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Journal Club

Journal Club. Alcohol, Other Drugs, and Health: Current Evidence September-October 2007. Featured Article. A simple score for predicting alcohol relapse after liver transplantation: results from 387 patients over 15 years De Gottardi A, et al. Arch Intern Med . 2007;167(11): 1183–1188.

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Journal Club

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  1. Journal Club Alcohol, Other Drugs, and Health: Current Evidence September-October 2007 www.aodhealth.org

  2. Featured Article A simple score for predicting alcohol relapse after liver transplantation: results from 387 patients over 15 years De Gottardi A, et al. Arch Intern Med. 2007;167(11): 1183–1188. www.aodhealth.org

  3. Study Objective • To identify risk factors for alcohol use after liver transplantation (LT) for alcoholic liver disease www.aodhealth.org

  4. Study Design • 387 patients who underwent LT for alcoholic liver disease were retrospectively enrolled in this study. • Pre-LT alcohol use was assessed with the High-Risk Alcoholism Relapse (HRAR) scale. • The HRAR assesses chronicity of heavy drinking, prior alcohol consumption, and prior alcohol treatment history. • Post-LT alcohol use was assessed at regular intervals over an average of 61 months. • Harmful use was defined as about >3.5 drinks of alcohol per day plus alcohol-related physical or mental consequences. www.aodhealth.org

  5. Assessing Validity of an Article about Prognosis • Are the results valid? • What are the results? • How can I apply the results to patient care? www.aodhealth.org

  6. Are the Results Valid? • Was the sample representative? • Were the subjects sufficiently homogeneous with respect to prognostic risk? • Was follow-up sufficiently complete? • Were objective and unbiased outcome criteria used? www.aodhealth.org

  7. Was the sample representative? • Patients included all those who received LT in 2 European hospitals between 1989 and 2005 (n=387). • Indication for LT was based on... • the presence of end-stage liver disease, in which LT was the only option for survival; • the absence of medical or surgical contraindications, and • a period of abstinence (a minimum of 3 months was considered necessary). www.aodhealth.org

  8. Were the subjects sufficiently homogeneous with respect to prognostic risk? • High-Risk Alcoholism Relapse (HRAR) scores: • 0–3 in 356 (93%) of subjects • 4–6 in 27 (7%) of subjects www.aodhealth.org

  9. Was follow-up sufficiently complete? • Average follow-up after LT was 61 months (range of 0–192 months). www.aodhealth.org

  10. Were objective and unbiased outcome criteria used? • Alcohol relapse was determined by self-report and thus could have been under-reported. • Uniform criteria were used to define the outcome of relapse. • No information about adherence to post LT follow-up visits was provided, raising a concern about selective reporting. www.aodhealth.org

  11. What are the Results? • How likely are the outcomes over time? • How precise are the estimates of likelihood? www.aodhealth.org

  12. How likely are the outcomes over time? Results: • During an average follow-up of 61 months after LT, 12% had harmful alcohol use. • In adjusted analyses, the following were significantly associated with harmful alcohol use after LT: • a score of >3 on the HRAR scale (odds ratio [OR], 10.7) • psychiatric comorbidity (OR, 7.8) • pre-LT abstinence from alcohol for ≤6 months (OR, 3.3) www.aodhealth.org

  13. How likely are the outcomes over time? (cont.) • Harmful alcohol use after LT occurred in… • 5% of patients with none of the above factors, • 18% with 1 factor, • 64% with 2 factors, and • 100% with all 3 factors. www.aodhealth.org

  14. How precise are the estimates of likelihood? • The 95% Confidence Intervals (CIs) are wide: • For a score of >3 on the HRAR scale: OR, 10.7; 95% CI, 3.8–30.0 • For psychiatric comorbidity: OR, 7.8; 95% CI, 3.1–20.0 • For pre-LT abstinence from alcohol for <6 months: OR, 3.3; 95% CI, 1.2–9.3 www.aodhealth.org

  15. How Can I Apply the Results to Patient Care? • Were the study patients and their management similar to those in my practice? • Was the follow-up sufficiently long? • Can I use the results in the management of patients in my practice? www.aodhealth.org

  16. Were the study patients similar to those in my practice? • 76% were male. • Average age at transplantation was 51 years. • 57% were “blue collar” workers. • 21% had an anxiety or depressive disorder. • 93% had low scores (0–3) on the HRAR scale. www.aodhealth.org

  17. Was the follow-up sufficiently long? • Average follow-up after LT was 61 months. www.aodhealth.org

  18. Can I use the results in the management of patients in my practice? • This observational study provides data indicating that LT patients are more likely to relapse if they have the following: • more chronic heavy drinking • greater daily alcohol consumption • extensive prior treatment histories • psychiatric comorbidity • shorter durations of abstinence • Knowledge of these factors can help predict the likelihood of relapse to harmful drinking. www.aodhealth.org

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