- Email: [email protected]
Alcoholic liver disease
washed. By contrast, the German workers always washed in the kitchen at the day’s end-but shared a communal basin and towel. Leslie Collier 8 Peto Place, London NW1 4DT, UK
1 Mann I. Correlation of race and way of life in Australia and the territory of Papua and New Guinea with incidence and severity of clinical trachoma. Am J Ophthalmol 1967; 63: 1302-09. 2 Sowa S, Sowa J, Collier LH, Blyth W. Trachoma and allied infections in a Gambian village. Medical Research Council special report series no 308. London: HM Stationery Office, 1965.
Alcoholic liver disease SiR-Sherlock’s review of alcoholic liver disease (Jan 28, 227) rightly reminds us that physicians should take an adequate alcohol history from their patients. She then suggests the use of the CAGE questionnaire to assist in diagnosing alcohol related problems if there is a suspicion that alcohol consumption is excessive. Waterson and Murray-Lyon,’ suggest that the CAGE questionnaire is becoming less useful because of a change in society’s knowledge about levels of alcohol consumption and our attitudes towards heavy drinking. We supported this view in our report2 showing inconsistencies in CAGE scores when the questions were asked of the same individuals with a gap of 7 years between the surveys. The CAGE questions begin "Have you ever..." and if someone answers
p
positively positively
on one
occasion, they should, logically,
answer
the same question on any subsequent occasion. We found that less than half our respondents scored the same score or higher the second survey. The usual cut-off point for the CAGE questionnaire is that a score of two or more indicates problematic drinking. In our survey only 41% of men and 43% of women who had scored two or more at the first survey also scored two or more at the second time point. We agree with Waterson and Murray-Lyon that the CAGE questionnaire is no longer useful as a screening tool. A WHO collaborative project has developed the alcohol use disorders identification test (AUDIT).3 The AUDIT questionnaire allows people to identify alcohol-related problems or feelings relating to the last year rather than ever and we believe this will become a more useful screening tool.
*Stephen J Green, Margaret J Whichelow and Oxford Regional Health Authority, Chesterton, Cambridge CB4 1RF, UK; and Institute of Public Health, University Forvie Site, Cambridge, UK
2 3
attended outpatient clinics for general medical complaints whereas in the fourth,’ the study population was a 1 % sample of general medicine admissions. Overall, for the 2002 patients studied, if a patient answers "Yes" to two or more of the CAGE questions, the sensitivity of the test for detecting alcohol abuse is 74%, the specificity 93% and the likelihood ratio 10-6. The CAGE questionnaire is simple to perform, rapid, and inexpensive, and should be used as a screening tool for alcohol abuse in all patients irrespective of the clinical suspicion of alcoholism. James Levine Division of
Murray-Lyon IM. Are the CAGE questions outdated? Br J Addiction 1988; 83: 1113-18. Green SJ, Whichelow MJ. Longitudinal validity of the CAGE questionnaire. Addiction Res 1994; 2: 195-201. Saunders JB, et al. Development of the Alcohol Use Disorders Identification Tests (AUDIT). Addiction 1993; 88: 791-804. Waterson EJ,
SIR-In Sherlock’s overview of alcoholic liver disease the usefulness of the CAGE criteria for detecting alcohol abuse is understated. Sherlock says that, "any suspicion that alcohol consumption is excessive should be followed by the CAGE questionnaire". Four prospective, cross-sectional studies have shown the usefulness of CAGE criteria as an independent screening tool for detecting alcohol abuse in the general medical population (table). In all four studies the gold standard used was DSM-IIIR criteria.’ Three of the studies 1-3 included patients who
Endocrinology and Metabolism, Mayo Clinic, Rochester, MN 55902, USA
Jones TV, Lindsey BA, Young P, Soltys R, Farani-Enayat B. Alcoholism screening questionnaires: are they valid in elderly medical outpatients? J Gen Int Med 1993; 8: 674-78. Magruder-Habib K, Stevens HA, Alling WC. Relative performance of the MAST, VAST, and CAGE versus DSM-III-R. J Clin Epidemiol
1
2
1993; 46: 435-41. Buchsbaum DG, Buchanan RG, Centor RM, Schnoll SH, Lawton MJ. Screening for alcohol abuse using CAGE scores and likelihood ratios. Ann Int Med 1991; 115: 774-77. Beresford TP, Blow FC, Hill E, Singer K, Lucey MR. Comparison of CAGE questionnaire and computer-assisted laboratory profiles in screening for covert alcoholism. Lancet 1990; 336: 482-85. DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed (revised). Washington, DC: American Psychiatric Association, 1987.
3
4
to
*Anglia
1
*Two or more positive responses to the four CAGE questions. Table: Prospective, cross-sectional studies done to evaluate the CAGE questionnaire
5
gives no reference I wonder how Sherlock intake of 160 g alcohol as "the minimum picked associated with significant liver damage" (my italics). Present convention is to relate 8 g alcohol to 1 unit (not 10 g as she states), so this would mean 20 units daily-a figure towards the top end of dangerous consumption. In the late 1960s we recorded a minimum figure half this amount (10 units) in a group of patients with cirrhosis;’ in 1981 we reported a mean daily intake of 19 units for men and 14 units for women, with a range of 8-50 units.2 A recent review of epidemiological evidence3 showed that the threshold for risk of cirrhosis could be as low as 4-6 units a day. The presence of the histocompatibility antigen (HLA) B8 is possibly associated with susceptibility to liver damage at lower levels of intake.4 It is important that we get the figure right-and I propose 5-10 units daily as a rough guide-at a time when there is increasing pressure, fuelled by the drinks industry, to have guidelines on sensible drinking, for which there is a broad professional consensus, relaxed. SiR-Since she a
daily
Alex Paton Knollbury, Chadlington, Oxon OX7 3NJ, UK
1
Stone WD, Islam NRK, Paton. The natural history of cirrhosis.
2
Saunders JB, Walters JRF, Davies P, Paton A. A 20-year prospective study of cirrhosis. BMJ 1981; 282: 263-66. Anderson P, Cremona A, Paton A, Turner C, Wallace P. The risk of alcohol. Addiction 1993; 88: 1493-508. Thomson AD, Bird GLA, Saunders JB. Alcoholic liver disease. Gut 1991; 32 (suppl): S97-103.
Quart J Med 1968, 37: 119-32. 3
4
651
1 Mann I. Correlation of race and way of life in Australia and the territory of Papua and New Guinea with incidence and severity of clinical trachoma. Am J Ophthalmol 1967; 63: 1302-09. 2 Sowa S, Sowa J, Collier LH, Blyth W. Trachoma and allied infections in a Gambian village. Medical Research Council special report series no 308. London: HM Stationery Office, 1965.
Alcoholic liver disease SiR-Sherlock’s review of alcoholic liver disease (Jan 28, 227) rightly reminds us that physicians should take an adequate alcohol history from their patients. She then suggests the use of the CAGE questionnaire to assist in diagnosing alcohol related problems if there is a suspicion that alcohol consumption is excessive. Waterson and Murray-Lyon,’ suggest that the CAGE questionnaire is becoming less useful because of a change in society’s knowledge about levels of alcohol consumption and our attitudes towards heavy drinking. We supported this view in our report2 showing inconsistencies in CAGE scores when the questions were asked of the same individuals with a gap of 7 years between the surveys. The CAGE questions begin "Have you ever..." and if someone answers
p
positively positively
on one
occasion, they should, logically,
answer
the same question on any subsequent occasion. We found that less than half our respondents scored the same score or higher the second survey. The usual cut-off point for the CAGE questionnaire is that a score of two or more indicates problematic drinking. In our survey only 41% of men and 43% of women who had scored two or more at the first survey also scored two or more at the second time point. We agree with Waterson and Murray-Lyon that the CAGE questionnaire is no longer useful as a screening tool. A WHO collaborative project has developed the alcohol use disorders identification test (AUDIT).3 The AUDIT questionnaire allows people to identify alcohol-related problems or feelings relating to the last year rather than ever and we believe this will become a more useful screening tool.
*Stephen J Green, Margaret J Whichelow and Oxford Regional Health Authority, Chesterton, Cambridge CB4 1RF, UK; and Institute of Public Health, University Forvie Site, Cambridge, UK
2 3
attended outpatient clinics for general medical complaints whereas in the fourth,’ the study population was a 1 % sample of general medicine admissions. Overall, for the 2002 patients studied, if a patient answers "Yes" to two or more of the CAGE questions, the sensitivity of the test for detecting alcohol abuse is 74%, the specificity 93% and the likelihood ratio 10-6. The CAGE questionnaire is simple to perform, rapid, and inexpensive, and should be used as a screening tool for alcohol abuse in all patients irrespective of the clinical suspicion of alcoholism. James Levine Division of
Murray-Lyon IM. Are the CAGE questions outdated? Br J Addiction 1988; 83: 1113-18. Green SJ, Whichelow MJ. Longitudinal validity of the CAGE questionnaire. Addiction Res 1994; 2: 195-201. Saunders JB, et al. Development of the Alcohol Use Disorders Identification Tests (AUDIT). Addiction 1993; 88: 791-804. Waterson EJ,
SIR-In Sherlock’s overview of alcoholic liver disease the usefulness of the CAGE criteria for detecting alcohol abuse is understated. Sherlock says that, "any suspicion that alcohol consumption is excessive should be followed by the CAGE questionnaire". Four prospective, cross-sectional studies have shown the usefulness of CAGE criteria as an independent screening tool for detecting alcohol abuse in the general medical population (table). In all four studies the gold standard used was DSM-IIIR criteria.’ Three of the studies 1-3 included patients who
Endocrinology and Metabolism, Mayo Clinic, Rochester, MN 55902, USA
Jones TV, Lindsey BA, Young P, Soltys R, Farani-Enayat B. Alcoholism screening questionnaires: are they valid in elderly medical outpatients? J Gen Int Med 1993; 8: 674-78. Magruder-Habib K, Stevens HA, Alling WC. Relative performance of the MAST, VAST, and CAGE versus DSM-III-R. J Clin Epidemiol
1
2
1993; 46: 435-41. Buchsbaum DG, Buchanan RG, Centor RM, Schnoll SH, Lawton MJ. Screening for alcohol abuse using CAGE scores and likelihood ratios. Ann Int Med 1991; 115: 774-77. Beresford TP, Blow FC, Hill E, Singer K, Lucey MR. Comparison of CAGE questionnaire and computer-assisted laboratory profiles in screening for covert alcoholism. Lancet 1990; 336: 482-85. DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed (revised). Washington, DC: American Psychiatric Association, 1987.
3
4
to
*Anglia
1
*Two or more positive responses to the four CAGE questions. Table: Prospective, cross-sectional studies done to evaluate the CAGE questionnaire
5
gives no reference I wonder how Sherlock intake of 160 g alcohol as "the minimum picked associated with significant liver damage" (my italics). Present convention is to relate 8 g alcohol to 1 unit (not 10 g as she states), so this would mean 20 units daily-a figure towards the top end of dangerous consumption. In the late 1960s we recorded a minimum figure half this amount (10 units) in a group of patients with cirrhosis;’ in 1981 we reported a mean daily intake of 19 units for men and 14 units for women, with a range of 8-50 units.2 A recent review of epidemiological evidence3 showed that the threshold for risk of cirrhosis could be as low as 4-6 units a day. The presence of the histocompatibility antigen (HLA) B8 is possibly associated with susceptibility to liver damage at lower levels of intake.4 It is important that we get the figure right-and I propose 5-10 units daily as a rough guide-at a time when there is increasing pressure, fuelled by the drinks industry, to have guidelines on sensible drinking, for which there is a broad professional consensus, relaxed. SiR-Since she a
daily
Alex Paton Knollbury, Chadlington, Oxon OX7 3NJ, UK
1
Stone WD, Islam NRK, Paton. The natural history of cirrhosis.
2
Saunders JB, Walters JRF, Davies P, Paton A. A 20-year prospective study of cirrhosis. BMJ 1981; 282: 263-66. Anderson P, Cremona A, Paton A, Turner C, Wallace P. The risk of alcohol. Addiction 1993; 88: 1493-508. Thomson AD, Bird GLA, Saunders JB. Alcoholic liver disease. Gut 1991; 32 (suppl): S97-103.
Quart J Med 1968, 37: 119-32. 3
4
651