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BACKGROUND There is limited information concerning whether social determinants of health affect postliver transplant (LT) outcomes. This study aims to understand to what extent the health of LT recipients' counties of residence influence long-term LT outcomes. METHODS We used the United Network for Organ Sharing data to identify adult LT recipients transplanted between January 2010 and June 2018. Patient-level data were matched to county-level County Health Ranking (CHR) data using transplant recipient zip code, and nationwide CHRs were created. Mixed-effects Cox proportional hazards models were used to examine associations between CHRs and graft and patient survival post-LT. RESULTS Health outcomes rank was significantly associated with posttransplant graft and patient survival, with worst tertile counties showing a 13% increased hazard of both graft failure and patient mortality compared to the best tertile counties. CONCLUSIONS Although county health is associated with LT outcomes, it also appears that LT recipient selection is effective at mitigating major disparities based on county of residence and helps yield equitable outcomes in this respect.

Pathologic alcohol use affects more than 2 billion people and accounts for nearly 6% of all deaths worldwide. There are three medications approved for the treatment of alcohol use disorder by the US Food and Drug Administration (FDA): disulfiram, naltrexone (oral and long-acting injectable), and acamprosate. Of growing interest is the use of anticonvulsants for the treatment of alcohol use disorder, although currently none are FDA approved for this indication. Baclofen, a γ-aminobutyric acid B receptor agonist used for spasticity and pain, received temporary approval for alcohol use disorder in France. Despite effective pharmacotherapies, less than 9% of patients who undergo any form of alcohol use disorder treatment receive pharmacotherapies. Current evidence does not support the use of pharmacogenetic testing for treatment individualization. The objective of this review is to provide knowledge on practice parameters for evidenced-based pharmacologic treatment approaches in patients with alcohol use disorder.

Objective Data examining usefulness of urine drug testing in addiction settings for accurately establishing diagnoses and informing treatment is limited. In this retrospective-cohort study we examined the utility of performing urine drug testing in patients presenting for an outpatient addiction assessment. Methods Urine drug testing and patient-reported substance use history were obtained from the medical record of patients who presented for an outpatient addiction evaluation. Patients who denied use of a substance within the window of detection but tested positive were considered to have misrepresented their use. Differences between patients accurately representing versus misrepresenting their use were evaluated. Sensitivity/specificity of drug tests were calculated from self-report and changes to treatment recommendations and diagnoses assessed. Results One hundred and seventy-four patients (mean age = 43.35 ± 15.68 years) were included and the sample was majority male (67%). Ninety-four (54%) patients reported use of a substance within the window of detection. Of 80 patients denying recent use, 14 tested positive (8%). There were no differences in sex (P = 0.78) or age (P = 0.12); referral sources differed significantly between correct and incorrect responders (P = 0.01). Specificity varied between 96% and 99%, while sensitivity had a wider range (17%-87%). Treatment recommendations and diagnoses were altered after review of drug testing results in 1 patient (0.5%). However, in the remainder, all patients were already diagnosed with a severe substance use disorder and had received recommendations to initiate residential/outpatient substance use treatment. Conclusions Among patients completing urine drug testing during outpatient substance use disorder evaluation positive screens alerted providers to undisclosed persistent substance use and potential withdrawal in 8% of the cohort and resulted in a change in diagnoses and/or treatment in 1 patient.

Background Cannabis is second only to alcohol as a substance of abuse and dependence in the United States. While there is extensive research examining alcohol use and bariatric surgery, there is currently little research and there are no published guidelines specific to cannabis use and bariatric surgery. Objectives To identify major themes and general guidelines applied by bariatric surgery psychology clinicians. Setting This practice survey was disseminated to bariatric surgery psychologists at various U.S. academic medical centers, hospitals, and private practices. Methods An electronic, 35-question survey was sent to 47 bariatric surgery psychologists to collect information on current clinical practice guidelines regarding cannabis use before and after bariatric surgery. Results The survey questionnaire was completed by 34 (72.34%) bariatric surgery psychologists. The major identified themes included: (1) the lack of a standardized assessment of cannabis use; (2) a requirement for 3 months of abstinence from cannabis before bariatric surgery; (3) recommended lifetime abstinence from cannabis after bariatric surgery; and (4) discussion of cannabis use risks following bariatric surgery, including appetite stimulation, addiction potential, and possible negative impacts on judgment. Conclusion Cannabis use will likely further increase in the United States. This survey highlighted common bariatric surgery psychology practices in the absence of extensive research and published guidelines. These findings suggest a preliminary framework with which to address cannabis use in patients seeking bariatric surgery. It is recommended that professional organizations and societies build on these initial survey findings to develop guidelines for more consistent, evidence-based practice regarding cannabis use and bariatric surgery.

Aims Replicate the previously reported association of elevated alcohol craving, measured by Penn Alcohol Craving Scale (PACS) during residential treatment, with post-treatment relapse and explore whether elevated craving scores 3 months post-treatment are also associated with subsequent relapse. Methods Alcohol craving was assessed with the PACS on admission and at several time points post-treatment in 190 subjects with DSM-IV diagnosis of alcohol dependence admitted to residential treatment. Data about relapse to any drinking (primary outcome measure) was collected at 3, 6, 9 and 12 months after treatment. Cox regression models were used to determine whether PACS scores were associated with relapse. Statistical models were adjusted for meaningful demographic and clinical covariates. Results Follow-up data was available for 149/190 (78%) of subjects. Elevated PACS scores at discharge were associated with increased relapse risk within the first 3 and 12 months after discharge (P = 0.032 and P = 0.045, respectively). Elevated PACS scores at 3 months were associated with increased risk of subsequent relapse within 12 months after treatment in contacted subjects (P = 0.034) and in the intent-to-treat analysis (P = 0.0001). Conclusions Our findings indicate strong association of post-treatment relapse with elevated alcohol craving measured at treatment completion and at 3 months after treatment and justify the use of this measure to guide relapse-prevention efforts.

OBJECTIVE: To examine associations between antidepressant use and healthcare utilization in young adults beginning maintenance HD therapy. Young adults on hemodialysis (HD) have high healthcare utilization, despite having less medical comorbidity than older patients. Depression and other psychosocial factors may contribute. Yet, this association in young adult HD patients has not been well described. PATIENTS AND METHODS: Antidepressant use, hospitalizations, and emergency department (ED visits were examined in young adults (aged 18 to 44 years) initiating HD (January 1, 2001-December 31, 2013; n=130) at a Midwestern USA institution. Primary outcomes included: hospitalization and ED visits during the first year. RESULTS: A depression diagnosis was common (36.2%) at HD start, yet only 21.5% of the cohort were receiving antidepressant therapy. The antidepressant group was more likely to have diabetes mellitus (64.3% vs. 32.4%), coronary artery disease (28.6% vs. 11.8%), and heart failure (32.1% vs. 14.7%); all P

With expanding experience and success of liver transplantation, increasing numbers of elderly candidates await and undergo liver transplantation. There is accumulating evidence that graft survival and mortality does not appear to differ significantly between the young and carefully selected elderly liver transplantation recipients. Although existing evidence suggests that psychosocial factors impact outcomes after liver transplantation in general, no such information is available specifically for elderly (age ≥65 years) liver transplantation recipients. We conducted a broad medical literature review of outcome studies of elderly liver transplantation recipients. In this review article, we summarize the findings and comment on psychosocial variables included in these studies.Ten outcome studies have reported on the impact of age on the liver transplantation outcomes. There is increasing evidence of favorable outcomes in elderly liver transplantation recipients. Few of these studies include measures of quality of life, functional improvement and other psychosocial variables.Very limited information is available about the impact of psychosocial factors on outcomes in elderly liver transplantation recipients. This dearth of information represents a critical gap in our knowledge and has implications for optimal candidate selection and outcomes after liver transplantation.

Background: We examined the association of adult lung transplant candidates’ self-reported affect with transplant-related outcomes, evaluating whether a positive (vs negative) frame of mind might be protective. Method: Consenting waitlisted candidates from 6 centers completed the questionnaires including the Positive and Negative Affect Schedule annually and posttransplant. Univariate logistic regression analysis was performed to determine the association of baseline affect with outcomes of death or delisting. Models were subsequently adjusted for age, marital status, and education. Results: Questionnaires were completed by 169 candidates (77.9% participation). Mean positive affect, negative affect, and positive-to-negative affect ratio (positivity ratio) were similar to expected norms. The scores of the questionnaire did not change significantly over time. Fifteen (8.9%) waitlisted participants died. Candidates who died while waiting had lower positivity ratios compared to those who survived (1.82 vs 2.45; P = .02). A more negative affect was associated with increased death on the waiting list (adjusted odds ratio [OR] 1.10; P = .021). Conversely, a higher positivity ratio was associated with decreased death while waiting (adjusted OR: 0.45; P = .027). Conclusion: Negative affect may represent a novel risk factor for death on the waitlist. Enhancing positive affect may represent a useful target for psychological optimization in lung transplant candidates.

The purpose of this study was to assess the availability of mental health (MH) and chemical dependency (CD) services at US transplant centers, because appropriate psychosocial assessment and care is associated with better transplant outcomes. We used the 2017-2018 American Hospital Association survey, Area Health Resource File, and Centers for Medicare & Medicaid Services Hospital Compare databases to quantify availability of services and examined associations of hospital- and health services area-level characteristics with odds of offering services with generalized linear mixed models. We found that 15% of transplant centers did not offer MH services and 62% did not offer CD services. Hospitals were more likely to offer MH services if they were larger (OR [95% CI]: 1.03 [1.01, 1.06]) and had a lower rate of uninsured patients in the health services area (OR [95% CI]: 0.89 [0.80, 0.99]) and were more likely to offer CD services if they were larger (OR [95% CI]: 1.02 [1.01, 1.03]) or were members of a system (OR [95% CI]: 2.31 [1.26, 4.24]). Additional research is needed to understand whether lack of MH or CD services at transplant centers affects patients' ability to access comprehensive psychosocial care and whether this affects patient outcomes.

OBJECTIVE Varenicline has been shown to be safe and effective in improving abstinence in smokers. However, results from randomized, placebo-controlled trials using varenicline for alcohol use disorders (AUDs) are inconsistent. The present systematic review and meta-analyses aimed to ascertain whether varenicline improves drinking-related outcomes in subjects with AUDs. DATA SOURCES Ovid, Embase, and Scopus databases were queried using the search terms varenicline, alcoholism, alcohol-related disorders, and drinking behavior for English-language publications until August 29, 2019, of randomized, placebo-controlled trials in humans. STUDY SELECTION A total of 197 articles were identified by the literature search. Studies of subjects with heavy drinking or alcohol dependence/AUD that reported alcohol use-related outcomes were examined. DATA EXTRACTION Weighted mean difference (WMD), standardized mean difference (SMD), and 95% CIs were calculated. The primary outcome of interest was percentage of heavy drinking days. Secondary outcomes included the number of drinks per drinking day, percentage of days abstinent, and change in alcohol craving. RESULTS Ten studies (n = 731, 66.6% male, 55.1% smokers) were included in the systematic review. In meta-analyses, no significant differences in percentage of heavy drinking days (n = 597; WMD = -1.09; 95% CI, -4.86 to 2.69; I² = 22%), number of drinks per drinking day (n = 570; WMD = -0.71; 95% CI, -1.44 to 0.03; I² = 0%), or percentage of days abstinent (n = 439; WMD = 3.89; 95% CI, -1.25 to 9.02; I² = 0%) were noted with varenicline use. Overall risk of bias was low. A statistically significant decrease in craving was observed (n = 436; SMD = -0.63; 95% CI, -1.18 to -0.08; I² = 84%). CONCLUSIONS In the present systematic review and meta-analyses, varenicline was shown to reduce alcohol craving but not improve drinking-related outcomes in subjects with AUDs.

Objective Cannabis is the most commonly used non-alcohol intoxicant in the general population. There are no consistent guidelines on the implications of cannabis abuse and dependence (CAD) in kidney transplant candidates. The aims of this study were to characterize kidney transplant candidates with comorbid CAD and examine the implications of CAD on transplant candidacy. Method This was a retrospective cohort study of kidney transplant candidates meeting diagnostic criteria for CAD at a tertiary center from 2012 to 2016. Candidates were reviewed for psychiatric and substance use disorders (SUDs), family history, and medical variables. The cohort was divided by severity of CAD and transplant listing status for comparisons. Statistical analysis included Kruskal-Wallis tests for continuous variables and Fisher's Exact Test for categorical variables. Results Sixty-one of 2067 (3%) kidney transplant candidates met criteria for CAD, and 13/61 (21%) underwent transplantation. Of 61, 58% smoked cannabis daily, 47% had alcohol dependence history, 31% had other illicit drug dependencies, 38% were smokers, 60% had a SUD family history, and 42% and 27% had depressive and anxiety disorders, respectively. Severity of CAD was inversely associated with transplant listing; those with cannabis abuse were more often listed than those with dependence (67% vs 33%, p = .02) by study end. Three case presentations illustrate cannabis-related issues. Conclusion In this cohort, kidney transplant candidates with comorbid CAD have high prevalence of other substance use disorders, psychiatric comorbidities, and strong family histories of addictions that resemble other SUD populations. These findings have implications for pre-transplant screening and treatment and post-transplant monitoring.

The United Network for Organ Sharing mandates a psychosocial assessment of transplant candidates before listing. A quantified measure for determining transplant candidacy is the Psychosocial Assessment of Candidates for Transplant (PACT) scale. This instrument's predictive value for survival has not been rigorously evaluated among lung transplantation recipients.We reviewed medical records of all patients who underwent lung transplantation at Mayo Clinic, Rochester from 2000-2012. A transplant psychiatrist had assessed lung transplant candidates for psychosocial risk with the PACT scale. Recipients were divided into high- and low psychosocial risk cohorts using a PACT score cutoff of 2. The main outcome variable was posttransplant survival. Mortality was analyzed using the Kaplan-Meier estimator and Cox proportional hazard models.This study included 110 lung recipients: 57 (51.8%) were females, 101 (91.8%) Whites, mean age: 56.4 years. Further, 7 (6.4%) recipients received an initial PACT score2 (poor or borderline candidates) and later achieved a higher score, allowing transplant listing; 103 (93.6%) received initial scores ≥2 (acceptable, good or great candidates). An initial PACT score2 was modestly associated with higher mortality (adjusted hazard ratio = 2.73, p = 0.04).Lung transplant recipients who initially received a low score on the PACT scale, reflecting poor or borderline psychosocial candidacy, experienced greater likelihood of mortality. This primary finding suggests that the psychosocial assessment, as measured by the PACT scale, may provide additional mortality risk stratification for lung transplant candidates.

Objective: The objective was to assess the clinical utility of the Adult ADHD Self-Report Scale (ASRS-v1.1) in identifying ADHD in alcoholics using the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) as the diagnostic “gold standard.” Method: We performed a secondary analysis of data from 379 treatment-seeking alcoholics who completed the ASRS-v1.1 and the ADHD module of the PRISM. Data analysis included descriptive statistics. Results: The prevalence of ADHD was 7.7% (95% CI = [5.4, 10.8]). The positive predictive value (PPV) of the ASRS-v1.1 was 18.1% (95% CI = [12.4, 25.7]) and the negative predictive value (NPV) was 97.6% (95% CI = [94.9, 98.9]). The ASRS-v1.1 demonstrated a sensitivity of 79.3% (95% CI = [61.6, 90.2]) and a specificity of 70.3% (95% CI = [65.3, 74.8]). Conclusion: The ASRS-v1.1 demonstrated acceptable sensitivity and specificity in a sample of treatment-seeking alcoholics when compared with the PRISM as the reference standard for ADHD diagnosis.

Purpose There is limited information about whether social determinants of health affect lung transplant outcomes. In this study we aimed to examine associations between nationwide County Health Rankings (CHR) and its domain specific sub-ranks and lung transplant graft and patient survival. Methods United Network for Organ Sharing and CHR datasets were linked by using transplant recipient's zip code of residence. Patient- and county-level characteristics were assessed for all adult lung transplant recipients from 2010-2018. CHR were calculated across all 3149 US counties and averaged across the eight study years and counties were assigned to a tertile for each of two overall ranks and six domain-specific sub-ranks. Mixed effects Cox proportional hazards models were used to examine associations between County Health Rankings and graft survival and patient survival post-lung transplant. Results Out of 15909 Lung Transplant recipients, 7084 resided in best, 6072 in middle and 2753 in worst terile. The Health Outcomes rank, Length of Life sub-rank, Quality of Life sub-rank, Clinical Care sub-rank, Social and Economic Factors sub-rank, and Physical Environment sub-rank were independently associated with both graft and patient survival (between 7 and 15% increased risk among counties in the worst tertiles compared to the best). However, these associations did not remain statistically significant when models were adjusted for all relevant patient characteristics, center lung transplant volume, and random effects for transplant center and county. Conclusion While county-level differences do affect lung transplant outcomes, these differences are largely accounted for by individual patient and transplant-specific characteristics. Further research is needed to ascertain whether these factors act as mediator factors.

Background Increasing numbers of patients over the age of 60 are undergoing liver transplantation. Objective We sought to determine whether age or clinical morbidities were associated with pre- and post-transplant executive and memory performance using the Brief Test of Adult Cognition by Telephone (BTACT). Methods Participants included 36 recipients with n = 20 in the older group (>60 y) and n = 16 in the younger group (≤60 years). The BTACT was administered an average of 3 months before transplant, and at follow-up post-transplant intervals of 3, 6, and 9 months. BTACT composite scores for memory and executive function with age and education norms were obtained. Results Older recipients were more likely to have hepatocellular carcinoma, a lower biological MELD score at transplant, less cellular rejection, and fewer post-operative hospital days. Older and younger recipients showed comparable pre-transplant executive and memory function and comparable post-transplant improvement. Both older and younger patients showed statistically significant improvement in executive function scores at 3 months post-transplant and maintained improvement at 6 and 9 months. Memory function improved significantly in older patients by 6 months post-transplant but did not improve significantly in the younger group. Conclusion Older liver transplant recipients were more likely to have hepatocellular carcinoma and a lower biological MELD score than younger recipients, but both age groups showed comparable pre-transplant cognitive performance and post-transplant cognitive improvement. Additionally, a normed telephone test can be used to effectively screen and track executive and memory function post-transplant.

Objective: To assess for intrasex and intersex differences in psychiatric comorbidity according to ADHD status in treatment-seeking adults with alcohol use disorders (AUDs). Method: This study was a secondary analysis of data utilizing descriptive statistics from 472 treatment-seeking alcoholics who completed the Psychiatric Research Interview for Substance and Mental Disorders (PRISM). Results: The prevalence of ADHD in males and females was 6.0% and 6.4%, respectively. Males with ADHD and AUDs had higher rates of current and lifetime drug use disorders, current depressive disorders, and current and lifetime anxiety disorders than male alcoholics without ADHD. No intrasex differences in psychiatric comorbidities were identified in female alcoholics with respect to ADHD status. Males with ADHD and AUDs were more likely to have had opioid dependence than ADHD-positive females. No other intersex differences were found. Conclusion: Positive ADHD status was associated with increased psychiatric comorbidity among treatment-seeking alcoholic men.

We assessed the impact of comorbid depression and anxiety disorders as well as positive and negative emotional states on alcohol consumption in alcohol dependent men and women.Per day alcohol consumption during 90 days before enrolment was assessed by the Time Line Follow Back (TLFB) in 287 men and 156 women meeting DSM-IV-TR criteria for alcohol dependence. Propensity to drink in negative/positive emotional states was assessed using the Inventory of Drug Taking Situations (IDTS). Psychiatric comorbidities, including major depressive disorder (MDD), substance-induced depression (SID), anxiety disorders (AnxD), or substance-induced anxiety (SIA) were identified by Psychiatric Research Interview of Substance and Mood Disorders (PRISM).In the combined group, increased number of drinks per day and number of heavy drinking days correlated with increased IDTS scores (all p 0.0001), while the lifetime history of MDD was associated with fewer drinking days (p = 0.045) but not average number of drinks per day. Male sex was associated with higher alcohol consumption per day (p 0.0001), but not with the number of drinking days (p 0.05). Lifetime MDD history was associated with less drinking days (p = 0.0084) and less heavy drinking days (p = 0.021) in alcohol dependent men, while current MDD was associated with higher alcohol use per day in alcohol dependent women (p = 0.044).Our findings suggest that emotional states and lifetime MDD history have sex-specific impact on alcohol use in alcohol dependent men and women. The mechanisms underlying these findings and their relevance to treatment outcomes need to be examined in future studies.

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals. ispartof: JOURNAL OF HEART AND LUNG TRANSPLANTATION vol:37 issue:7 pages:803-823 ispartof: location:United States status: published

Background Liver transplant candidates undergo psychosocial assessment as a component of their pretransplant evaluation. Global psychosocial assessment scales, including the Psychosocial Assessment of Candidates for Transplantation (PACT), capture and quantify these psychiatric and social variables. Objective Our primary aim was to assess for an association between global PACT score and survival in liver transplant recipients. Methods This retrospective cohort study examined records of all liver recipients at one U.S. Transplant Center from 2000 to 2012 with outcomes monitoring until 07/01/2016. We investigated for associations between the following variables and mortality: PACT score, age, gender, marital status, race, alcoholic liver disease (ALD), and body mass index (BMI). Statistical methods included Student's t-test, Wilcoxon rank sum test, chi-square, Fisher's exact test, Kaplan–Meier curve, and Cox proportional hazard models. Results Of 1040 liver recipients, 538 had a documented PACT score. Among these, PACT score was not associated with mortality. In women, a lower PACT score was associated with mortality (p = 0.003) even after adjustments for age, marital status, and BMI. Women with ALD had a 2-fold increased hazard of death (p = 0.012). Increasing age was associated with increased risk of death for the cohort as a whole (p = 0.019) and for men (p = 0.014). In men, being married and BMI were marginally protective (p = 0.10 and p = 0.13, respectively). Conclusions Transplant psychosocial screening scales, specifically the PACT, identify psychosocial burden and may predict post-transplant outcomes in certain populations. In female liver recipients, lower PACT scores and ALD were associated with a greater risk of post-transplant mortality.

Psychosocial assessment is an essential component of the pretransplant evaluation. Many individuals have significant psychosocial problems, and they are either denied for transplantation or deferred from listing and transplant until the psychosocial issues are addressed.The primary aim of this study was to evaluate the outcomes of patients who initially had significant psychosocial problems, but who addressed them and received a heart transplant.This retrospective study included heart transplant recipients from 1/1/2000 to 12/31/2012. Those with initial Psychosocial Assessment of Candidates for Transplantation (PACT) scale score2 were compared with those whose initial score was ≥2 for the variables new onset depression and anxiety, length of stay, rejection, and survival using logistic and linear regression and Cox proportional hazards modeling.Of 164 heart recipients with pretransplant PACT scores, 46 (28%) were female, 154 (94%) were white, and the mean age was 52.7 years. Only 11 (7%) received an initial PACT score2; these candidates underwent heart transplantation after their scores increased to ≥2. Initial PACT2 increased the odds of new depression by 11-fold (p = 0.002), but was not associated with differences in survival, posttransplant length of stay, the occurrence of treated episodes of rejection or new anxiety (p ≥ 0.20 for all).Among heart recipients, initially high pretransplant psychosocial risk, as assessed by PACT, was associated with posttransplant new episode depression. However, after addressing the primary psychosocial issues before transplant, posttransplant length of stay, organ rejection, and survival were the same as those without prior psychosocial concerns.

BACKGROUND: Sleep disturbances are extremely common in alcohol recovery. Systematic research into the relationship between alcohol relapse and sleep disturbances using validated scales and accounting for potential confounders is lacking. METHODS: Patients admitted to a 1-month residential addiction treatment program were administered the Pittsburg Sleep Quality Index (PSQI) at admission/discharge. In addition, the Alcohol Use Disorders Identification Test (AUDIT), Patient Health Questionnaire-9 (PHQ-9), and Pennsylvania Alcohol Craving Scale (PACS) were administered. Patients were contacted every 3 months over 1 year following discharge. Associations of clinical factors with time until relapse were examined using univariate Cox proportional hazard models. RESULTS: One-hundred and nineteen patients with alcohol use disorders met inclusion criteria (mean age 50.6 ± 13.2 years, 57% male), relapse data were available for 81 patients. Eighty percent of subjects had other psychiatric diagnoses, 66.3% had sleep disturbances at the time of admission, and 57.1% were using hypnotics; 49.1% of patients had sleep disturbances at discharge. Sleep disturbances at admission and discharge were not associated with alcohol relapse at 12 months (OR = 1.00, 95%CI = 0.89-1.13; p = 0.95 and OR = 0.97, 95%CI = 0.86-1.09; p = 0.61). The PSQI sub-scale scores were also not associated with relapse at 12 months. The use of alcohol to help fall asleep (OR = 3.26, 95% CI = 1.33-7.95; p = 0.008), hypnotic use at admission(OR = 4.03, 95%CI = 1.63-9.97; p = 0.002) and age (OR = 1.03, 95%CI = 1.00-1.06; p = 0.035) were associated with relapse over 12 months. CONCLUSION: In patients completing a residential treatment program, sleep disturbances as measured by the PSQI were not associated with alcohol relapse at 12 months. Alcohol use as a hypnotic and hypnotic use at admission were associated with subsequent relapse. Language: en

Objective The aim of this study is to describe the clinical phenotype of alcohol use disorder (AUD) treatment-seeking patients with Roux-en-Y Gastric Bypass Surgery (RYGB) history; and to compare it to AUD obese non-RYGB controls. Methods Retrospective study of electronic medical records for all patients 30–60 years treated at the Mayo Clinic Addiction Treatment Program, between June, 2004 and July, 2012. Comparisons were performed with consumption patterns pre-RYGB and at time of treatment; excluding patients with AUD treatments pre-RYGB. Results Forty-one out of 823 patients had a RYGB history (4.9%); 122 controls were selected. Compared to controls, the RYGB group had significantly more females [ n = 29 (70.7%) vs. n = 35 (28.7%) p p = 0.002). On average, RYGB patients reported resuming alcohol consumption 1.4 ± 0.2 years post-surgery, meeting criteria for AUD at 3.1 ± 0.5 years and seeking treatment at 5.4 ± 0.3 years postoperatively. Pre-surgical drinks per day were significantly fewer compared to post-surgical consumption [2.5 ± 0.4 vs. 8.1 ± 1.3, p = 0.009]. Prior to admission, RYGB patients reported fewer drinking days per week vs. controls (4.7 ± 0.3 vs. 5.5 ± 1.8 days, p = 0.02). Neither RYGB, gender, age nor BMI was associated with differential drinking patterns. Conclusion The results of this study suggest that some patients develop progressive AUD several years following RYGB. This observation has important clinical implications, calling for AUD-preventive measures following RYGB. Further large-scale longitudinal studies are needed to clarify the association between RYGB and AUD onset.

AIMS: Prior studies have established variation at the PNPLA3 gene to be associated with a risk of developing alcoholic liver disease (ALD). We attempt to replicate this finding and other potential genetic variations previously associated with ALD utilizing a case-control design in a cohort of subjects with alcohol use disorders. SHORT SUMMARY: This case-control study performed in a US clinical sample of heavy drinkers, replicates the previously reported association between ALD and rs738409 polymorphism in the PNPLA3 gene in heavy drinkers. This association persisted after accounting for the subject’s diabetes status. METHODS: Patients of European ancestry with a history of ALD were identified (n = 169). Controls consisted of patients without ALD who were from the same cohorts and were ≥ 30 years of age, had lifetime total years drinking ≥20 and lifetime maximum drinks per day ≥12 (n = 259). Patients were genotyped for 40 candidate single nucleotide polymorphisms (SNPs) selected for the purpose of testing their association with ALD. The association of each SNP with ALD was tested using a logistic regression model, assuming log-additive allele effects. Bonferroni correction was applied and multivariable logistic regression models were used to account for relevant covariates. RESULTS: Age, sex, and body mass index (BMI) distributions were similar between cases and controls. Diabetes was more prevalent in the ALD cases. Three SNPs were associated with ALD at the nominal significance level (rs738409 in PNPLA3, P = 0.00029; rs3741559 in AQP2, P = 0.0185; rs4290029 in NVL, P = 0.0192); only PNPLA3 rs738409 SNP was significant at the Bonferroni-corrected P-value threshold of 0.00125. Association results remained significant after adjustment for diabetes status. CONCLUSION: Our case-control study confirmed that PNPLA3 rs738409 SNP is associated with ALD. This is an important replication in a US clinical sample with control subjects who had long histories of alcohol consumption.

The number of living kidney donations is increasing in many countries, in response to increasing demand, lengthening waiting lists for transplants from deceased donors, and, in some areas, cultural or religious resistance to deceased donation. In most such donations the donor and recipient are related genetically or emotionally, but there are various routes by which a donor may give a kidney to a recipient who is a stranger. The practice of paired, pooled or chained donation - in which a recipient receives an organ from a stranger, in return for which that recipient‘s emotionally or genetically related (but incompatible) donor gives a kidney to another stranger - is accepted and growing. In contrast, the selling of organs by donors is controversial and generally illegal, except in a few countries.

This study evaluated the impact of psychiatric comorbidities in liver transplant (LT) recipients aged ≥65 years (elderly) on length of hospital-stay (LOS), death, and a composite outcome of graft loss or death.This retrospective study assessed impact of psychiatric comorbidities in 122 elderly LT recipients and a matched group of 122 LT recipients aged65 years (younger). Associations were assessed using adjusted multivariable regression models.Among elderly, median age at LT was 68 years, most were males (62%), white (85%) and 61.7% had a history of any psychiatric diagnosis. Among younger, median age was 55, most were males (67.2%), white (77.5%) and 61.5% had any psychiatric diagnosis. Median LOS was 8 days for both groups. Among elderly, after a median follow-up of 5 years, 25.4% died and 29.5% experienced graft loss or death. History of adjustment disorder, history of depression, past psychiatric medication use, and pain prior to LT were associated with an increased risk of death or the composite graft loss or death. Perioperative use of SSRIs and lack of sleeping medication use were associated with longer LOS. Among aged65, after median follow-up of 4.7 years, 21 patients (17%) died and 25 (20%) experienced graft loss or death; history of depression, perioperative SSRIs or sleeping medications use was associated with increased mortality and graft-loss or death.Six out of 10 patients among both elderly and younger cohorts had pre-LT psychiatric comorbidities, some of which adversely affected outcomes after LT.

The majority of liver transplantation centers have required patients with alcohol-induced liver disease to demonstrate a period of abstinence (generally 6 months' duration) to qualify for transplant listing. This requirement has excluded patients with alcoholic hepatitis from transplant consideration. Since 2011, several studies have examined the outcomes of patients undergoing liver transplantation with brief abstinence as a lifesaving intervention for alcoholic hepatitis. This review includes each of the recent studies and discusses their implications for general transplant practice.A Medical Literature Analysis and Retrieval System search revealed five published studies - three prospective and two retrospective - pertaining to liver transplantation for alcoholic hepatitis. Among patients with medication-nonresponsive alcoholic hepatitis, those who underwent transplantation had superior survival. Liver recipients with alcoholic hepatitis had comparable survival to those with 6 or more months of abstinence. Their relapse rates were not statistically different in the short term over those transplanted with longer abstinence, although some patients in each prospective cohort relapsed to drinking despite narrow inclusion criteria and extensive pretransplant staff reviews and posttransplant surveillance.Liver transplantation is a reasonable treatment consideration for highly selective cases of alcoholic hepatitis. Further research is needed to refine inclusion criteria, address posttransplant relapse prevention interventions, and monitor long-term outcomes.

Synthetic κ-opioid receptor (KOR) agonists induce dysphoric and pro-depressive effects and variations in the KOR (OPRK1) and prodynorphin (PDYN) genes have been shown to be associated with alcohol dependence. We genotyped 23 single nucleotide polymorphisms (SNPs) in the PDYN and OPRK1 genes in 816 alcohol-dependent subjects and investigated their association with: (1) negative craving measured by a subscale of the Inventory of Drug Taking Situations; (2) a self-reported history of depression; (3) the intensity of depressive symptoms measured by the Beck Depression Inventory-II. In addition, 13 of the 23 PDYN and OPRK1 SNPs, which were previously genotyped in a set of 1248 controls, were used to evaluate association with alcohol dependence. SNP and haplotype tests of association were performed. Analysis of a haplotype spanning the PDYN gene (rs6045784, rs910080, rs2235751, rs2281285) revealed significant association with alcohol dependence (p = 0.00079) and with negative craving (p = 0.0499). A candidate haplotype containing the PDYN rs2281285-rs1997794 SNPs that was previously associated with alcohol dependence was also associated with negative craving (p = 0.024) and alcohol dependence (p = 0.0008) in this study. A trend for association between depression severity and PDYN variation was detected. No associations of OPRK1 gene variation with alcohol dependence or other studied phenotypes were found. These findings support the hypothesis that sequence variation in the PDYN gene contributes to both alcohol dependence and the induction of negative craving in alcohol-dependent subjects.

Background and Objectives The aim of this study was to investigate potential gender differences in situations associated with heavy alcohol drinking. Methods Data from 395 alcohol dependent patients participating in the Mayo Clinic Intensive Addiction Program were evaluated. Each participant completed the inventory of drug taking situations (IDTS), Penn alcohol craving scale (PACS), patient health questionnaire (PHQ-9), and/or Beck depression inventory (BDI). Gender differences in IDTS scores representing three domains (negative, positive, and temptation) of situations associated with heavy alcohol use were examined. Results Women with alcohol dependence report a higher frequency of heavy drinking in unpleasant emotional (IDTS negative scores mean ± SD women vs. men: 52.3 ± 22.1 vs. 43.8 ± 21.8; p = .0006), and as a result of temptation (IDTS temptation scores mean ± SD women vs. men: 40.4 ± 23.0 vs. 35.3 ± 20.8; p = .035). Upon admission, women also scored significantly higher on depressive symptoms as measured by the BDI (23.4 ± 11.4 vs. 18.2 ± 9.8, p

Background and Objectives: Alcoholism treatment interventions, both psychosocial and pharmacologic, aim to reduce cravings to drink. Yet, the role of craving in treatment outcomes remains unclear. This study evaluated craving intensity measured with the Penn Alcohol Craving Scale (PACS) at admission and discharge from residential treatment as a predictive factor of relapse after treatment. Methods: The study cohort included 314 alcohol-dependent subjects. Associations between relapse after discharge, PACS score, and clinical variables were investigated using time-to-event analyses. The primary analysis, based on the intent-to-treat principle, presumed relapse in those declining follow-up or not responding to contact attempts. Secondary analysis utilized data from 226 subjects successfully contacted after discharge with a median follow-up time of 365 days. Results: The intent-to-treat analysis demonstrated that relapse was associated with higher level of craving at admission (p= .002) and discharge (p < .001). The analysis of data from patients successfully contacted after discharge led to similar results. A multivariable analysis indicated that relapse rates increased as PACS scores increased, and a higher discharge PACS score was significantly associated with relapse (p= .006) even after adjusting for covariates. Conclusions and Scientific Significance: This study demonstrates that higher PACS scores at the time of admission and discharge are associated with relapse following residential addiction treatment. These data support the role of craving in relapse and the utility of craving measurement as a clinical guide in assessing relapse risk. (Am J Addict 2012;21:S20–S26)

To further explore reports of association of alcohol dependence and response to acamprosate treatment with the GATA4 rs13273672 single nucleotide polymorphism (SNP), we genotyped this and 10 other GATA4 SNPs in 816 alcohol-dependent cases and 1248 controls. We tested for association of alcohol dependence with the 11 SNPs individually and performed a global test for association using a principle components analysis. Our analyses demonstrate significant association between GATA4 and alcohol dependence at the gene level (P = 0.009) but no association with rs13273672. Further studies are needed to identify potential causal GATA4 variation(s) and the functional mechanism(s) contributing to this association.

Background Psychopathology has been commonly observed in liver transplant candidates, and up to 40% have comorbid psychiatric disorders. This illness burden may negatively impact quality of life and transplant outcome. Liver transplantation for cholangiocarcinoma remains uncommon due to the complex treatment protocol. We assessed for pretransplant psychopathology and substance use disorders in liver transplant recipients with cholangiocarcinoma to better characterize this patient group. Methods We retrospectively reviewed the records of 143 liver transplant recipients who completed pretransplant psychological screening with the PAS, BDI-FS, BSI-18, and the SAAST between 2000 and 2004. The majority completed an evaluation by a transplant psychiatrist. Rates of pretransplant psychiatric and substance use symptoms and disorders were compared between 26 patients with cholangiocarcinoma and 117 other liver recipients using χ2 or Fisher's exact tests. Results Of the total cohort, 35% had a pretransplant psychiatric diagnosis, 35% had a substance use disorder, and 43% were current or former smokers. The cholangiocarcinoma cohort had significantly lower scores on the PAS, BDI-FS, and the BSI-18. On interview, the cholangiocarcinoma group was less likely to have an alcohol use disorder (P = 0.03) or any substance use disorder (P = 0.04), but the two groups did not differ significantly in the likelihood of having a psychiatric disorder or smoking history. Conclusions This study suggests that patients with cholangiocarcinoma have lower rates of alcohol and drug use disorders than other liver transplant recipients. They do not differ in rates of psychiatric disorders or smoking. Psychosocial assessment and support are recommended throughout the transplant process.

Trazodone is one of the most commonly prescribed hypnotic medications in patients with sleep disturbances in alcohol recovery. A recent study concluded that treating insomnia with trazodone in patients with alcohol dependence might impede improvements in alcohol consumption and lead to increased drinking when trazodone is stopped. We set out to investigate the relationship between trazodone use during alcoholism treatment and relapse rates in patients who were discharged from a residential alcohol treatment program. We retrospectively reviewed records of patients with a diagnosis of alcohol dependence in a residential addiction treatment center from 2005 to 2008 and analyzed the association of trazodone use at discharge and alcohol relapse at 6 months. We also assessed the association between trazodone use and relapse at 6 months adjusting for sex, drug dependence, nonsubstance use Axis I psychiatric diagnoses, patient self-report of difficulties with sleep, and anti-dipsotropic medication use at discharge and evaluated pair-wise interactions of trazodone use with the adjustment variables. Of 283 patients eligible for inclusion, 85 (30%) were taking trazodone at discharge. Older age, self-reported sleep problems, and having a nonsubstance use Axis I psychiatric diagnosis were associated with trazodone use. After discharge, 170 (60%) subjects responded to follow-up efforts. Neither intent to treat nor responder only analysis revealed any association between trazodone use and relapse. Our retrospective study of a complex patient population discharged from a residential treatment setting did not find an association between trazodone use at discharge and relapse rates at 6 months.

Despite the high prevalence rate of comorbid alcohol dependence and bipolar disorder, little is known about how many bipolar patients are actively engaged in addiction treatment or the alcohol consumption characteristics of this group. This retrospective study reviewed the medical records from patients with alcohol dependence admitted to residential treatment at our institution (n = 588). The analyses focused on alcoholism severity measures and discharge clinical diagnoses. Patients with alcoholism + bipolar disorder compromised only 5% of the total study group. The number of drinking years was lower for patients with alcoholism + bipolar disorder (23.1 ± 17.7) than for those with alcoholism + depression (26.8 ± 13.9) or alcoholism alone (28.1 ± 13.2). A trend of higher mean lifetime maximum daily drinks was observed for patients with alcoholism + bipolar disorder; this was because of the significantly higher maximum drinks for women with bipolar disorder (21.0 ± 11.5) than for women in other diagnostic groups. Despite high rates of comorbidity in community-based studies, this retrospective study suggests that patients with bipolar disorder are not highly represented in residential alcoholism addiction treatment. Future studies are encouraged to better understand utilization rates of addiction treatment among patients with bipolar disorder and to identify clinical correlates that predispose bipolar women to high-dose drinking.

Background/goals Interferon-induced depression affects 20% to 40% of patients treated for chronic hepatitis C virus (HCV). The aim of our study was to examine the influence of antidepressant treatment and whether this improves the likelihood of completing therapy. Methods One hundred randomly selected patients with chronic HCV undergoing antiviral therapy at a single center were identified. Patients were categorized as Group 1 (no depressive symptoms during treatment), Group 2 (depressive symptoms without antidepressant therapy), Group 3 (preexisting or prophylactic antidepressants before therapy), and Group 4 (on-demand antidepressant therapy for depressive symptoms). Results Mean age was 49 years with 72% men. Genotype 1 infection was noted in 65% of patients, and the mean pretreatment HCV RNA level was 1,419,919 IU. Patients without earlier depression receiving on-demand therapy (Group 4) had a significantly higher rate of antiviral treatment completion compared with Group 3 (92% vs. 52%; P=0.01). Patients in groups 1 and 4 with no baseline history of depression had similar treatment completion rates. No significant relationship between the use of antidepressant therapy, SVR or premature cessation of therapy was observed. Conclusions Preexisting depression was associated with lower antiviral treatment completion rates despite the use of prophylactic antidepressant therapy. In patients without preexisting depression, however, on-demand antidepressant therapy for depressive symptoms was strongly associated with the highest treatment completion rates in the cohort. Antidepressant therapy for new or worsening depressive symptoms independent of baseline depression status did not affect the probability of achieving SVR or stopping treatment prematurely.

The purpose of this study was to measure spiritual well-being (SWB), private religious practices (PRP), positive religious coping, abstinence self-efficacy (AASE), affiliation with AA (AAA), and their associations with alcoholics in treatment. Seventy-four adults in a three-week outpatient addiction treatment program were assessed at admission and discharge. Wilcoxon signed rank and t tests demonstrated significant increases in all variables. Spearman correlation coefficients detected significant associations between the spiritual variables, SWB and AASE, as well as PRP and AAA. Findings suggest that spiritual variables can change during treatment and that there may be connections between spiritual variables and variables associated with longer-term recovery.

Background and Aims Depression and anxiety are often comorbid with alcoholism and contribute to craving and relapse. We aimed to estimate the prevalence of life-time diagnoses of major depressive disorder (MDD), substance-induced depression (SID), anxiety disorder (AnxD) and substance-induced anxiety (SIA), the effects of these comorbidities on the propensity to drink in negative emotional states (negative craving), and test whether these effects differ by sex. Design Secondary analyses of baseline data collected in a single-arm study of pharmacogenetic predictors of acamprosate response. Setting Academic medical center and affiliated community-based treatment programs in the American upper mid-west. Participants A total of 287 males and 156 females aged 18–80 years, meeting DSM-IV criteria for alcohol dependence. Measurements The primary outcome measure was ‘propensity to drink in negative emotional situations’ (determined by the Inventory of Drug Taking Situations) and the key predictors/covariates were sex and psychiatric comorbidities, including MDD, SID, AnxD and SIA (determined by Psychiatric Research Interview of Substance and Mood Disorders). Findings The prevalence of the MDD, SID and AnxD was higher in females compared with males (33.1 versus 18.4%, 44.8 versus 26.4% and 42.2 versus 27.4%, respectively; P