Hemraj Pal

Validation of the alcohol, smoking and substance involvement screening test (ASSIST)

AIM The concurrent, construct and discriminative validity of the World Health Organizations Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were examined in a multi-site international study. PARTICIPANTS One thousand and 47 participants, recruited from drug treatment (n = 350) and primary health care (PHC) settings (n = 697), were administered a battery of instruments. MEASUREMENTS Measures included the ASSIST; the Addiction Severity Index-Lite (ASI-Lite); the Severity of Dependence Scale (SDS); the MINI International Neuropsychiatric Interview (MINI-Plus); the Rating of Injection Site Condition (RISC); the Drug Abuse Screening Test (DAST); the Alcohol Use Disorders Identification Test (AUDIT); the Revised Fagerstrom Tolerance Questionnaire (RTQ); and the Maudsley Addiction Profile (MAP). FINDINGS Concurrent validity was demonstrated by significant correlations between ASSIST scores and scores from the ASI-Lite (r = 0.76-0.88), SDS (r = 0.59), AUDIT (r = 0.82) and RTQ (r = 0.78); and significantly greater ASSIST scores for those with MINI-Plus diagnoses of abuse or dependence (P < 0.001). Construct validity was established by significant correlations between ASSIST scores and measures of risk factors for the development of drug and alcohol problems (r = 0.48-0.76). Discriminative validity was established by the capacity of the ASSIST to discriminate between substance use, abuse and dependence. Receiver operating characteristic (ROC) analysis was used to establish cut-off scores with suitable specificities (50-96%) and sensitivities (54-97%) for most substances. CONCLUSIONS The findings demonstrated that the ASSIST is a valid screening test for identifying psychoactive substance use in individuals who use a number of substances and have varying degrees of substance use.

A Randomized Controlled Trial of a Brief Intervention for Illicit Drugs Linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in clients recruited from primary health care settings in four countries

AIMS This study evaluated the effectiveness of a brief intervention (BI) for illicit drugs (cannabis, cocaine, amphetamine-type stimulants and opioids) linked to the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). The ASSIST screens for problem or risky use of 10 psychoactive substances, producing a score for each substance that falls into either a low-, moderate- or high-risk category. DESIGN Prospective, randomized controlled trial in which participants were either assigned to a 3-month waiting-list control condition or received brief motivational counselling lasting an average of 13.8 minutes for the drug receiving the highest ASSIST score. SETTING Primary health-care settings in four countries: Australia, Brazil, India and the United States. PARTICIPANTS A total of 731 males and females scoring within the moderate-risk range of the ASSIST for cannabis, cocaine, amphetamine-type stimulants or opioids. MEASUREMENTS ASSIST-specific substance involvement scores for cannabis, stimulants or opioids and ASSIST total illicit substance involvement score at baseline and 3 months post-randomization. FINDINGS Omnibus analyses indicated that those receiving the BI had significantly reduced scores for all measures, compared with control participants. Country-specific analyses showed that, with the exception of the site in the United States, BI participants had significantly lower ASSIST total illicit substance involvement scores at follow-up compared with the control participants. The sites in India and Brazil demonstrated a very strong brief intervention effect for cannabis scores (P < 0.005 for both sites), as did the sites in Australia (P < 0.005) and Brazil (P < 0.01) for stimulant scores and the Indian site for opioid scores (P < 0.01). CONCLUSIONS The Alcohol, Smoking and Substance Involvement Screening Test-linked brief intervention aimed at reducing illicit substance use and related risks is effective, at least in the short term, and the effect generalizes across countries.

The impact of HIV/AIDS on the quality of life: a cross sectional study in north India

OBJECTIVE To determine the impact of Human Deficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) on the quality of life (QOL) on such patients in North India. DESIGN A cross sectional study. SETTING Outpatient setting and wards, Department of Medicine at a premier tertiary health care center, North India. PARTICIPANTS Sixty-eight consecutive HIV/AIDS patients attending Medicine out patient department and/or admitted to the wards of All India Institute of Medical Sciences were administered a structured questionnaire by the HIV nurse coordinator. QOL was evaluated using the WHOQOL-Bref (Hindi) instrument. ANALYSIS One way Analysis of Variance (ANOVA) was performed to find out significant difference between the clinical categories and socio-demographic variables on QOL domains. RESULTS The overall QOL mean score on a scale of 0-100 was found to be 25.8. Similarly, on the scale of 0-100 the mean scores in the four domains of QOL in descending order were social (80.9); psychological (27.5); physical (17.7) and environmental domain (11.65). There was a significant difference of quality of life in the physical domain between asymptomatic patients (14.6) and patients with AIDS (10.43) defining illnesses (p< 0.001) and asymptomatic and early symptomatic (12) patients (p=0.014). QOL in the psychological domain was significantly poorer in early symptomatic (12.1) (p< 0.05) and AIDS patients (12.4) (p< 0.006) as compared to asymptomatic individuals (14.2). A significant difference in QOL scores in the psychological domain was observed with respect to the educational status (p< 0.037) and income of patients (p< 0.048). Significantly better QOL scores in the physical (p< 0.040) and environmental domain (p< 0.017) were present with respect to the occupation of the patients. Patients with family support had better QOL scores in environmental domain. CONCLUSIONS In our study, QOL is associated with education, income, occupation, family support and clinical categories of the patients.

Endoscopic or percutaneous biliary drainage for gallbladder cancer: a randomized trial and quality of life assessment.

BACKGROUND & AIMS Patients with carcinoma of the gallbladder (GBC) and obstructive jaundice are usually not amenable to curative resection. Effective palliation by biliary decompression is the goal of treatment. Endoscopic stenting (ES) and percutaneous transhepatic biliary drainage (PTBD) can provide biliary decompression. We compared unilateral PTBD and ES in patients with a hilar block caused by GBC and assessed their quality of life (QOL). METHODS Consecutive patients with GBC not suitable for curative resection with Bismuth type 2 or 3 block were randomized to either PTBD or ES with a 10F plastic stent. Technical success, successful drainage, early cholangitis, complications, procedure-related mortality, 30-day mortality, survival, and QOL before and 1 and 3 months after stenting were compared between the 2 groups. All patients were followed up until death. RESULTS Fifty-four patients were randomized to PTBD or ES (27 each). Successful drainage was better in the PTBD group (89% vs 41%; P < .001). Early cholangitis was significantly higher in the ES group (48% vs 11%; P = .002). Procedure-related (4% vs 8%) and 30-day mortality (4% vs 8%) and median survival were similar (60 days in both; P = .71). Although the World Health Organization-Quality of Life 1- and 3-month physical and psychological scores were better after PTBD, the difference was not significant. The European Organization for Research and Treatment of Cancer (EORTC)-Quality of Life Questionnaire 30 global health status at 3 months was significantly better after PTBD (75 vs 30.5, P = .02). The EORTC symptom scores improved in both groups, but only fatigue was significantly better after PTBD. CONCLUSIONS PTBD provides better biliary drainage and has lower complication rates in patients with GBC and hilar block.

Quality of Life in Indian Patients with Rheumatoid Arthritis

Purpose of Study: Rheumatoid arthritis (RA) is a multisystem disease with various extra-articular manifestations (EAMs). Health-related quality of life (HRQOL) issues are assuming increasing importance in chronic rheumatic diseases like RA. No data on QOL in RA is available from the Indian subcontinent. There is also a paucity of literature on the impact of EAMs on HRQOL in RA. The objective of this study was to address these lacunae. Methods: The study group comprised 81 patients with RA from a rheumatology clinic in India. Quality of life was estimated by the generic HRQOL measure: World Health Organization quality of life instrument (WHOQOL-Bref). Disease activity in RA was measured by calculating Disease Activity Score-28 (DAS28). Results: The mean HRQOL scores of the patients were 12.0±2.8, 13.2±2.7, 14.4±2.9 and 13.3±2.6 in the physical, psychological, social, and environmental domains of the WHOQOL-Bref respectively. Age, gender, disease duration, educational status, constitutional symptoms, rheumatoid factor positivity, erosions and deformities did not influence HRQOL. Disease activity had a negative influence on the physical and psychological domains. Patients with EAMs had significantly higher DAS28 scores compared to patients without EAMs. Even after adjustment for disease activity, patients with EAMs had lower HRQOL scores than patients without these features (statistically significant for physical domain). Conclusions: The physical domain of HRQOL is most affected in Indian patients with RA. Increasing disease activity and presence of EAMs worsens the quality of life.

Quality of life measures in lung cancer

Lung cancer is one of the leading causes of cancer death worldwide. Survival has not improved significantly in spite of newer therapies. In view of the high-symptom burden and severe morbidity, evaluation of quality of life (QOL) becomes important in these patients. Several instruments are now available for this purpose, and have demonstrated good correlation with performance status, symptoms, and survival. Quality of life assessments also help in comparing different therapeutic regimes, thus allowing selection of the appropriate modality. Problems of inconsistent interpretability and high-patient dropout rate poses a challenging problem that needs to be tackled. In spite of these drawbacks, QOL is now considered to be an essential component of lung cancer management and should be performed routinely. Such a practice will help the physician plan appropriate treatment strategies and set practical therapeutic goals.

Psychiatric co-morbidity associated with pheniramine abuse and dependence

The abuse of cough syrups containing antihistamines and codeine is being increasingly noted. The abuse of antihistamines alone has also been reported. The use of antihistamines alone or in combination with other substances of abuse may predispose individuals to develop psychiatric symptoms or syndromes as a part of intoxication, withdrawal or as co-morbid conditions. We present two case reports to highlight the occurrence of co-morbid psychopathology in association with antihistamine abuse and dependence. Case I used high doses of pheniramine for about 2 years and became suspicious of his wife; he even doubted the paternity of his yet-to-be-born child. The associated behavioural abnormalities suggested that he was acting out on the delusion. He also had seizures associated with the intake of a high dose of pheniramine. Case II had multiple substance use, and dependence on alcohol and pheniramine. He demonstrated abnormal behaviour suggestive of psychosis and organic brain syndrome that persisted for a few days and remitted on discontinuation of the substances. These two cases demonstrate the occurrence of psychotic syndromes associated with heavy pheniramine use. The psychopathology can vary from an independent psychotic syndrome to an organic brain syndrome-like disorder.