1-6 ALCOHOLISM IN THE ELDERLY
This letter to the editor comments on an article on alcohol-related problems in older persons Archives Int. Med. 1996; 156: 1150-56. The correspondent reemphasizes that concurrent use of high-risk medications and alcohol is common in the elderly: NSAIDs, aspirin, sedative-hypnotics, antidepressants, antihypertensives, antacids, H-receptor antagonists, warfarin, and medications for congestive heart failure, gout, and diabetes.
Alcohol abuse is often misdiagnosed in the elderly. Physiologically it is not the same in the elderly as in the young. The volume of distribution of ethanol is smaller. Alcohol can affect hepatic drug metabolism by inhibiting drug oxidation and by stimulating hepatic enzymes. Alcohol further reduces hepatobiliary transport and hepatic glutathione levels.
Alcohol affects drug disposition in different ways, depending on whether use is acute or chronic:

• Reduces clearance of chlorodiazepoxide and diazepam.
• Increases (chronic use) clearance of phenytoin or decreases it (acute ingestion).
• Enhances hepatoxicity of acetaminophen.
• May prolong bleeding times and can aggravate chronic blood loss from the GI tract associated with NSAIDs.
• Potentiates effects of warfarin (acute use) and increases its clearance (chronic use).
• Increases half-life of tolbutamide.
• Can exaggerate hypoglycemia by affecting gluconeogenesis.
• Potentiates adverse effects of antidepressants.
• Heightens CNS effects of benzodiazepines.
• Affects barbiturate metabolism, decreasing half life and increasing clearance.
• Increases CNS effects of some antihistamines.
• Increases extrapyramidal effects of phenothiazines.
• Phenothiazines and cimetidine can decrease metabolism of alcohol and increase blood levels.
• Alcohol (acute use) decreases clearance of opiates.

Archives Int. Med. January 27, 1996; 157: 242-43 letter to the editor from a Pharm D in Somerset, NJ

Comment:

Alcohol use and abuse is common in the elderly. All patients should be screened. In the elderly relatively low levels of alcohol use alone, or in combination with medications can be harmful.
I would not expect to remember all these details. As a general rule, alcohol use with any medication can be assumed to be potentially harmful. RTJ

1-7 FAILURE OF COOKING TO PREVENT SHELLFISH-ASSOCIATED VIRAL GASTROENTERITIS
Outbreaks of Norwalk-like viral gastroenteritis associated with eating shellfish have been reported with increasing frequency. Most have occurred among persons who ate shellfish raw.
Shell fish can also transmit hepatitis A, shigella, Vibrio cholerae, Vibrio vulnificus, and salmonella. Aside from ecological control of waters, the mainstay of prevention has been tracing and recall of contaminated oysters and education of consumers about risks of eating raw shellfish and the importance of adequate cooking. This study asks: What is the true protective effect of cooking?
Conclusion: Oyster eaters who reported eating only thoroughly cooked oysters were as likely to become ill as those who ate raw oysters.

STUDY

1. Describes the largest outbreak of oyster-associated gastroenteritis ever reported. (Florida-1995.)
2. Interviewed persons from 38 gatherings where illness was reported. Traced oysters by means of tags and dealer records. Measured water quality in harvest areas. Examined stools for small round structured viruses by electron microscopy.

RESULTS

1. Of over 200 oyster eaters, 58% became ill.
2. Most oyster eaters ate only cooked (grilled, fried, or stewed) oysters.
3. Those reporting eating only thoroughly cooked oysters were as likely to become ill as those who ate raw oysters.
4. Small round structured viruses were identified in stools of 9 persons.
5. Results of water quality tests for fecal coliforms were within acceptable limits.

DISCUSSION

1. Findings of high attack rates in persons who ate cooked oysters and the lack of appreciable protective effect of thorough cooking have important implications for shell fish eaters. This reemphasize the importance of avoiding initial contamination of oysters in their beds.
2. This outbreak demonstrates that oysters cooked to the point where oyster eaters consider them done or overdone are able to transmit enough virus to cause disease in a substantial proportion of people. It is possible that the level of cooking that would be required to inactivate small round structured viruses might render the oysters unpalatable to consumers.
3. Guidelines for safe cooking of shellfish have focused on reducing the risk of bacterial illness. But hepatitis and poliovirus (which are more heat sensitive than small round structured viruses) demonstrate a remarkable ability to persist. After 30 minutes of steaming, when the internal temperature of oysters reached 940 C, 7% of experimentally inoculated poliovirus was still viable. Even a small amount of virus remaining could be clinically significant.
4. "Our investigation again demonstrates the inadequacy of fecal coliform monitoring to define water quality."
5. Once in shellfish, viruses can survive for periods of weeks even when the shellfish are properly handled.
6. However, information about potential risks of eating oysters is unlikely to deter most oyster eaters.

CONCLUSION

"Our findings of acceptable water quality measures for fecal contamination and the lack of appreciable protective effect from cooking leave the consumer with no assurance of safety."

Archives Int. Med. January 13, 1997; 157: 111-16 Original investigation, first author from Center for Disease Control, Atlanta, GA

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