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The Employee Stress and Alcohol Project (ESAP) developed an interactive computer-based alcohol abuse prevention and early intervention program accessible to employees over the Internet. Behavioral health research recommends that specialists develop and provide comprehensive yet cost-effective approaches to alcohol abuse prevention, early intervention, and treatment within the context of workplace managed care. ESAP is implementing this web site for a diverse 8,567-employee work site. ESAP's web site enables employees to self-assess their stress levels, coping styles, and risk for alcohol-related problems. It provides personalized feedback, recommendations, mini-workshops, a drinking journal, links to other online resources, and an interactive forum for direct participant-to-participant communication. ESAP's web site provides resources for employees who are concerned about another individual's drinking as well as information about adolescent alcohol use. This article discusses the implications of incorporating the ESAP web site into worksite alcohol abuse prevention and early intervention programming.

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Alcohol-dependent outpatients were clustered on the basis of their responses on the Millon Clinical Multiaxial Inventory (MCMI; Millon, 1983) personality disorder scales; male and female patients were clustered separately. The clusters were compared with respect to self-reported psychiatric, interpersonal, and drinking problems. The results, along with those of previous cluster analyses with male inpatients, suggest several reliable personality subtypes. One type (more common in inpatient settings) scores high on Negativistic and Avoidant/Schizoid or Dependent scales and reports numerous problems and intense distress. A second type (more common in outpatient settings) reports few problems and scores highest on Compulsive or Histrionic/Narcissistic scales. A third group (found in all and only male samples) scores high on Narcissism and Antisocial scales, readily admits substance problems, and may be interpersonally controlling and distancing.

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A total of 1780 patients without symptoms of cerebral ischemia undergoing coronary artery bypass grafting (CABG) were screened before surgery for carotid stenosis by pneumophlethysmography. An abnormal test was defined as a difference in ophthalmic artery pressures of > or = 5 mmHg or ophthalmic-brachial pressure index < or = 0.69. Some 99 patients (5.6%) had an abnormal ocular pneumoplethysmographic measurement (89 unilateral, ten bilateral). Of these, 26 patients underwent prophylactic carotid endarterectomy before CABG (group 1), while the remaining 73 patients had reconstruction without previous carotid endarterectomy (group 2). A total of 100 patients (group 3) with normal ocular pneumoplethysmographic results were used as controls. The three groups were comparable with respect to age, diabetes, hypertension, smoking and severity of coronary artery disease. Early (30-day) postoperative stroke rates were 0 and 4% (n = 3) for groups 1 and 2 respectively, and 0% for group 3 (P > 0.07). Early mortality rates after CABG for groups 1 and 2 were 4% (n = 1) and 1% (n = 1), respectively and 2% (n = 2) for groups 3 (P > 0.4). Late follow-up (mean 48 months) demonstrated stroke rates of 0% for group 1, and 10% and 4% for groups 2 and 3 (P > 0.08). The early mortality and stroke rates in the ten patients with bilateral abnormal ocular pneumoplethysmographic values were 0 and 0%. However, late strokes occurred significantly more often (43%) in patients with bilateral abnormal results compared with those with unilateral abnormal findings when both groups did not undergo carotid endarterectomy (P < 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

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A simple, self-report scale to predict who would leave substance misuse treatment against medical advice was developed and tested. Scale items were drawn from the Inventory of Interpersonal Problems which measures interpersonal distress in the same format that the SCL-90-R uses to measure personal distress. Potential items were selected using data from an initial sample of 66 patients at a substance misuse clinic. Factor analytic techniques were then used to decide which of these items to include in the scale. It was tested using 98 patients not included in the initial sample. Logistic regression analysis confirmed that patients with high scores on the scale were significantly more likely to leave treatment than were patients with low scores.

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Three thousand sixty-six patients underwent cardiopulmonary bypass at the Maimonides Medical Center over a 5-year period from January 1, 1987, to January 1, 1992. Of these patients, 1,890 (62%) were less than 70 years of age, 969 (32%) ranged from 70 to 79 years of age, and 207 (7%) were 80 years of age or older. The overall 30-day mortality rate was 8%. Eleven patients developed acute mesenteric ischemia from 24 hours to 12 days postoperatively. At the time of diagnosis, the majority of patients presented with late classical signs and symptoms of acute mesenteric ischemia including abdominal distension, respiratory distress, hypotension, oliguria, and sepsis. All patients underwent immediate laparotomy. Extensive bowel necrosis was found in all, and resection was possible in eight patients. All patients died as a result of this complication. Using the exact trend test, we found a statistically significant increase in the incidence of deaths due to acute mesenteric ischemia after cardiopulmonary bypass in older compared with younger patients. This fatal complication after cardiopulmonary bypass occurs more often than previously believed and is a relatively common cause of death in the elderly.

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The prevalence of potentially significant intra-abdominal pathologies or vascular anomalies in candidates for infrarenal aortic aneurysm repair remains unclear. This study retrospectively reviewed 130 consecutive patients with aortic aneurysms (4.5-10.0 cm in largest diameter) who had undergone contrast-enhanced abdominal computed tomography. The overall incidence of potentially significant pathologies was 31.5%. Gallstones were detected in 25 patients (19.2%), adrenal masses in six (4.6%), pancreatic tumors in two (1.5%), renal stones in two (1.5%), liver metastases in one (0.8%), retroperitoneal lymphoma in one (0.8%) and left gastric artery aneurysm in one (0.8%). Other pathologies included renal cysts in 42 patients (32.3%), colonic diverticulosis in nine (6.9%) and hepatic cysts in three (2.3%). Major vascular anomalies were encountered in only three of the 130 patients (2.3%) and these included two with a left-sided inferior vena cava and one case of retroaortic left renal vein. This study emphasizes the high incidence of potentially significant intra-abdominal pathologies and the low incidence of major vascular anomalies associated with infrarenal aortic aneurysm. The impact of such findings on the management of aortic aneurysms is discussed.

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Continuous ambulatory ECG (CAECG) monitoring has been advocated as an effective low-cost preoperative method for detecting silent myocardial ischemia in patients undergoing peripheral vascular surgery. In addition, silent ischemic events are associated with an increased incidence of postoperative myocardial infarctions. Ninety-six patients (mean age 73 years) admitted for elective aortic (24) or infrainguinal (72) operations over a 2-year period underwent 24-hour two- or three-lead CAECG monitoring. Results were reviewed by a single cardiologist blinded to the study. The criterion for ischemia was ST segment depressions of 1 mm or greater for 40 seconds or more 60 msec after the J point. Postoperative myocardial infarction was determined by ECG changes and/or elevated serum creatinine phosphokinase with positive MB isoenzymes. Risk factors included hypertension (71%), history of coronary artery disease (66%), smoking (61%), and diabetes mellitus (47%). Nine out of 96 patients (9.4%) had a positive CAECG test for silent myocardial ischemia. Only one patient (11.1%) developed postoperative myocardial infarction and there were no deaths in this group. The incidence of postoperative myocardial infarction in the nonischemic group was 16.1% (14/87). However, the mortality in this group was 6.9% (6/87). New and malignant arrhythmias requiring preoperative medical intervention were observed in seven patients (7.4%): two cases of ventricular tachycardia and five cases of atrial flutter/fibrillation. Contrary to previous reports, CAECG monitoring for silent ischemia was not a significant predictor of postoperative myocardial infarction or mortality in our patient population. However, we continue to recommend the preoperative use of CAECG monitoring as a diagnostic tool for unsuspected malignant arrhythmias.

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Though the focus on interpersonal interaction is a powerful therapeutic factor in group therapy, traditional chemical dependency therapy groups generally fail to employ the interactional group orientation. An interactional approach can be effectively applied to alcoholics if the following guidelines are observed: (1) recovery is always accorded priority, (2) the patient accepts identification as an alcoholic, (3) anxiety is carefully modulated, (4) the proper distinction is made between what the alcoholic is and is not responsible for, (5) the therapist is thoroughly familiar with Alcoholics Anonymous language, steps, and traditions. It is important that therapists not permit misperceptions of A.A. to be used as therapy resistance and that they be able to harness the wisdom of A.A. for psychotherapeutic ends. Group therapists must also be prepared to deal with common themes arising in the treatment of the alcoholic patient: idealization, devaluation, externalization, defiance, grandiosity, conning, and avoidance.

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The mercapturic acid conjugate of acetaminophen has been proposed as an index of the toxic intermediate of acetaminophen metabolism which is responsible for the increased incidence of liver injury in alcoholics taking the drug. Previous studies which compared alcoholics with normal patients failed to show any significant difference in mercapturic acid production. We undertook a longitudinal study in recovering alcoholics to test the hypothesis that abstinence should lead to a decrease in acetaminophen-mercapturic acid excretion. The patients were given a 1500 mg dose of acetaminophen soon after they stopped drinking then again approximately 2 weeks later. Urine was collected for 24 h and assayed for mercapturic acid conjugate. There was no significant difference in mercapturic acid excretion when the two measurements were compared. If the toxic intermediate hypothesis is correct, either the effect of alcohol is prolonged, or additional factor other than alcohol exposure may influence mercapturic acid excretion.

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