Maristela Monteiro

Alcohol consumption and burden of disease in the Americas: implications for alcohol policy

OBJECTIVES To describe patterns of alcohol consumption in the Americas, to estimate the burden of disease attributable to alcohol in the year 2000, and to suggest implications for policies to reduce alcohol-related disease burden. METHODS Two dimensions of alcohol exposure were included in this secondary data analysis: average volume of alcohol consumption and patterns of drinking. There were two main outcome measures: mortality (number of deaths) and disability-adjusted life years (DALYs) lost (number of years of life lost due to premature mortality and disability). Separate estimates were obtained for different sexes, age groups and WHO regions. RESULTS Despite regional variations, alcohol consumption in the Americas averaged more than 50% higher than worldwide consumption. Patterns of irregular heavy drinking prevailed. Alcohol consumption caused a considerable disease burden: 4.8% of all the deaths and 9.7% of all DALYs lost in the year 2000 were attributable to drinking, with most of the burden occurring outside North America. Intentional and unintentional injuries accounted for 59.8% of all alcohol-related deaths and 38.4% of the alcohol-related disease burden. Of all risk factors compared here, alcohol accounted for the greatest proportion of risk, followed by smoking. CONCLUSIONS Interventions should be implemented to reduce the high burden of alcohol-related disease in the Americas. Given the epidemiological structure of this burden, injury prevention including, but not restricted to, prevention of traffic injuries, as well as appropriate treatment options, should play an important role in comprehensive plans to reduce the alcohol-related public health burden.

Drug interactions between psychoactive substances and antiretroviral therapy in individuals infected with human immunodeficiency and hepatitis viruses.

The liver disease characteristic of alcohol dependence encompasses three main related entities: steatosis, alcoholic hepatitis, and cirrhosis. Alcoholic cirrhosis is a leading cause of global morbidity and mortality. Alcohol intake among injecting drug users is a major contributor to transmission of viral infections, such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C viruses (HCV). HIV and HCV coinfected patients develop liver diseases earlier and more severely than the monoinfected individuals, including hepatocellular carcinoma. Interactions exist between the therapeutic drugs used to minimize and control the drug and alcohol dependence. Furthermore, drug–drug interactions occur between the highly active antiretroviral therapy (HAART) and alcohol, different HAART components and methadone, or each one of the therapies with the other, thus contributing to a higher toxicity level. With the evolution of effective antiretroviral therapy, survival of persons with HIV, and the syndrome it causes, acquired immunodeficiency syndrome (AIDS) has increased dramatically. Drug–drug interactions may appear between alcohol and anti-HBV or anti-HCV, therapy in the presence or absence of anti-HIV therapy. Several other medical-, social-, and drug-related factors of this population have to be considered when providing HAART. Because many coinfected patients also have problems with substance use, dealing with their drug dependence is an important first step in an attempt to improve adherence to and tolerance of antiviral therapy. It is necessary to minimize the risk of liver disease acceleration and/or reinfection with hepatitis viruses. Knowledge of potential drug interactions between methadone, antiretroviral therapy, psychoactive drugs, and antipsychotics and the role of coinfection with HBV or HCV and the drugs used in eradicating viral hepatitis permits suitable antiretroviral combinations.

Alcohol Attributable Fraction for Injury Morbidity from the Dose‐Response Relationship of Acute Alcohol Consumption: Emergency Department Data from 18 Countries

AIMS To calculate the alcohol-attributable fraction (AAF) of injury morbidity by volume of consumption prior to injury based on newly reported relative risk (RR) estimates. DESIGN AAF estimates based on the dose-response RR estimates obtained from previous pair-matched case-crossover fractional polynomial analysis of mean volume in volume categories were calculated from the prevalence of drinking prior to injury in each volume category. SETTING Thirty-seven emergency departments (EDs) across 18 countries. PARTICIPANTS Probability samples of patients, with equal representation of each shift for each day of the week, totaling 14,026 who arrived at the ED within six hours of injury from ED studies conducted between 2001 and 2011. MEASUREMENTS AAF was analyzed by gender, age (18-30; >30), cause of injury (traffic, assault, fall, other), and country detrimental drinking pattern (DDP). FINDINGS For the EDs analyzed, 16.4% of all injuries were estimated to be attributable to alcohol, and the AAF did not vary by age but was over twice as large for males (20.6%; 19.3-21.8) than for females (8.6%; 7.5-9.7%). While females were at greater risk of injury than males at higher volume levels, lower prevalence of women drinking at higher levels contributed to overall lower AAF for women. Assault-related injuries showed the largest AAF (44.1%; 37.6-42.6). AAF was slightly higher for injuries from falls (14.3%; 12.9-15.7) than motor vehicle crashes (11.1%; 9.3-12.9). AAF was higher in those countries with a DDP of 3 (18.6; 17.5-19.7) and 4 (19.4%; 17.3-21.6) than those with a DDP of 2 (12.0%; 10.5-13.5). CONCLUSIONS Alcohol-attributable injuries presenting in emergency departments are higher for males than females, for violence-related injuries compared with other types of injury, and for countries with more detrimental drinking patterns compared with those with less detrimental patterns.

Relative risk of injury from acute alcohol consumption: modeling the dose-response relationship in emergency department data from 18 countries

AIMS To update and extend analysis of the dose-response relationship of injury and drinking by demographic and injury subgroups and country-level drinking pattern, and examine the validity and efficiency of the fractional polynomial approach to modeling this relationship. DESIGN Pair-matched case-cross-over analysis of drinking prior to injury, using categorical step-function and fractional polynomial analysis. SETTING Thirty-seven emergency departments (EDs) across 18 countries. PARTICIPANTS A total of 13 119 injured drinkers arriving at the ED within 6 hours of the event. MEASUREMENTS The dose-response relationship was analyzed by gender, age, cause of injury (traffic, violence, fall, other) and country detrimental drinking pattern (DDP). FINDINGS Estimated risks were similar between the two analytical methods, with injury risk doubling at one drink [odds ratio (OR) = 2.3-2.7] and peaking at about 30 drinks. Although risk was similar for males and females up to three drinks (OR = 4.6), it appeared to increase more rapidly for females and was significantly higher starting from 20 drinks [female OR = 28.6; confidence interval (CI) = 16.8, 48.9; male OR = 12.8; CI = 10.1, 16.3]. No significant differences were found across age groups. Risk was significantly higher for violence-related injury than for other causes across the volume range. Risk was also higher at all volumes for DDP-3 compared with DDP-2 countries. CONCLUSIONS There is an increasing risk relationship between alcohol and injury but risk is not uniform across gender, cause of injury or country drinking pattern. The fractional polynomial approach is a valid and efficient approach for modeling the alcohol injury risk relationship.

Alcohol per capita Consumption, Patterns of Drinking and Abstention Worldwide after 1995*

3 0 3.0 803.3 5.3 12 36 0 Algeria 3 0 0.3 0.5 80 98 0 Argentina 2 1 1.0 7,970.0 10.5 7 21 1 Armenia 2 0 1.9 536.7 2.9 12 36 0 Australia 1 1 0.0 20,840.0 9.2 7 10 1 Austria 1 0 1.0 27,760.0 14.1 13 33 1 Azerbaijan 3 0 1.9 446.7 3.5 12 36 0 Barbados 2 0 –0.5 6,610.0 7.3 29 70 0 Belarus 4 0 4.9 2,250.0 13.4 2 4 1 Belgium 1 0 0.5 26,403.3 11.6 14 27 0 Belize 4 0 2.0 2,700.0 7.5 24 44 0.5 Bolivia 3 0 3.0 963.3 6.2 24 45 1 Bosnia and Herzegovina 3 0 3.0 7.7 12 36 0 Botswana 3 0 3.0 3,250.0 4.9 37 70 0 Brazil 3 1 3.0 4,586.7 8.9 36 57 1 Bulgaria 2 1 3.0 1,196.7 14.5 12 36 1 Burkina Faso 3.3 3.9 Burundi 4.7 6.4 Cambodia 3 0 0.5 273.3 0.8 74 96 0 Cameroon 2.6 3.7 Canada 2 1 2.0 19,506.7 9.7 17 28 1 Central African Republic 1.7 3.3 Chile 3 0 2.0 4,720.0 8.9 31 47 1 China 2 1 1.0 690.0 4.6 16 71 1 Colombia 3 0 2.0 2,450.0 8.6 31 47 0.5 Costa Rica 4 0 2.0 2,696.7 7.5 45 75 1 Croatia 3 0 4.5 4,526.7 17.6 12 36 0 Cuba 2 0 2.0 5.3 29 70 0 Cyprus 1 0 1.0 12,053.3 9.7 1 15 0 Czech Republic 2 1 1.0 5,200.0 15.2 3 8 1 Democratic People’s Rep. of Korea 5.3 Denmark 1 1 2.0 33,970.0 14.4 2 4 1 Djibouti 0.47 0.5 0.9 Dominican Republic 2 0 1.0 1,673.3 5.9 29 70 0 Ecuador 3 0 1.0 1,520.0 7.9 20 40 0.5 Egypt 2 0 0.5 1.0 70 98 0.5 El Salvador 4 0 2.0 1,780.0 4.7 9 38 0 Eritrea 1.0 2.5 Estonia 3 0 5.0 3,300.0 7.7 5 10 1

Alcohol, diabetes, and public health in the Americas

This article describes epidemiological evidence on the association between alcohol use and diabetes, and the implications for clinical management and public health policies in the Americas. Heavy alcohol use is a risk factor for both diabetes and poor treatment adherence, despite evidence that moderate drinking can protect against type 2 diabetes under some circumstances. The burden of disease from diabetes associated with excessive alcohol consumption warrants both clinical and public health measures. On the clinical level, research on early interventions to prevent hazardous drinking shows that new screening, brief intervention, and referral techniques are effective ways to manage hazardous drinking in primary care settings. On the population level, restrictions on alcohol marketing and other alcohol control policies reduce the frequency and intensity of alcohol consumption in at-risk populations. These policy actions are recommended within the context of the World Health Organizations global strategy to reduce the harmful use of alcohol.

Inefficiency of the anticoagulant therapy in the regression of the radiation-induced optic neuropathy in Cushing’s disease

Radiation-induced optic neuropathy is a rare complication (prevalence less than 1%) following radiotherapy of the sellar region. However, the vasculopathy in Cushing’s disease predisposes to radiation-induced injury. We report the case of a 24-year-old man with Cushing’s disease since he was 16. The hormonal study including bilateral inferior petrosal sinus catheterization diagnosed a pituitary right lesion, but imagiology was always negative. He underwent a transsphenoidal microadenomectomy and the pathological study showed the presence of corticotrophic hyperplasia but no adenoma. Secondary hypothyroidism and hypogonadism as well as permanent diabetes insipidus were diagnosed and because the patient was not cured he underwent a second transsphenoidal total hypophysectomy. After that and because he was still hypercortisolemic, pituitary external irradiation was given in a total dose of 6000 rad. Six months later he developed progressive bilateral visual loss. Cerebral MR revealed focal enhancement of the enlarged optic nerves and chiasm, associated with demyelination areas of the posterior visual pathways. Treatment was tried first with high doses of corticosteroids and later with anticoagulants- heparin EV. 1000 U/h during 7 days followed by warfarin, but unsuccessfully, probably because the patient was already amaurotic at the beginning of the last treatment.

Diagnostic of alcoholism: How useful is the combination of gamma glutamyl transferase with different biochemical markers? ☆

The present paper analyses the alterations in sensitivity, specificity and in the positive predictive value (PPV) of GGT as a state marker of alcohol abuse when used either alone or in combination with glutamate pyruvate transaminases (SGPT), glutamate oxalacetate (SGOT) and mean corpuscular volume (MCV). The results obtained with an alcoholic (n = 70) and non-alcoholic sample (n = 63) showed that the best combination considering sensitivity was obtained when GGT was combined with MCV (80%). However, this combination produced the largest decrease in PPV. The relevance of taking into account not only sensitivity but also PPV when the markers are to be used as screening tests in unselected populations is discussed.

Risk of injury after alcohol consumption from case-crossover studies in five countries from the Americas.

AIMS This study aimed to: (i) provide relative risk (RR) estimates between acute alcohol use and injuries from emergency departments (EDs) in the Dominican Republic, Guatemala, Guyana, Nicaragua and Panama, and (ii) test whether the RR differs if two control periods for the estimates were used. DESIGN Case-crossover methodology was used to obtain estimates of the RR of having an injury within 6 hours after drinking alcohol, using a pair-matching design with control periods of the same time of day on the day prior to injury, and the same time of day and day of week during the week prior to injury. SETTING EDs. PARTICIPANTS A total of 2503 injured patients from EDs were interviewed between 2010 and 2011, with a response rate of 92.6%. MEASUREMENTS Number of drinks consumed within 6 hours prior to the injury and in the two control periods. FINDINGS The RR of injury after drinking alcohol was 4.38 [95% confidence interval (CI): 3.29-5.84] using the prior week as the control period, and 5.35 (CI: 3.50-8.17) using the prior day as a control period. The RR was 5.08 (CI: 4.15-6.23) in multiple matching. Those drinking one to two drinks had a RR of 4.85 (CI: 3.12-7.54); those drinking three to five drinks an RR of 5.00 (CI: 3.47-7.18); those drinking six to 15 drinks an RR of 4.54 (CI: 3.36-6.14); and those drinking 16 or more drinks an RR of 10.42 (CI: 4.38-24.79). CONCLUSIONS As in other countries, drinking alcohol is an important trigger for an injury in the Dominican Republic, Guatemala, Guyana, Nicaragua and Panama.

Mortality from diseases, conditions and injuries where alcohol is a necessary cause in the Americas, 2007-09

AIMS To describe mortality from diseases, conditions and injuries where alcohol was a necessary cause in selected countries in the Americas. DESIGN A descriptive, population-based study. SETTING The data come from 16 countries in North, Central and South America for the triennium 2007-09 (latest available data). PARTICIPANTS/CASES A total of 238 367 deaths were analyzed. MEASUREMENTS We calculated age-adjusted and age-specific mortality rates by sex and country using the Pan American Health Organization (PAHO) mortality database. FINDINGS The annual average of deaths where alcohol was a necessary cause in the 16 countries was 79, 456 (men comprised 86% and women 14%). People aged 40-59 years represented 55% overall. Most deaths were due to liver diseases (63% overall) and neuropsychiatric disorders (32% overall). Overall age-adjusted rates/100,000 were higher in El Salvador (27.4), Guatemala (22.3), Nicaragua (21.3) and Mexico (17.8) and lower in Colombia (1.8), Argentina (4.0) and Canada (5.7). The age groups at the highest risk were 54-59 to 64-69 years in most countries. In Guatemala, El Salvador and Nicaragua the rates increased earlier, among those aged 30-49 years. Male rates were higher than female rates in all countries, but the male : female ratio varied widely. CONCLUSIONS Diseases, conditions or injuries where alcohol is a necessary cause are an important cause of premature mortality in the Americas, especially among men. Some countries show high risk of dying from this group of causes.