Hélène Rigole

Are preoperative patterns of alcohol consumption predictive of relapse after liver transplantation for alcoholic liver disease

Predictive factors for alcoholic relapse after liver transplantation (LT) performed for alcoholic liver disease (ALD) have been assessed in numerous studies, often with contradictory results. The aim of the study was to assess pretransplantation alcohol consumption characteristics on alcoholic relapse after LT. Patients transplanted for ALD for at least 6 months were included. An anonymous questionnaire assessed socio‐demographic characteristics, medical history, and alcohol consumption before and after LT. Relapse was defined as any alcohol use after LT. Severe relapse was defined by heavy drinking: more than 21 units/week for males and 14 units/week for females. A total of 61 patients were studied. The mean follow up after LT was 49 ± 34 months. Alcoholic relapse occurred in 32 of 61 patients (52%) and severe relapse in eight of 61 patients (13%). Risk factors for severe relapse were: length of abstinence before LT (P = 0.0001), more than one alcohol withdrawal before LT (P = 0.001), alcohol dependence (P = 0.05), alcohol abuse in first relatives (P = 0.05), and younger age (P = 0.05). Information on previous alcohol consumption (dependence, number of withdrawals, family history) helps to predict severe relapse after LT in patients with ALD, allowing early awareness and specific postoperative care.

Alcoolodépendance : diagnostic et traitement

PURPOSE Prevalence of alcohol dependence remains stable across time between 5-7% in men and 2-3% in women, corresponding to at least 1.5 million patients in France. A review about alcohol dependence is warranted, not only as prevalence of this disease is high, but also because of recent significant improvement in caring for these patients. CURRENT KNOWLEDGE AND KEY POINTS Management of alcohol withdrawal is well codified and chiefly entails the prescription of long half-life benzodiazepines, thiamin, and appropriate rehydratation. The objective is to prevent withdrawal syndrome, which can result in delirium tremens and seizures. Several drugs and therapies have proven efficacy to maintain abstinence. Cognitive behavioral therapies evaluate those factors triggering alcohol consumption, and involve behavioral techniques to promote a change. Motivational interviewing enhances individual effectiveness of treatment, and capacity to maintain abstinence. Three molecules used in France have proven efficacy through several mechanisms: acamprosate which interacts with GABAergic and glutamatergic central transmission; naltrexone, an antagonist of opiate receptors; disulfiram which has antabuse-like effect through inhibition of acetaldehyde dehydrogenase. FUTURE PROSPECTS AND PROJECTS Main research strategies currently developed are: (i) investigating consumption of multiple psychoactive substances, and (ii) understanding the neurobiology of dependence, which may lead to new therapeutic discoveries.

CXCR3 expression on peripheral CD4+ T cells as a predictive marker of response to treatment in chronic hepatitis C

We monitored in fifty individuals with chronic hepatitis C (CHC) the expression of CCR5 and CXCR3, two chemokine receptors involved in the intra-hepatic recruitment of T cells, at the surface of circulating CD4+ T cells. The percentage of CD4+ T cells expressing CCR5 and/or CXCR3 was increased in patients. The increased percentage of CD4+ CXCR3+ T lymphocytes was linked to serum level of aspartate aminotransferase (AST) and to fibrosis METAVIR score. CD4+ T cell surface CCR5 and CXCR3 densities increased after 6 months of treatment with pegylated interferon-alpha and ribavirin. The pre-therapeutic percentage of CD4+ CXCR3+ T cells was correlated with alanine aminotransferase serum level at 12 months, and viral load at 24 months after treatment initiation. Thus, in CHC we observed a high CXCR3 expression on peripheral blood CD4+ T cells which correlates with AST serum level and liver fibrosis, and is predictive of the response to treatment.

Impact of tobacco and alcohol consumption in patients registered on waiting list on early morbidity following liver transplantation.

BACKGROUND Liver transplantation (LT) is a high-risk surgery associated with postoperative complications. Smoking and drinking are known risk factors of long-term post-LT complications, but their role in early complications is still questioned. PATIENTS AND METHODS We retrieved from our medical files the data of all patients registered for LT and who had had a consultation with a physician specialized in substance abuse. Consumption of alcohol, tobacco, and drugs before and after registration for LT was assessed. RESULTS One hundred and five patients were included. Pre-registration smoking and drinking rates were 75.3 and 69.5%, respectively. Forty-three patients continued smoking and nine continued drinking until LT. Mortality and early morbidity rates were not impacted by smoking or drinking. Active smokers had significantly increased prevalence of bacterial cholangitis in comparison to patients who stopped smoking when registered for LT. CONCLUSION Persistent drinking in patients registered for LT is rare as compared to smoking; however, in our series, smoking until LT was not associated with major risk of early complication, except for cholangitis. This suggests that clinicians should take time to encourage patients to quit smoking and the intervention of a team specialized in substance abuse could be highly beneficial.

Investigation of Cognitive Improvement in Alcohol-Dependent Inpatients Using the Montreal Cognitive Assessment (MoCA) Score

Background. Cognitive dysfunction is a common feature in alcohol use disorders. Its persistence following alcohol detoxification may impair quality of life and increase the risk of relapse. We analyzed cognitive impairment changes using the Montreal Cognitive Assessment (MoCA) score in a large sample of alcohol-dependent inpatients hospitalized for at least 4 weeks. Method. This was an observational longitudinal survey. Inclusion criteria were alcohol dependence (DSM-IV) and alcohol abstinence for at least one week. The MoCA test was administered on admission and at discharge. Results. 236 patients were included. The mean MoCA score significantly increased from 22.1 ± 3.7 on admission to 25.11 ± 3.12 at discharge. The corresponding effect-size of improvement was high, 1.1 [95% CI 1.0–1.2]. The degree of improvement was inversely correlated with the baseline MoCA score. The rate of high and normal, that is, >26, MoCA values increased from 15.8% on admission to 53.8% at discharge. MoCA score improvement was not correlated with the total length of abstinence prior to admission. Conclusion. The MoCA score seems to be a useful tool for measuring changes in cognitive performance in alcohol-dependent patients. A significant improvement in cognitive function was observed whatever the degree of impairment on admission and even after a long abstinence period.

Measuring sleep disturbances in patients with alcohol use disorders: a short questionnaire suitable for routine practice.

Objectives:Sleep disturbance constitutes a major risk factor for drinking relapse after alcohol withdrawal and necessitates regular follow-up. We reported previously that the sum-score of the 4 sleep items of the Hamilton Anxiety and Depression Scales (the Short Sleep Index [SSI]) constitutes a valid and simple sleep measurement tool. The objective of this study was to evaluate the psychometric features of the SSI relative to the lengthier Pittsburgh Sleep Quality Index (PSQI), which is widely used for measuring sleep disturbance in patients with alcohol use disorders during and after alcohol withdrawal. Methods:In this French, multicenter, cross-sectional survey, alcoholic patients were recruited in 2 academic hospitals and 1 community treatment center. Demographic data, alcohol history, and current consumption of alcohol and other abused substances were documented. The SSI and the PSQI questionnaires were completed in face-to-face interviews by a trained clinical research associate. Results:A total of 257 patients were studied (88 females), with a mean age of 49 years (range: 24-80 years). The prevalence of sleep disturbance as measured by the PSQI and the SSI was 73.5% and 74.3%, respectively. The correlation between the 2 indices was strong (r = 0.764; 95% CI: 0.709-0.811), with negative and positive predictive values for the SSI (score > 1) of 71.2% and 89%, respectively, and an area under the receiver operating characteristic curve of 0.91 (95% CI: 0.85-0.92). The discriminant and convergent validity of the SSI was found to be noninferior to the PSQI. Conclusions:Compared to the PSQI, the SSI represents a quick, quantifiable, and reliable method that could help clinicians assess and manage sleep disturbance in alcoholic patients.

Generalized pruritus revealing hereditary haemochromatosis.

277 Letters to the Editor Sir, Hereditary haemochromatosis (HH) is an autosomal recessive disorder characterized by iron accumulation in various organs of the body (1). Pruritus has seldom been reported as a disclosing symptom of iron overload without cholestasis (2–3). We present here a case of generalized pruritus that revealed HH and was improved by regular phlebotomies. A 47-year-old woman was seen for a 1-year history of severe generalized pruritus resistant to antihistamine treatment. Her past medical history was notable for sigmoidectomy in 1989, resection of benign colonic polyps in 2001 and osteoarthritis of the hands. She denied taking any drug. At presentation, she complained of weakness, chronic fatigue and unexplained weight loss of 3 kg. Except hand osteoarthritis, physical examination was unremarkable. Skin or mucosal hyperpigmentation, cardiac symptoms, hepatosplenomegaly and loss of libido were absent. Laboratory investigations including full blood cell and eosinophil counts, erythrocyte sedimentation rate, C-reactive protein, serum protein electrophoresis, kidney and liver function tests, calcium, phosphorus, fasting blood glucose, thyroid stimulating hormone, follicle-stimulating hormone, luteinizing hormone, oestradiol, cortisolaemia, hepatitis B, hepatitis C and HIV serologies proved either normal or negative. Serum iron, ferritin and transferrin saturation values were elevated to 34 µmol/l (normal <27 µmol/l), 430 ng/ml (normal <185 ng/ml) and 68% (normal <45%), respectively. Molecular analysis confirmed the HH diagnosis with a homozygous C282Y mutation of the HFE gene. Chest X-ray and abdominal ultrasound showed no anomaly. Hand radiographs did not show characteristic changes of HH arthropathy. Hepatic magnetic resonance imaging assessed iron overload estimated to 290±50 µmol/g (normal <36 µmol/g). The liver had a homogenous appearance; no dilatation of the main bile duct and the intrahepatic bile ducts was noted. Of note, there was no family history of HH. Regular phlebotomy therapy was initiated at the dose of 400 ml once every other week during 10 months. The patient reported improvement in pruritus even though it did not completely disappear. The phlebotomies resulted in iron depletion with normalization of serum iron, ferritin and transferrin saturation values, 22 µmol/l, 156 ng/ml and 42%, respectively. Maintenance regimen of phlebotomy was then started once every other month, which resulted in the elevation of ferritin level (266 ng/ml). The patient denied any flare up of the pruritus. DISCUSSION Generalized pruritus is an unusual presentation of haemochromatosis only reported twice (2–3). Pruritus is more frequently caused by iron deficiency (4). Arguments that support a correlation between pruritus and HH …

Feasibility and Efficacy of an Addiction Treatment Program in Patients With Upper Aerodigestive Tract Cancer

Background: Continuing to smoke or to drink after the treatment of an upper aerodigestive tract (UADT) cancer is known to worsen the prognosis. We assessed the feasibility and efficacy of an addiction treatment program integrated into the cancer treatment. Method: In four units devoted to UADT tumors, we proposed an addiction treatment to all patients still drinking or smoking at the end of the cancer treatment; the abstinence rate was assessed 6 and 12 months later. Results: One hundred and sixteen patients were included. Among the 73 patients still drinking and/or smoking at the end of the cancer treatment, 46.6% accepted an addiction treatment. In the latter, abstinence rate was increased, 52.2% versus 31.03% ( p = .07) at M12. In patients both drinking and smoking, addiction treatment doubled the rate of abstinence of both products (31% vs. 14%). Conclusion: Offering addiction treatment to patients with UADT cancer improves abstinence rate and helps maintain long-term withdrawal.