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Letters to the Editor |
1 Department of Psychiatry, University Hospital, Clermont-Ferrand, France
2 Biochemistry Department, General Hospital, Moulins, France
aAddress correspondence to this author at: Centre Médico-Psychologique-B, Rue Montalembert, F-63003 Clermont-Ferrand Cedex 1, France. Fax 33-4-7375-2074; e-mail rschwan{at}chu-clermontferrand.fr.
To the Editor:
Approximately 20% of patients seen in clinical practice have an underlying alcohol-use disorder (1). In the last 20 years, specialist work on alcohol misuse has focused mainly on diagnosis at the dependence stage. However, there is also a need to direct attention to alcohol abuse, the long, little-studied, and insufficiently treated disease during which processes damaging to health and social functioning are initiated. Recently, Legros et al. (2) concluded that as a biomarker, asialotransferrin offered the best differentiation between moderate and abusive alcohol consumption.
From a methodologic point of view, clinical investigations concerning biomarkers of alcohol abuse or alcohol dependence have to define their study populations according to internationally accepted clinical categories of alcohol misuse (DSM IV and CIM 10) or to patient populations well defined by alcohol intake (e.g., 0–10, 10–20 g/day, and so forth). This is the basic requirement to make these investigations reproducible, comparable, and interpretable by doctors working in care.
Legros et al. (2), in their excellent work on the efficacy of asialotransferrin and disialotransferrin, recommended the "analysis of the asialo-Tf [asialotransferrin] isoform, which will be present in 92% of alcohol abusers and absent in 95% of moderate alcohol consumers", and Arndt (3) cited numerous advantages, including high specificity, simple standardization of the analytical definition, and the possibility of producing specific antibodies for direct assay, as strong arguments in favor of asialotransferrin. In this sense, the results of the study by Legros et al. (2) are very promising.
Nevertheless, we found in the study by Legros et al. the methodologic problem of definition of the study population. The "alcohol abusers" in that study were probably poorly identified. No inclusion criteria according to alcohol abuse defined by DSM IV (F305) and checked by the corresponding MINI questions were used (4). One criterion for inclusion in the study was an AUDIT score >11. Patients with AUDIT scores between 7 and 11 were excluded. The mean AUDIT score for the included patients was, in fact, 27. However, the internationally validated cutoff for the AUDIT questionnaire is 8; higher AUDIT scores seem associated with greater severity of alcohol misuse, and scores >12 are characteristic of alcohol dependence (5).
Another inclusion criterion of this study was a daily ethanol intake >50 g. In fact, the alcohol abusers included drank, on average, 166 g/day, with a range from 70 to 310 g/day. In a recent study determining the nutritional intake of alcohol-dependent patients, Manari et al. (6) reported that the dependent patients included had mean ethanol consumption of 162 g/day. Nicolas et al. (7) reported a mean ethanol intake in alcohol-dependent patients of 177 g/day. Legros et al. (2) may therefore not have fully differentiated between alcohol abuse and alcohol dependence according to the DSM IV criteria. Alcohol-dependent patients may thus have been unwittingly included in that study. Testing patients with dependence but using the term "abuse" to classify them will tend to overestimate test sensitivity, producing serious consequences in screening practice.
References
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