIV. In order to design future interventions to increase HIV screening uptake, we examined the interrelationship among alcohol misuse, sexual risk for HIV and HIV screening uptake among these patients.
A random sample of 18-64-year-old English- or Spanish-speaking patients at two EDs during July-August 2009 completed a self-administered questionnaire about their alcohol use using the Alcohol Use Questionnaire, the Alcohol Use Disorders Identification Test (AUDIT), and the HIV Sexual Risk Questionnaire. Study participants were offered a rapid HIV test after completing the questionnaires. Binging (≥ five drinks/occasion for men, ≥ four drinks for women) was assessed and sex-specific alcohol misuse severity levels (low-risk, harmful, hazardous, dependence) were calculated using AUDIT scores. Analyses were limited to participants who had sexual intercourse in the past 12 months. Multivariable logistic regression was used to assess the associations between HIV screening uptake and (1) alcohol misuse, (2) sexual risk for HIV, and (3) the intersection of HIV sexual risk and alcohol misuse. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were estimated. All models were adjusted for patient demographic characteristics and separate models for men and women were constructed.
Of 524 participants (55.0% female), 58.4% identified as white, non-Hispanic, and 72% reported previous HIV testing. Approximately 75% of participants reported drinking alcohol within the past 30 days and 74.5% of men and 59.6% of women reported binge drinking. A relationship was found between reported sexual risk for HIV and alcohol use among men (AOR 3.31 [CI 1.51-7.24]) and women (AOR 2.78 [CI 1.48-5.23]). Women who reported binge drinking were more likely to have higher reported sexual risk for HIV (AOR 2.55 [CI 1.40-4.64]) compared to women who do not report binge drinking. HIV screening uptake was not higher among those with greater alcohol misuse and sexual risk among men or women.
The apparent disconnection between HIV screening uptake and alcohol misuse and sexual risk for HIV among ED patients in this study is concerning. Brief interventions emphasizing these associations should be evaluated to reduce alcohol misuse and sexual risk and increase the uptake of ED HIV screening.
PMCID: PMC3686630  PMID: 23721108
Emergency services; Hospital; Ethanol/blood; Questionnaires; Sexual behavior risk; HIV; Intervention
4.  Associations Between AUDIT-C and Mortality Vary by Age and Sex 
Population Health Management  2010;13(5):263-268.
We sought to determine the sex- and age-specific risk of mortality associated with scores on the 3-item Alcohol Use Disorder Identification Test–Consumption (AUDIT-C) questionnaire using data from a national sample of Veterans Health Administration (VHA) patients. Men (N = 215,924) and women (N = 9168) who completed the AUDIT-C in a patient survey were followed for 24 months. AUDIT-C categories (0, 1–4, 5–8, 9–12) were evaluated as predictors of mortality in logistic regression models, adjusted for age, race, education, marital status, smoking, depression, and comorbidities. For women, AUDIT-C scores of 9–12 were associated with a significantly increased risk of death compared to the AUDIT-C 1-4 group (odds ratio [OR] 7.09; 95% confidence interval [CI] = 2.67, 18.82). For men overall, AUDIT-C scores of 5–8 and 9–12 were associated with increased risk of death compared to the AUDIT-C 1-4 group (OR 1.13, 95% CI = 1.05, 1.21, and OR 1.63, 95% CI = 1.45, 1.84, respectively) but these associations varied by age. These results provide sex- and age-tailored risk information that clinicians can use in evidence-based conversations with patients about the health-related risks of their alcohol consumption. This study adds to the growing literature establishing the AUDIT-C as a scaled marker of alcohol-related risk or “vital sign” that might facilitate the detection and management of alcohol-related risks and problems. (Population Health Management 2010;13:263–268)
PMCID: PMC3135896  PMID: 20879907
5.  Sex Differences in Alcohol Misuse and Estimated Blood Alcohol Concentrations Among Emergency Department Patients: Implications for Brief Interventions 
The objective was to assess the relationship between alcohol use and misuse and patient sex among emergency department (ED) patients by comparing self-reported estimates of quantity and frequency of alcohol use; estimated blood alcohol concentrations (eBACs) when typically drinking, and during heavy episodic drinking (binging); and alcohol misuse severity, to understand sex differences in alcohol use and misuse for this population.
The authors surveyed a random sample of non-intoxicated, sub-critically ill or injured, 18 to 64 year-old English- or Spanish-speaking patients on randomly selected dates and times at two EDs during July 2009 and August 2009. Participants self-administered a questionnaire about their self-reported alcohol use during a typical month within the past 12 months, and the Alcohol Use Disorders Identification Test (AUDIT). Using the formulae by Matthews and Miller, sex-specific eBACs were calculated for participants according to their reported weight and the number of reported alcoholic drinks consumed on days when typically drinking, and on days of heavy episodic (binge) drinking (≥ 5 drinks/occasion for men, ≥ 4 drinks for women). Sex-specific alcohol misuse severity levels (low-risk, harmful, hazardous, and dependence) were calculated using AUDIT scores. Wilcoxon rank-sum and Pearson’s chi-square tests were used to compare outcomes by sex. Negative binomial regression was used to assess the relationship between sex and the number of drinks consumed on a typical day, the number of days spent drinking and binging, and estimated AUDIT scores. Logistic regression was used to assess the outcome of the presence of binging according to sex. Multinomial logistic regression was used to compare by sex the percentage of days spent drinking and binging in one month, eBACs when typically drinking and when binging, and AUDIT at-risk drinking levels. Incidence rate ratios (IRRs) and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were estimated. All models were adjusted for patient demographic characteristics.
Of the 513 participants, 52.1% were women, 55.8% were white non-Hispanic, and their median age was 34 years (IQR 25 to 46 years). Men reported greater mean alcohol consumption than women when typically drinking (4.3 vs. 3.3 drinks per day; p < 0.001), and during heavy episodic drinking (8.6 vs. 5.3/drinks per occasion; p < 0.001). Men spent more days drinking (IRR 1.41, 95% CI = 1.19 to 1.65) and engaging in heavy episodic drinking (IRR 1.68, 95% CI = 1.31 to 2.17) than women. Additionally, men were more likely to engage in heavy episodic drinking (AOR 1.72, 95% CI = 1.16 to 2.56) than women. However, the mean eBACs for men and women were similar when typically drinking (0.05 vs. 0.06; p < 0.13) and during heavy episodic drinking (0.13 vs. 0.12; p < 0.13). Mean AUDIT scores were greater for men than women (7.5 vs. 5.3; p < 0.001), although alcohol misuse severity levels were similar between men and women (24.4% vs. 26.6% for hazardous, 2.8% vs. 2.2% for harmful, and 6.5% vs. 3.4% for dependence; p < 0.38).
Although men drink more than women, women have similar eBACs with comparable levels of alcohol misuse. Women may benefit from recognizing that they are reaching similar levels of intoxication compared to men. Addressing these differences and possible health implications in future ED brief interventions may induce changes in problematic alcohol use among women.
PMCID: PMC3424395  PMID: 22849748
6.  Inconsistencies between alcohol screening results based on AUDIT-C scores and reported drinking on the AUDIT-C questions: prevalence in two US national samples 
The AUDIT-C is an extensively validated screen for unhealthy alcohol use (i.e. drinking above recommended limits or alcohol use disorder), which consists of three questions about alcohol consumption. AUDIT-C scores ≥4 points for men and ≥3 for women are considered positive screens based on US validation studies that compared the AUDIT-C to “gold standard” measures of unhealthy alcohol use from independent, detailed interviews. However, results of screening—positive or negative based on AUDIT-C scores—can be inconsistent with reported drinking on the AUDIT-C questions. For example, individuals can screen positive based on the AUDIT-C score while reporting drinking below US recommended limits on the same AUDIT-C. Alternatively, they can screen negative based on the AUDIT-C score while reporting drinking above US recommended limits. Such inconsistencies could complicate interpretation of screening results, but it is unclear how often they occur in practice.
This study used AUDIT-C data from respondents who reported past-year drinking on one of two national US surveys: a general population survey (N = 26,610) and a Veterans Health Administration (VA) outpatient survey (N = 467,416). Gender-stratified analyses estimated the prevalence of AUDIT-C screen results—positive or negative screens based on the AUDIT-C score—that were inconsistent with reported drinking (above or below US recommended limits) on the same AUDIT-C.
Among men who reported drinking, 13.8% and 21.1% of US general population and VA samples, respectively, had screening results based on AUDIT-C scores (positive or negative) that were inconsistent with reported drinking on the AUDIT-C questions (above or below US recommended limits). Among women who reported drinking, 18.3% and 20.7% of US general population and VA samples, respectively, had screening results that were inconsistent with reported drinking.
This study did not include an independent interview gold standard for unhealthy alcohol use and therefore cannot address how often observed inconsistencies represent false positive or negative screens.
Up to 21% of people who drink alcohol had alcohol screening results based on the AUDIT-C score that were inconsistent with reported drinking on the same AUDIT-C. This needs to be addressed when training clinicians to use the AUDIT-C.
PMCID: PMC3946205  PMID: 24468406
AUDIT-C; Brief intervention; Unhealthy alcohol use; Alcohol screening; Heavy episodic drinking
7.  Alcohol Screening Scores and the Risk of New-Onset Gastrointestinal Illness or Related Hospitalization 
Excessive alcohol use is associated with a variety of negative health outcomes, including liver disease, upper gastrointestinal bleeding, and pancreatitis.
To determine the 2-year risk of gastrointestinal-related hospitalization and new-onset gastrointestinal illness based on alcohol screening scores.
Retrospective cohort study.
Male (N = 215, 924) and female (N = 9,168) outpatients who returned mailed questionnaires and were followed for 24 months.
Alcohol Use Disorder Identification Test—Consumption Questionnaire (AUDIT-C), a validated three-item alcohol screening questionnaire (0–12 points).
Two-year risk of hospitalization with a gastrointestinal disorder was increased in men with AUDIT-C scores of 5–8 and 9–12 (OR 1.54, 95% CI = 1.27–1.86; and OR 3.27; 95% CI = 2.62–4.09 respectively), and women with AUDIT-C scores of 9–12 (OR 6.84, 95% CI = 1.85 – 25.37). Men with AUDIT-C scores of 5–8 and 9–12 had increased risk of new-onset liver disease (OR 1.49, 95% CI = 1.30–1.71; and OR 2.82, 95% CI = 2.38–3.34 respectively), and new-onset of upper gastrointestinal bleeding (OR 1.28, 95% CI = 1.05–1.57; and OR 2.14, 95% CI = 1.54-2.97 respectively). Two-year risk of new-onset pancreatitis in men with AUDIT -C scores 9–12 was also increased (OR 2.14; 95% CI = 1.54–2.97).
Excessive alcohol use as determined by AUDIT-C is associated with 2-year increased risk of gastrointestinal-related hospitalization in men and women and new-onset liver disease, upper gastrointestinal bleeding, and pancreatitis in men. These results provide risk information that clinicians can use in evidence-based conversations with patients about their alcohol consumption.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1688-7) contains supplementary material, which is available to authorized users.
PMCID: PMC3138581  PMID: 21455813
alcohol; AUDIT; gastrointestinal; hospitalization; new-onset; women
8.  Comparing short versions of the AUDIT in a community-based survey of young people 
BMC Public Health  2013;13:301.
The 10-item Alcohol Use Disorders Identification Test (AUDIT-10) is commonly used to monitor harmful alcohol consumption among high-risk groups, including young people. However, time and space constraints have generated interest for shortened versions. Commonly used variations are the AUDIT-C (three questions) and the Fast Alcohol Screening Test (FAST) (four questions), but their utility in screening young people in non-clinical settings has received little attention.
We examined the performance of established and novel shortened versions of the AUDIT in relation to the full AUDIT-10 in a community-based survey of young people (16–29 years) attending a music festival in Melbourne, Australia (January 2010).
Among those reporting drinking alcohol in the previous 12 months, the following statistics were systematically assessed for all possible combinations of three or four AUDIT items and established AUDIT variations: Cronbach’s alpha (internal consistency), variance explained (R2) and Pearson’s correlation coefficient (concurrent validity). For our purposes, novel shortened AUDIT versions considered were required to represent all three AUDIT domains and include item 9 on alcohol-related injury.
We recruited 640 participants (68% female) reporting drinking in the previous 12 months. Median AUDIT-10 score was 10 in males and 9 in females, and 127 (20%) were classified as having at least high-level alcohol problems according to WHO classification.
The FAST scored consistently high across statistical measures; it explained 85.6% of variance in AUDIT-10, correlation with AUDIT-10 was 0.92, and Cronbach’s alpha was 0.66. A number of novel four-item AUDIT variations scored similarly high. Comparatively, the AUDIT-C scored substantially lower on all measures except internal consistency.
Numerous abbreviated variations of the AUDIT may be a suitable alternative to the AUDIT-10 for classifying high-level alcohol problems in a community-based population of young Australians. Four-item AUDIT variations scored more consistently high across all evaluated statistics compared to three-item combinations. Novel AUDIT versions may be more effective than many established shortened versions as an alternative screening tool to the AUDIT-10 to measure hazardous or harmful alcohol consumption in this population.
PMCID: PMC3691761  PMID: 23556543
Alcohol screening; Alcohol use disorders identification test; AUDIT; Alcohol consumption; Young adult; Adolescents
9.  Patient-Centered Research 
Alcohol use disorders are common and poorly detected in most primary care settings. We implemented a new method of screening for alcohol use disorders among primary care patients.
A health screening Interactive Voice Response (IVR) interviewing system (respondents answer pre-recorded questions via touch tone telephones) that includes the Alcohol Use Disorders Identification Test (AUDIT) was developed and administered in an urban primary care practice housed in a county hospital. Patients were contacted for screening approximately two weeks prior to their next scheduled visit. At the conclusion of the interview, patients heard on-line feedback advising them on safe-drinking behaviors (appropriate to their AUDIT score). Each patient's primary care physician was faxed a report of the screening results, clinical management recommendations, and referral resources.
Of 6035 eligible patients contacted, 86% (5174) agreed to begin the interview, resulting in 2997 interviews in which all necessary alcohol-related questions were answered (58% completion rate). Seventy-one percent of respondents were female; 58% white, 32% black, and 6% Hispanic; the mean age was 49 ± 14.8; insurance status was: 26% uninsured, 24% private, 17% managed care, 17% Medicaid, 16% Medicare. Screening results for 7.9% of respondents were within the hazardous range (AUDIT = 8–10) and 14.1% screened in the harmful range (AUDIT = *11). As expected, increased AUDIT scores (*8) were more prevalent among men (29.3% of men and 10.8% for women). After controlling for gender, the Cochran-Mantel-Haenszel test was used to compare AUDIT level across age groups (p = 0.001) and racial groups (p = 0.018). Hazardous drinking rates were similar across age groups (range: 4.9–7%) and racial groups (range; 4.1–7.9%). A larger proportion of respondents with AUDIT scores indicating harmful use of alcohol were between the ages of 26–55 (range: 14.4–19.8%), with the highest proportion falling within the 36–45 age group. Hispanic and Black respondents were most likely to report harmful drinking/dependence—16.6% and 16.4%, respectively. However, when rates of hazardous and harmful drinking behaviors are considered together, there was little difference among races (18.5 to 22.9%).
Using a computerized interview allowed us to screen many more patients for alcohol use disorders than would normally be screened in most primary care settings. The finding that 20% of our patients reported hazardous or harmful drinking behaviors alerts us to how common this stigmatized problem is. IVR systems should be considered as effective tools to screen patients for a prevalent, sensitive issue such as alcohol misuse. We are in the process of examining the effects of novel treatment approaches for alcohol use disorders in primary care.
PMCID: PMC1495738
10.  Red Blood Cell Transfusion and Mortality in Trauma Patients: Risk-Stratified Analysis of an Observational Study 
PLoS Medicine  2014;11(6):e1001664.
Using a large multicentre cohort, Pablo Perel and colleagues evaluate the association of red blood cell transfusion with mortality according to the predicted risk of death for trauma patients.
Please see later in the article for the Editors' Summary
Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death.
Methods and Findings
A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: <6%, 6%–20%, 21%–50%, and >50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction <0.0001). Transfusion was associated with an increase in all-cause mortality among patients with <6% and 6%–20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08–7.13, p<0.0001, and OR 2.31, 95% CI 1.96–2.73, p<0.0001, respectively), but with a decrease in all-cause mortality in patients with >50% predicted risk of death (OR 0.59, 95% CI 0.47–0.74, p<0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05–3.24, p<0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (<6%) predicted risk of death (p-value for interaction <0.0001). As this was an observational study, the results could have been affected by different types of confounding. In addition, we could not consider haemoglobin in our analysis. In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar.
The association of transfusion with all-cause mortality appears to vary according to the predicted risk of death. Transfusion may reduce mortality in patients at high risk of death but increase mortality in those at low risk. The effect of transfusion in low-risk patients should be further tested in a randomised trial.
Trial registration NCT01746953
Please see later in the article for the Editors' Summary
Editors' Summary
Trauma—a serious injury to the body caused by violence or an accident—is a major global health problem. Every year, injuries caused by traffic collisions, falls, blows, and other traumatic events kill more than 5 million people (9% of annual global deaths). Indeed, for people between the ages of 5 and 44 years, injuries are among the top three causes of death in many countries. Trauma sometimes kills people through physical damage to the brain and other internal organs, but hemorrhage (serious uncontrolled bleeding) is responsible for 30%–40% of trauma-related deaths. Consequently, early trauma care focuses on minimizing hemorrhage (for example, by using compression to stop bleeding) and on restoring blood circulation after blood loss (health-care professionals refer to this as resuscitation). Red blood cell (RBC) transfusion is often used for the management of patients with trauma who are bleeding; other resuscitation products include isotonic saline and solutions of human blood proteins.
Why Was This Study Done?
Although RBC transfusion can save the lives of patients with trauma who are bleeding, there is considerable uncertainty regarding the balance of risks and benefits associated with this procedure. RBC transfusion, which is an expensive intervention, is associated with several potential adverse effects, including allergic reactions and infections. Moreover, blood supplies are limited, and the risks from transfusion are high in low- and middle-income countries, where most trauma-related deaths occur. In this study, which is a secondary analysis of data from a trial (CRASH-2) that evaluated the effect of tranexamic acid (which stops excessive bleeding) in patients with trauma, the researchers test the hypothesis that RBC transfusion may have a beneficial effect among patients at high risk of death following trauma but a harmful effect among those at low risk of death.
What Did the Researchers Do and Find?
The CRASH-2 trail included 20,127 patients with trauma and major bleeding treated in 274 hospitals in 40 countries. In their risk-stratified analysis, the researchers investigated the effect of RBC transfusion on CRASH-2 participants with a predicted risk of death (estimated using a validated model that included clinical variables such as heart rate and blood pressure) on admission to hospital of less than 6%, 6%–20%, 21%–50%, or more than 50%. That is, the researchers compared death rates among patients in each stratum of predicted risk of death who received a RBC transfusion with death rates among patients who did not receive a transfusion. Half the patients received at least one transfusion. Transfusion was associated with an increase in all-cause mortality at 28 days after trauma among patients with a predicted risk of death of less than 6% or of 6%–20%, but with a decrease in all-cause mortality among patients with a predicted risk of death of more than 50%. In absolute figures, compared to no transfusion, RBC transfusion was associated with 5.1 more deaths per 100 patients in the patient group with the lowest predicted risk of death but with 11.9 fewer deaths per 100 patients in the group with the highest predicted risk of death.
What Do These Findings Mean?
These findings show that RBC transfusion is associated with an increase in all-cause deaths among patients with trauma and major bleeding with a low predicted risk of death, but with a reduction in all-cause deaths among patients with a high predicted risk of death. In other words, these findings suggest that the effect of RBC transfusion on all-cause mortality may vary according to whether a patient with trauma has a high or low predicted risk of death. However, because the participants in the CRASH-2 trial were not randomly assigned to receive a RBC transfusion, it is not possible to conclude that receiving a RBC transfusion actually increased the death rate among patients with a low predicted risk of death. It might be that the patients with this level of predicted risk of death who received a transfusion shared other unknown characteristics (confounders) that were actually responsible for their increased death rate. Thus, to provide better guidance for clinicians caring for patients with trauma and hemorrhage, the hypothesis that RBC transfusion could be harmful among patients with trauma with a low predicted risk of death should be prospectively evaluated in a randomised controlled trial.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Druin Burch
The World Health Organization provides information on injuries and on violence and injury prevention (in several languages)
The US Centers for Disease Control and Prevention has information on injury and violence prevention and control
The National Trauma Institute, a US-based non-profit organization, provides information about hemorrhage after trauma and personal stories about surviving trauma
The UK National Health Service Choices website provides information about blood transfusion, including a personal story about transfusion after a serious road accident
The US National Heart, Lung, and Blood Institute also provides detailed information about blood transfusions
MedlinePlus provides links to further resources on injuries, bleeding, and blood transfusion (in English and Spanish)
More information in available about CRASH-2 (in several languages)
PMCID: PMC4060995  PMID: 24937305
11.  Alcohol Screening Scores and 90 Day Outcomes in Patients with Acute Lung Injury 
Critical care medicine  2013;41(6):1518-1525.
The effects of excess alcohol consumption (alcohol misuse) on outcomes in patients with acute lung injury (ALI) have been inconsistent, and there are no studies examining this association in the era of low tidal volume ventilation and a fluid conservative strategy. We sought to determine whether validated scores on the Alcohol Use Disorders Identification Test (AUDIT) that correspond to past year abstinence (zone 1), low-risk drinking (zone 2), mild to moderate alcohol misuse (zone 3), and severe alcohol misuse (zone 4) are associated with poor outcomes in patients with ALI.
Secondary analysis.
The Acute Respiratory Distress Syndrome (ARDS) network, a consortium of 12 university centers (44 hospitals) dedicated to the conduct of multi-center clinical trials in patients with acute lung injury.
Patients meeting consensus criteria for ALI enrolled in one of three recent ARDS network clinical trials.
Measurements and Main Results
Of 1,133 patients enrolled in one of three ARDS network studies, 1,037 patients had an AUDIT score available for analysis. Alcohol misuse was common with 70 (7%) of patients having AUDIT scores in zone 3 and 129 (12%) patients in zone 4. There was a u-shaped association between validated AUDIT zones and death or persistent hospitalization at 90 days (34% in zone 1, 26% in zone 2, 27% in zone 3, 36% in zone 4; p < 0.05 for comparison of zone 1 to zone 2 and zone 4 to zone 2). In a multiple logistic regression model, there was a significantly higher odds of death or persistent hospitalization in patients in AUDIT zone 4 when compared to those in zone 2 (adjusted OR 1.70; 95% CI 1.00, 2.87; p = 0.048).
Severe, but not mild to moderate alcohol misuse is independently associated with an increased risk of death or persistent hospitalization at 90 days in ALI patients.
PMCID: PMC4048714  PMID: 23538449
alcohol use disorders identification test; acute lung injury; alcohol use disorder; alcohol misuse; unhealthy alcohol use
12.  Alcohol Consumption among HIV-Infected Persons in a Large Urban HIV Clinic in Kampala Uganda: A Constellation of Harmful Behaviors 
PLoS ONE  2015;10(5):e0126236.
Alcohol use by persons living with HIV/AIDS (PLWHA) negatively impacts the public health benefits of antiretroviral therapy (ART). Using a standardized alcohol assessment tool, we estimate the prevalence of alcohol use, identify associated factors, and test the association of alcohol misuse with sexual risk behaviors among PLWHA in Uganda.
A cross-section of PLWHA in Kampala were interviewed regarding their sexual behavior and self-reported alcohol consumption in the previous 6 months. Alcohol use was assessed using the alcohol use disorders identification test (AUDIT). Gender-stratified log binomial regression analyses were used to identify independent factors associated with alcohol misuse and to test whether alcohol misuse was associated with risky sexual behaviors.
Of the 725 subjects enrolled, 235 (33%) reported any alcohol use and 135 (18.6%) reported alcohol misuse, while 38 (5.2%) drank hazardous levels of alcohol. Alcohol misuse was more likely among subjects not yet on ART (adjusted prevalence ratio [aPR] was 1.65 p=0.043 for males and 1.79, p=0.019 for females) and those with self-reported poor adherence (aPR for males=1.56, p=0.052, and for females=1.93, p=0.0189). Belonging to Pentecostal or Muslim religious denominations was protective against alcohol misuse compared to belonging to Anglican and Catholic denominations in both sexes (aPR=0.11 for men, p<0.001, and aPR=0.32 for women, p=0.003). Alcohol misuse was independently associated with reporting risky sexual behaviors (aPR=1.67; 95% CI: 1.07–2.60, p=0.023) among males, but not significant among females (aPR=1.29; 95% CI: 0.95–1.74, p=0.098). Non-disclosure of HIV positive status to sexual partner was significantly associated with risky sex in both males (aPR=1.69; p=0.014) and females (aPR 2.45; p<0.001).
Alcohol use among PLWHA was high, and was associated with self-reported medication non-adherence, non-disclosure of HIV positive status to sexual partner(s), and risky sexual behaviors among male subjects. Interventions targeting alcohol use and the associated negative behaviors should be tested in this setting.
PMCID: PMC4427399  PMID: 25962171
13.  Detecting alcohol-related problems in developing countries: A comparison of two screening measures in India 
There is inadequate recognition of alcohol misuse as a public health issue in India. Information on screening measures is critical for prevention and early intervention efforts. This study critically evaluated the full and shorter versions of the AUDIT and RAPS4-QF as screening measures for alcohol use disorders (AUDs) in a community sample of male drinkers in Goa, India.
Data from male drinking respondents in a population study on alcohol use patterns and sexual risk behaviors in randomly selected rural and urban areas of North Goa are reported. Overall, 39% (n=743) of the 1899 screened men, age 18 to 49, reported consuming alcohol in the last 12 months. These current drinkers were administered the screening measures as part of detailed interviews on drinking patterns and AUD symptoms. Receiver Operating Characteristic (ROC) analysis was conducted for each combination of screening measure and criterion (alcohol dependence or any AUD). Reliability and correlations among the 4 measures were also examined.
All four measures performed well with area under the curves (AUCs) of at least .79. The full screeners that included both drinking patterns and problem items (the AUDIT and the RAP4-QF) performed better than their shorter versions (the AUDIT-C and the RAPS4) in detecting AUDs. Performance of the AUDIT and RAPS4-QF improved with lowered and raised thresholds, respectively, and alternate cut-off scores are suggested. Scores on the full measures were significantly correlated (.80). Reliability estimates for the AUDIT measures were higher than those for the RAPS4 measures.
All measures were efficient at detecting AUDs. When screening for alcohol-related problems among males in the general population in India, cut-off scores for screeners may need to be adjusted. Selecting an appropriate screening measure and cut-off score necessitates careful consideration of the screening context and resources available to confirm alcohol-related diagnoses.
PMCID: PMC2789891  PMID: 19740136
Alcohol-related problems; screening measures; ROC; India
14.  Alcohol Sales and Risk of Serious Assault 
PLoS Medicine  2008;5(5):e104.
Alcohol is a contributing cause of unintentional injuries, such as motor vehicle crashes. Prior research on the association between alcohol use and violent injury was limited to survey-based data, and the inclusion of cases from a single trauma centre, without adequate controls. Beyond these limitations was the inability of prior researchers to comprehensively capture most alcohol sales. In Ontario, most alcohol is sold through retail outlets run by the provincial government, and hospitals are financed under a provincial health care system. We assessed the risk of being hospitalized due to assault in association with retail alcohol sales across Ontario.
Methods and Findings
We performed a population-based case-crossover analysis of all persons aged 13 years and older hospitalized for assault in Ontario from 1 April 2002 to 1 December 2004. On the day prior to each assault case's hospitalization, the volume of alcohol sold at the store in closest proximity to the victim's home was compared to the volume of alcohol sold at the same store 7 d earlier. Conditional logistic regression analysis was used to determine the associated relative risk (RR) of assault per 1,000 l higher daily sales of alcohol. Of the 3,212 persons admitted to hospital for assault, nearly 25% were between the ages of 13 and 20 y, and 83% were male. A total of 1,150 assaults (36%) involved the use of a sharp or blunt weapon, and 1,532 (48%) arose during an unarmed brawl or fight. For every 1,000 l more of alcohol sold per store per day, the relative risk of being hospitalized for assault was 1.13 (95% confidence interval [CI] 1.02–1.26). The risk was accentuated for males (1.18, 95% CI 1.05–1.33), youth aged 13 to 20 y (1.21, 95% CI 0.99–1.46), and those in urban areas (1.19, 95% CI 1.06–1.35).
The risk of being a victim of serious assault increases with alcohol sales, especially among young urban men. Akin to reducing the risk of driving while impaired, consideration should be given to novel methods of preventing alcohol-related violence.
In a population-based case-crossover analysis, Joel Ray and colleagues find that the risk of being a victim of serious assault increases with retail alcohol sales, especially among young urban men.
Editors' Summary
Alcohol has been produced and consumed around the world since prehistoric times. In the Western world it is now the most commonly consumed psychoactive drug (a substance that changes mood, behavior, and thought processes). The World Health Organization reports that there are 76.3 million persons with alcohol use disorders worldwide. Alcohol consumption is an important factor in unintentional injuries, such as motor vehicle crashes, and in violent criminal behavior. In the United Kingdom, for example, a higher proportion of heavy drinkers than light drinkers cause violent criminal offenses. Other figures suggest that people (in particular, young men) have an increased risk of committing a criminally violent offense within 24 h of drinking alcohol. There is also some evidence that suggests that the victims as well as the perpetrators of assaults have often been drinking recently, possibly because alcohol impairs the victim's ability to judge potentially explosive situations.
Why Was This Study Done?
The researchers wanted to know more about the relationship between alcohol and intentional violence. The recognition of a clear link between driving when impaired by alcohol and motor vehicle crashes has led many countries to introduce public awareness programs that stigmatize drunk driving. If a clear link between alcohol consumption by the people involved in violent crime could also be established, similar programs might reduce alcohol-related assaults. The researchers tested the hypothesis that the risk of being hospitalized due to a violent assault increases when there are increased alcohol sales in the immediate vicinity of the victim's place of residence.
What Did the Researchers Do and Find?
The researchers did their study in Ontario, Canada for three reasons. First, Ontario is Canada's largest province. Second, the province keeps detailed computerized medical records, including records of people hospitalized from being violently assaulted. Third, most alcohol is sold in government-run shops, and the district has the infrastructure to allow daily alcohol sales to be tracked. The researchers identified more than 3,000 people over the age of 13 y who were hospitalized in the province because of a serious assault during a 32-mo period. They compared the volume of alcohol sold at the liquor store nearest to the victim's home the day before the assault with the volume sold at the same store a week earlier (this type of study is called a “case-crossover” study). For every extra 1,000 l of alcohol sold per store per day (a doubling of alcohol sales), the overall risk of being hospitalized for assault increased by 13%. The risk was highest in three subgroups of people: men (18% increased risk), youths aged 13 to 20 y (21% increased risk), and those living in urban areas (19% increased risk). At peak times of alcohol sales, the risk of assault was 41% higher than at times when alcohol sales were lowest.
What Do These Findings Mean?
These findings indicate that the risk of being seriously assaulted increases with the amount of alcohol sold locally the day before the assault and show that the individuals most at risk are young men living in urban areas. Because the study considers only serious assaults and alcohol sold in shops (i.e., not including alcohol sold in bars), it probably underestimates the association between alcohol and assault. It also does not indicate whether the victim or perpetrator of the assault (or both) had been drinking, and its findings may not apply to countries with different drinking habits. Nevertheless, these findings support the idea that the consumption of alcohol contributes to the occurrence of medical injuries from intentional violence. Increasing the price of alcohol or making alcohol harder to obtain might help to reduce the occurrence of alcohol-related assaults. The researchers suggest that a particularly effective approach may be to stigmatize alcohol-related brawling, analogous to the way that driving under the influence of alcohol has been made socially unacceptable.
Additional Information.
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Bennetts and Seabrook
The US National Institute on Alcohol Abuse and Alcoholism provides information on all aspects of alcohol abuse, including an article on alcohol use and violence among young adults
Alcohol-related assault is examined in the British Crime Survey
Alcohol Concern, the UK national agency on alcohol misuse, provides fact sheets on the health impacts of alcohol, young people's drinking, and alcohol and crime
The Canadian Centre for Addiction and Mental Health in Toronto provides information about alcohol addiction (in English and French)
PMCID: PMC2375945  PMID: 18479181
15.  Validity of carbohydrate deficient transferrin and other markers as diagnostic aids in the detection of alcohol related seizures 
OBJECTIVE—The role of alcohol misuse in the genesis of seizures is probably often undetected. The aim was to investigate the utility of carbohydrate deficient transferrin (CDT) compared with other biomarkers and clinical examination in the diagnosis of alcohol related seizures.
METHODS—The study included consecutively 158 seizure patients—83 men and 75 women—with mean age 45 (16-79) years. Seizures related to alcohol use were identified by a score ⩾8 in the alcohol use disorders identification test (AUDIT positive). AUDIT was applied as the gold standard to which sensitivity and specificity of the various markers were related. Blood samples were obtained from 150 patients on admission and analysed for ethanol, liver enzymes, and CDT, using AXIS Biochemicals' %CDT-TIA kit.
RESULTS—53 patients (34%) were AUDIT positive. Using the commonly applied decision value for %CDT of 5.0%, a sensitivity of 41% and a specificity of 84% were obtained. Analysis of receiver operator characteristics (ROC) curves disclosed an optimal cut off value for %CDT of 5.4%, which yielded a sensitivity of 39% and a specificity of 88%. At a specificity of 80%, the sensitivity was 43% for %CDT and 26% for GGT. The %CDT sensitivity was markedly higher for men than for women. Compared with GGT, ASAT, ALAT, and ASAT/ALAT ratio, CDT was the best single biomarker for alcohol related seizures. However, even in the subgroup of withdrawal seizures, the sensitivity level barely exceeded 50%. Clinicians scored alcohol as the main cause of the seizure in only 19 cases (12%). In 38 (24%) cases, clinicians suspected that alcohol had a role (sensitivity of 62% at a specificity of 89%). Their ability to identify AUDIT positive patients was better than that of any biomarker, but many cases were missed. Agreement of clinicians' scores to CDT was only fair (κ=0.28). CDT concentrations were significantly increased among alcohol abstaining patients on enzyme-inducing antiepileptic drugs. Six out of 16 patients with false positive CDT results were exposed to such drugs.
CONCLUSIONS—CDT is not recommended as a stand alone marker for alcohol related seizures, but may provide a useful contribution to the overall diagnostic investigation of seizures. Confirmatory studies are needed as to the apparent vulnerability of CDT to antiepileptic drugs.

PMCID: PMC1736803  PMID: 10675217
16.  Alcohol misuse, genetics, and major bleeding among warfarin therapy patients in a community setting† 
Little is known about the impact of alcohol consumption on warfarin safety, or whether demographic, clinical, or genetic factors modify risk of adverse events. We conducted a case–control study to assess the association between screening positive for moderate/severe alcohol misuse and the risk of major bleeding in a community sample of patients using warfarin.
The study sample consisted of 570 adult patients continuously enrolled in Group Heath for at least 2 years and receiving warfarin. The main outcome was major bleeding validated through medical record review. Cases experienced major bleeding, and controls did not experience major bleeding. Exposures were Alcohol Use Disorders Identification Test Consumption Questionnaire (AUDIT-C) scores and report of heavy episodic drinking (≥5 drinks on an occasion). The odds of major bleeding were estimated with multivariate logistic regression models. The overall sample was 55% male, 94% Caucasian, and had a mean age of 70 years.
Among 265 cases and 305 controls, AUDIT-C scores indicative of moderate/severe alcohol misuse and heavy episodic drinking were associated with increased risk of major bleeding (OR = 2.10, 95% CI = 1.08–4.07; and OR = 2.36, 95% CI = 1.24–4.50, respectively). Stratified analyses demonstrated increased alcohol-related major bleeding risk in patients on warfarin for ≥1 year and in those with a low-dose genotype (CYP2C9*2/*3, VKORC1(1173G>A), CYP4F2*1), but not in other sub-groups evaluated.
Alcohol screening questionnaires, potentially coupled with genetic testing, could have clinical utility in selecting patients for warfarin therapy, as well as refining dosing and monitoring practices.
PMCID: PMC4478047  PMID: 25858232
warfarin; AUDIT-C; alcohol; CYP2C9; VKORC1; CYP4F2; major bleeding; pharmacoepidemiology
17.  Gender differences in the relationship between alcohol use and depressive symptoms in St. Petersburg, Russia 
Gender differences in the relationship between alcohol use and depressive symptoms are inconsistent, and few studies have addressed this issue in Russia. Because this finding may have important implications for interventions to reduce alcohol misuse or alcohol related problems in Russia, we conducted a study to investigate whether the association between alcohol use and depressive symptoms differs by gender at high risk for HIV.
We used the Alcohol Use Disorders Identification Test (AUDIT) and the 10-item Center for Epidemiological Studies Depression Scale to measure alcohol use and depressive symptoms among 307 patients who attended a clinic for sexually transmitted infections in St. Petersburg, Russia. Logistic regression models were applied for the analysis.
The comparison of data between men and women revealed a significant quadratic term of alcohol use and significant interactions between alcohol use and gender on depressive symptoms. Men with an AUDIT score in the first and fourth quartiles were more likely to report depressive symptoms in comparison to men in the second quartile. Their odds ratios (ORs) and 95% confidence intervals (CIs) were 7.54 (2.00–28.51) and 5.06 (1.31–19.63), respectively. Among women, a linear trend was observed such that those who misused alcohol were three times more likely to have depressive symptoms than those who did not misuse alcohol (OR = 3.03, 95% CI, 1.05–8.80).
The association between alcohol use and depressive symptoms differed by gender. Additional research is needed to investigate this relationship in Russia. Strategies to reduce alcohol-related problems in Russia may need to consider these differences.
PMCID: PMC3519357  PMID: 23240098
alcohol; depression; depressive symptoms; gender differences; Russia
18.  Individual and Community Level Risk-Factors for Alcohol Use Disorder among Conflict-Affected Persons in Georgia 
PLoS ONE  2014;9(5):e98299.
The evidence on alcohol use disorder among conflict-affected civilian populations remains extremely weak, despite a number of potential risk-factors. The aim of this study is to examine patterns of alcohol use disorder among conflict-affected persons in the Republic of Georgia.
A cross-sectional survey of 3600 randomly selected internally displaced persons (IDPs) and former IDPs. Two alcohol use disorder outcomes were measured: (i) having at least hazardous alcohol use (AUDIT score ≥8); (ii) episodic heavy drinking (consuming >60 grams of pure alcohol per drinking session at least once a week). Individual level demographic and socio-economic characteristics were also recorded, including mental disorders. Community level alcohol environment characteristics relating to alcohol availability, marketing and pricing were recorded in the respondents' communities and a factor analysis conducted to produce a summary alcohol environment factor score. Logistic regression analyses examined associations between individual and community level factors with the alcohol use disorder outcomes (among men only).
Of the total sample, 71% of men and 16% of women were current drinkers. Of the current drinkers (N = 1386), 28% of men and 1% of women were classified as having at least hazardous alcohol use; and 12% of men and 2% of women as episodic heavy drinkers. Individual characteristics significantly associated with both outcomes were age and experiencing a serious injury, while cumulative trauma events and depression were also associated with having at least hazardous alcohol use. For the community level analysis, a one unit increase in the alcohol environment factor was associated with a 1.27 fold increase in episodic heavy drinking among men (no significant association with hazardous alcohol use).
The findings suggest potential synergies for treatment responses for alcohol use disorder and depression among conflict-affected populations in Georgia, as well as the need for stronger alcohol control policies in Georgia.
PMCID: PMC4035315  PMID: 24865450
19.  Screening and brief interventions for hazardous and harmful alcohol use among hospital outpatients in South Africa: results from a randomized controlled trial 
BMC Public Health  2013;13:644.
High prevalence rates of hazardous and harmful alcohol use have been found in a hospital outpatient setting in South Africa. Hospital settings are a particularly valuable point of contact for the delivery of brief interventions because of the large access to patient populations each year. With this in mind, the primary purpose of this randomized controlled trial is to provide screening for alcohol misuse and to test the effectiveness of brief interventions in reducing alcohol intake among hospital outpatients in South Africa.
The study design for this effectiveness study is a randomized controlled trial with 6- and 12-month follow-ups to examine the effects of a brief alcohol intervention to reduce alcohol use by hazardous or harmful drinkers in a hospital setting. Outpatients were screened for alcohol problems, and those identified as hazardous or harmful drinkers were randomized into an experimental or control group. The experimental group received one brief counselling session on alcohol risk reduction, while the control group received a health education leaflet.
Of the 1419 screened for alcohol misuse who agreed to participate in the trial 392 (27.6%) screened positive for hazardous or harmful use on the Alcohol Use Disorder Identification Test (AUDIT) (score 7/8-19) and 51 (3.6%) had an AUDIT score of 20 or more. Among the 282 (72%) hospital outpatients who also attended the 12-month follow-up session, the time effects on the AUDIT scores were significant [F (1,195 = 7.72), P < 0.01] but the intervention effect on the AUDIT score was statistically not significant [F (1,194 = 0.06), P < 0.804].
Given the lack of difference in outcome between control and intervention group, alcohol screening and the provision of an alcohol health education leaflet may in itself cause reduction in drinking.
Trial registration
PMCID: PMC3849548  PMID: 23844552
20.  A Peer-drinking Group Motivational Intervention among Thai Male Undergraduate Students 
Excessive alcohol consumption, particularly among young males, is an important global health problem, in part because of the increased risks of intentional and non-intentional injuries, uses of illicit drug, crime, and psychiatric disorders. There are no data available to evaluate the extent to which interventions are effective in reducing hazardous/harmful alcohol consumption among young males in Thailand. We examined the efficacy of alcohol harm reduction strategies administered as a peer-drinking group motivational intervention (PD-GMI) among Thai male undergraduates.
We used a quasi-experimental study design that included two student groups assessed at baseline and at two time points post-intervention. Participants were students enrolled in two public universities and who reported alcohol consumption during the current academic year. Students in one university were assigned to an assessment-only study group (n=110); and students in the other university were assigned to a 2-hour PD-GMI (n=115). This intervention was designed to (1) increase the awareness of risks associated with hazardous/harmful alcohol consumption; (2) enhance students' motivation to change their drinking behaviors; and (3) encourage harm reduction strategies during episodes of alcohol consumption. Alcohol consumption and adverse consequences were assessed using the Alcohol Use Disorders Identification Test (AUDIT) and the Rutgers Alcohol Problem Index (RAPI).
Students receiving the intervention had significant reductions in mean AUDIT scores; 50.4% at baseline to 1-month and 61.2% at baseline to 3-month post-intervention. Their mean RAPI scores were also reduced; 42.0% at baseline to 1-month and 42.9% at baseline to 3-month post-intervention. Reductions in alcohol consumption and the prevalence of harmful alcohol consumption patterns were statistically significant among students in the intervention group versus those in the control group. The reductions remained after adjustments for baseline differences.
These results suggest the efficacy of the PD-GMI intervention for reducing alcohol consumption and adverse consequences among Thai male students.
PMCID: PMC3683575  PMID: 20347584
alcohol; harm reduction; group motivational intervention; students; Thailand
21.  Childhood trauma exposure and alcohol dependence severity in adulthood: mediation by emotional abuse severity and neuroticism 
Childhood trauma has been linked to a number of negative outcomes later in life, including alcohol dependence. Previous studies have suggested a mediating role for neuroticism in the relationship between childhood trauma and psychopathology. In this study we investigate the prevalence of multiple types of childhood trauma in treatment-seeking alcohol dependent patients, and the associations between childhood trauma and alcohol dependence severity using multiple mediation analysis.
The prevalence of five types of childhood trauma – emotional abuse, sexual abuse, physical abuse, emotional neglect, and physical neglect – was assessed in treatment seeking alcohol dependent patients (n = 280) and healthy controls (n = 137) using the Childhood Trauma Questionnaire. Multiple mediation analyses were used to model associations between childhood trauma measures and alcohol-related outcomes, primarily the severity of alcohol dependence in the alcohol dependent sample.
Childhood trauma was significantly more prevalent and more severe in the alcohol dependent subjects. In addition, childhood trauma was found to influence alcohol dependence severity, an effect that was mediated by neuroticism. When individual trauma types were examined, emotional abuse was found to be the primary predictor of alcohol dependence severity, both directly and through the mediating effects of the impulsivity subfacet of neuroticism. Physical abuse also had a moderate direct effect on alcohol dependence severity. Mediation analysis did not reveal any association between childhood trauma and AUDIT score in the non-dependent control sample.
Childhood trauma is highly prevalent in treatment-seeking alcoholics and may play a significant role in the development and severity of alcohol dependence through an internalizing pathway involving negative affect. Our findings suggest that alcoholics with a history of childhood emotional abuse may be particularly vulnerable to severe dependence.
PMCID: PMC3620963  PMID: 23278300
22.  The Association between Alcohol Consumption Patterns and Health-Related Quality of Life in a Nationally Representative Sample of South Korean Adults 
PLoS ONE  2015;10(3):e0119245.
This study examined the relationship between alcohol consumption and health-related quality of life (HRQOL) in a nationally representative sample of middle-aged to older South Koreans. Data collected from 3,408 men and 3,361 women aged ≥ 40 years were obtained from the 2010 and 2011 Korea National Health and Nutrition Examination Survey. Based on the World Health Organization guidelines, the participants were categorized into zones I (0–7), II (8–15), III (16–19), or IV (20–40) according to their Alcohol Use Disorders Identification Test (AUDIT) scores, with a higher zone indicating a higher level of alcohol consumption. Data collected from the AUDIT and EuroQol 5-Dimension (EQ-5D) test were subjected to multiple regression analysis in order to examine the relationship between alcohol consumption patterns and health-related quality of life, and to identify intersex and interzone differences. Significant intersex differences were found for the mean total AUDIT and EQ-5D scores and the proportion of participants rating their pain/discomfort and impairment in mobility and usual activities as “moderate” or “severe” (p < 0.001). The analysis of the EQ-5D scores by alcohol consumption pattern and sex suggested the existence of an inverted U-shaped relationship between the total AUDIT and EQ-5D scores. The HRQOL of moderate alcohol drinkers was higher than that of non-drinkers and heavy drinkers. The results of this study will be valuable in designing appropriate interventions to increase the HRQOL impaired by the harmful use of alcohol, in comparing HRQOL among different countries, and in implementing alcohol-related health projects.
PMCID: PMC4365041  PMID: 25786249
23.  Alcohol use in the first three years of bereavement: a national representative survey 
Earlier results concerning alcohol consumption of bereaved persons are contradictory. The aim of the present study was to analyze the relationship between bereavement and alcohol consumption accounting for time and gender differences on a nationally representative sample from Hungary ("Hungarostudy Epidemiological Panel Survey", N = 4457)
Drinking characteristics of mourning persons (alcohol consumption, dependence symptoms, and harmful consequences of alcohol use) in the first three years of grief were examined among persons between 18-75 years using the Alcohol Use Disorders Identification Test (AUDIT).
Men bereaved for one year scored higher on two dimensions of AUDIT (dependence symptoms and harmful alcohol use), while men bereaved for two years scored higher on all three dimensions of AUDIT compared to the non-bereaved. The rate of men clinically at-risk concerning alcohol consumption among the non-bereaved is 12.9%, and among men bereaved for one year is 18.4% (a non-significant difference), while 29.8% (p < 0.001, OR = 2,781) among men bereaved for two years. However, men bereaved for three years did not differ from the non-bereaved in their drinking habits. In case of bereaved women, again no difference was found with respect to alcohol use compared to the non-bereaved.
Among bereaved men, the risk of alcohol related problems tends to be higher, which can be shown both among men bereaved for one year as well as men bereaved for two years. Considering the higher morbidity and mortality rates of bereaved men, alcohol consumption might play a mediator role. These facts draw attention to the importance of prevention, early recognition, and effective therapy of hazardous drinking in bereaved men.
PMCID: PMC3286419  PMID: 22248360
bereavement; alcohol consumption; national representative survey; gender differences
24.  Using the AUDIT-PC to Predict Alcohol Withdrawal in Hospitalized Patients 
Alcohol withdrawal syndrome (AWS) occurs when alcohol-dependent individuals abruptly reduce or stop drinking. Hospitalized alcohol-dependent patients are at risk. Hospitals need a validated screening tool to assess withdrawal risk, but no validated tools are currently available.
To examine the admission Alcohol Use Disorders Identification Test-(Piccinelli) Consumption (AUDIT-PC) ability to predict the subsequent development of AWS among hospitalized medical-surgical patients admitted to a non-intensive care setting.
Retrospective case–control study of patients discharged from the hospital with a diagnosis of AWS. All patients with AWS were classified as presenting with AWS or developing AWS later during admission. Patients admitted to an intensive care setting and those missing AUDIT-PC scores were excluded from analysis. A hierarchical (by hospital unit) logistic regression was performed and receiver-operating characteristics were examined on those developing AWS after admission and randomly selected controls. Because those diagnosing AWS were not blinded to the AUDIT-PC scores, a sensitivity analysis was performed.
The study cohort included all patients age ≥18 years admitted to any medical or surgical units in a single health care system from 6 October 2009 to 7 October 2010.
After exclusions, 414 patients were identified with AWS. The 223 (53.9 %) who developed AWS after admission were compared to 466 randomly selected controls without AWS. An AUDIT-PC score ≥4 at admission provides 91.0 % sensitivity and 89.7 % specificity (AUC = 0.95; 95 % CI, 0.94–0.97) for AWS, and maximizes the correct classification while resulting in 17 false positives for every true positive identified. Performance remained excellent on sensitivity analysis (AUC = 0.92; 95 % CI, 0.90–0.93). Increasing AUDIT-PC scores were associated with an increased risk of AWS (OR = 1.68, 95 % CI 1.55–1.82, p < 0.001).
The admission AUDIT-PC score is an excellent discriminator of AWS and could be an important component of future clinical prediction rules. Calibration and further validation on a large prospective cohort is indicated.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-013-2551-9) contains supplementary material, which is available to authorized users.
PMCID: PMC3889973  PMID: 23959745
alcoholism; addictive behavior; screening; risk assessment; hospital medicine
25.  Alcohol use, military sexual trauma, expectancies, and coping skills in women veterans presenting to primary care 
Addictive behaviors  2013;39(2):10.1016/j.addbeh.2013.02.006.
Little is known regarding alcohol use and its correlates in women veterans. An understanding of these variables is of utility to providers in primary care at Veterans Affairs (VA) hospitals, who are among the first to identify and intervene for problem drinking.
The objective of this study was to describe and explore the associations between posttraumatic stress disorder symptoms, experience of military sexual trauma (MST), expectancies for alcohol use, and coping skills in predicting drinking behavior.
Each month all women veterans attending appointments in primary care were mailed a letter alerting them to the study. Women then received a call asking them to participate, and many were directly recruited at their primary care appointment. Participants then completed a survey of current alcohol use and related variables in a private room.
Participants were 93 women veterans seeking care at VA.
Main measures
Measures included the Alcohol Use Disorders Identification Test, a modified version of the VA MST screen, the Davidson Trauma Scale; the Coping Inventory for Stressful Situations, and the Brief Comprehensive Effects of Alcohol Questionnaire.
Key results
Positive expectancies and evaluations emerged as significant correlates of AUDIT scores, while PTSD symptoms were not related to AUDIT scores. A hierarchical regression revealed a significant positive interaction between avoidance coping and positive evaluations. Depression, positive evaluations and avoidance coping were significant independent predictors of AUDIT scores in the final model, but MST was not.
Findings highlight the importance of considering of the function of alcohol use when delivering clinical interventions and the need for further research on the association between MST and drinking in women veterans.
PMCID: PMC3819401  PMID: 23498717
Women veterans; Alcohol; Coping; Expectancies; Military sexual trauma

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