563 - Alcohol Use Disorder Screen, Salpingectomy, Tolerations 2
From JAMA’s Rational Clinical Examination Series
1) How to Best Screen for Alcohol Use Disorder
Screening for risky alcohol drinking, and brief counseling intervention if positive, has been recommended by the US Preventive Services Task Force (USPSTF) consistently since 1996. In medical school, most of us learned the CAGE questions (Have your tried to cut down drinking? Are you annoyed by people asking about your drinking? Have you felt guilty about your drinking? Do you ever drink alcohol as an eye-opener?), but these ask mainly about alcoholism, or more severe alcohol use disorder (AUD). But the concept of “unhealthy alcohol use” is broader, encompassing binge drinking and chronic drinking (“risky drinking”) above recommended levels in addition to alcoholism.
The USPSTF recommends using a broader approach to screening to prevent morbidity and mortality from the whole range of unhealthy alcohol use. The recommended brief screening methods included the Alcohol Use Disorder Identification Test – Consumption (AUDIT-C) and the Single Alcohol Use Question (SASQ). A recent entry in the Rational Clinical Examination Series looked at the diagnostic/screening utility of these questionnaires recently.
The authors completed a systematic review that searched comprehensively for diagnostic questions that detected both heavier than normal use as well as alcohol use disorder by DSM5 criteria. They found 35 studies which were generally of high quality. Most used the AUDIT or AUDIT-C, the National Institute of Alcohol Abuse and Alcoholism single item tool (which is basically the SASQ), and a few others screening tools. Diagnostic test characteristics for detecting alcohol use disorder (mild and greater) are presented below as likelihood ratios (LR) for positive (+) and negative (-) tests. As a reminder, LR+s are categorized as >10 (excellent), 5-10 (good), 2-5 (fair) and 1-2 (poor). LR-s are categorized as <0.1 (excellent), 0.1-0.2 (good), 0.2-0.5 (fair) and 0.5-1 (poor).
The NIAAA screener in adults works well for AUD in adults (LR+ 10, 95% confidence interval (CI) 6.7-16, LR- 0.09, 95%CI 0.03-0.26). The AUDIT-C has slightly less helpful characteristics (LR+ 1.9, 95%CI 1.7-2.2, LR- 0.37, 95%CI 0.32-0.43). Remember, the AUDIT-C looks mainly at amount of consumption of alcohol and is designed to screen for risky drinking also. The full AUDIT is a better at AUD diagnosis (LR+6.5, 95%CI 3.9-11, LR- 0.33, 95%CI 0.03-0.52), and is a necessary follow-on screening after a positive AUDIT-C to distinguish alcoholism from risky drinking. The T-ACE (tolerance, annoyed, cut-down, eye opener) worked very well in pregnancy, but not a lot better than the AUDIT.
John’s Comments:
It is sometimes hard to keep straight in the face of evidence like this that the full AUDIT and other measures like CAGE and T-ACE are used to diagnosed alcoholism/alcohol use disorder, whereas the “consumption”-related screeners like NIAAA/SASQ and AUDIT-C are meant to pick up any risky drinking to sort out later. In our recent research project on screening and managing unhealthy alcohol use, just getting clinicians to screen for risky drinking at all was an accomplishment. This important preventive screening commonly gets lost in all the other competing demands, but it’s a relatively easy, important screening, and patients do get better with our brief counseling. Try out the AUDIT-C or SASQ in your practice – it was surprising to our participants how big a problem this was for our patients.
Reference:
· Wood E, Pan J, Cui Z, et al. Does This Patient Have Alcohol Use Disorder?: The Rational Clinical Examination Systematic Review. JAMA. 2024;331(14):1215. Link
From the Literature
2) Opportunistic Salpingectomy for Ovarian Cancer Prevention
High-grade serous ovarian cancer (HGSOC) is the most common and most fatal form of ovarian cancer, affecting 1 in 70 females. No effective screening test is available for HGSOC, and patients often present in an advanced stage of disease. Around 70%–80% of deaths from ovarian cancer are caused by HGSOC. Research has shown that HGSOC originates in the fallopian tubes. As such, the practice of opportunistic salpingectomy (OS), which is the surgical removal of the fallopian tubes during benign gynecologic surgery (hysterectomy or instead of tubal ligation) while leaving the ovaries intact, has gained traction as a key strategy in reducing ovarian cancer risk.
First described in 2010, a growing body of evidence supports the practice of OS. Studies have highlighted the potential for OS to reduce ovarian cancer risk. A population-based cohort has shown OS can lower the risk of HGSOC in the general population by 65%. Studies have also shown no increase in surgical complications. Specifically, no significant increase has been found in operative time, blood transfusions, postoperative recover, readmissions, postoperative complications, infections, or fever compared with hysterectomy or tubal ligation.
Although OS offers the opportunity to significantly decrease the risk of ovarian cancer, it does not eliminate the risk entirely. Counseling women who are undergoing routine pelvic surgery about the risks and benefits of salpingectomy should include an informed consent discussion about the role of oophorectomy and bilateral salpingo-oophorectomy. Bilateral salpingo-oophorectomy that causes surgical menopause also reduces the risk of ovarian cancer but may increase the risk of cardiovascular disease, cancer other than ovarian cancer, osteoporosis, cognitive impairment, and all-cause mortality. Additionally, ovarian function does not appear to be affected by salpingectomy at the time of hysterectomy based on surrogate serum markers.
A 2019 Committee Opinion from the American College of Obstetrics and Gynecology emphasized that the risks and benefits of salpingectomy should be discussed with patients who desire permanent sterilization. It noted that plans to perform an opportunistic salpingectomy should not alter the intended route of hysterectomy and surgeons should continue to observe and practice minimally invasive techniques.
While OS shows promise, some challenges remain. Counseling patients effectively on the risks and benefits of salpingectomy requires a nuanced understanding of individual cancer risk, family planning desires, and surgical candidacy. Additionally, concerns about long-term ovarian function after salpingectomy have been raised, although current data suggest that the impact on ovarian reserve and hormonal function is minimal.
Mark’s Comments:
I had not heard of this until listening to a recent podcast. OS certainly seems a reasonable approach to help minimize risk for ovarian cancer, especially considering the potential benefits (including preservation of ovarian function) versus the low risk of additional complications. However, careful patient education and counseling is still important, including the fact that, unlike a tubal ligation, OS is not reversable.
References:
· ACOG Committee Opinion No. 774: Opportunistic Salpingectomy as a Strategy for Epithelial Ovarian Cancer Prevention. Obstet Gynecol April 2019;133(4):p e279-e284. Link
· Werger M et al. Opportunistic salpingectomy to decrease the risk of ovarian cancer. CMAJ June 10, 2024 196 (22) E765. Link
From PeerRxMed ( www.PeerRxMed.org )
3) Tolerations 2: Breaking Free from Them Before They Break You
"Your life does not get better by chance, it gets better by change." – Jim Rohn
Tolerations, the subtle annoyances we live with every day, are more than just minor inconveniences. These seemingly small stressors slowly chip away at our mental energy and focus. While acknowledging them is a start, the next step is learning how to systematically identify and resolve them. This follow-up to a recent blog will explore strategies for recognizing these energy drains and offer a practical solution for addressing them.
As previously shared, resolving a decade long toleration has led to an overwhelming sense of relief. But as I relished the clarity that came with addressing this, other things I’ve been tolerating have come into finer focus – the computer keys that regularly stick, the unread “I’ll get to later” e-mail, the passport that has needed to be renewed since January, and numerous others. This led to the realization that what I need is a system – a practical and sustainable approach to dealing with these recurring energy drains.
Indeed, as minor as they might seem, tolerations have a measurable impact on our mental well-being. In fact, research shows unfulfilled goals, unresolved stressors, or unaddressed conflicts, no matter how “small,” remain active in our subconscious, creating a cognitive load that drains mental resources. In healthcare, where quick thinking and mental clarity are paramount, these ongoing distractions can add unnecessary mental clutter, potentially leading to diminished job performance. The good news is that even addressing the smallest tolerations can improve both mental clarity and emotional resilience. In fact, achieving these small goals causes a release of dopamine (our brain’s "feel-good" chemical), which reinforces positive behavior and makes tackling bigger issues more manageable as well.
To begin the process of naming and eliminating these tolerations, consider performing regular “toleration audits.” This simple but highly effective strategy begins with systematically identifying all the small irritations, frustrations, or inefficiencies in your life and writing them down. Consider separating them into different areas of your life (work, home, relationships, finances, etc.) and make it your goal to list as many as you can (for fun, aim for 30 or more – trust me, they’re there). Once you have your list, prioritize each item and start with the smallest, easiest ones. The goal is to build momentum as well as increased awareness of places and patterns in your life where you are “settling” for less than what you desire.
Remember, the process of identifying and addressing tolerations is an ongoing journey, not a one-time fix. The good news is that even small actions can lead to big shifts in how we feel and function. This week, I challenge you to conduct your own “Toleration Audit.” Then, share what you’ve learned and your intentions for change with your PeerRx partner. Take time to laugh at some of the ridiculous things you’ve been tolerating and be sure to celebrate each small victory. By consistently addressing these energy drains, you’ll find greater focus, a heightened sense of accomplishment, and greater peace of mind. And we could all sure use more of that ….
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.
Mark and John
Carilion Clinic Department of Family and Community Medicine