Alcohol consumption among victims of external causes in a university general hospital

OBJECTIVE: To estimate frequency of alcohol consumption among victims of external causes cared for in a hospital. METHODS: Study performed with victims cared for in a university general hospital in the city of Uberlândia (Southeastern Brazil), between February and August 2004. Blood alcohol content was determined from 85 patients in the emergency room. Other 301 patients, hospitalized in the outpatient clinics, were interviewed about possible alcohol consumption prior to trauma. The Cut-down, Annoyed by criticism, Guilty and Eye-opener (CAGE) questionnaire was applied in both groups. Fisher’s exact test was employed to compare frequencies. RESULTS: Blood alcohol content was positive among 31.8% of patients tested, who most frequently required hospitalization (70.4% versus 37.9%; p<0.05). Proportionately, positive blood alcohol content was more frequent (p<0.05) among victims of physical aggression (57.1%) than fall victims (18.2%) or those of traffi c accidents (29.3%). In outpatient clinics, 29.9% of patients mentioned alcohol consumption, proportionately more frequent (p<0.01) among victims of physical aggression (67.4%) than traffi c accident victims (27.8%) or fall victims (19.3%). Among those who had drunk alcohol and were approached in the emergency room or in the outpatient clinics, the following was observed: the majority was male (85.2% and 80.4%), the occurrence of trauma was higher (p<0.05) on weekends (63% and 57.8%) and at night (59.3% and 57.8%), and the CAGE questionnaire was positive among 81.5% and 82.2% of them. CONCLUSIONS: About a third of patients had drunk alcoholic beverages prior to trauma and the majority of them were male. Proportionately, previous alcohol consumption was more frequent among patients who were victims of violence. CAGE results show that most patients, victims of external causes after alcohol consumption, were not occasional drinkers, but probably chronic users or alcoholics. DESCRIPTORS: Alcohol Drinking. Alcoholic Intoxication. Aggression. Accidents, Traffi c. Accidental Falls. External Causes.


INTRODUCTION
The abusive use of alcoholic beverages is an important public health problem in many countries.In Brazil, two national surveys estimated that between 9% a and 12.3% 3 of the population is dependent on alcohol, 74.6% have already consumed it some time in their lives (80.4% in Southeastern Brazil), 3 29% are occasional drinkers and do not drink heavily, and 24% drink heavily and regularly.a Several factors may lead to an increase in alcohol consumption in the a Laranjeira R, Pinsky I, Zaleski M, Caetano R. I levantamento nacional sobre os padrões de consumo de álcool na população brasileira [internet] Brasília: Secretaria Nacional Antidrogas; 2007 [cited 2008 Aug 3].Available from: http://www.senad.gov.br/relatorio_padroes_consumo_alcool.pdfpopulation, such as easy access, low cost and marketing. 2In addition, alcohol drinking is socially acceptable, sometimes even in amounts considered abusive, it is used as a way to facilitate inter-personal relationships and establish social bonds, and it may also be part of the code of politeness in several contexts. 17usive and/or inadequate consumption of this substance can lead to serious organic, psychological and social consequences.Among these are the occurrences of injuries from external causes, especially accidents or violence, described by the "Política Nacional de Redução da Morbi-mortalidade por Acidentes e Violência" (National Policy on the Reduction of Morbimortality from Accidents and Violence) as the group of occurrences that causes death or health problems and require care in health services.Accident is viewed as the "unintentional and avoidable event, which causes physical and/or emotional injuries", and violence as the "event represented by actions performed by individuals, groups, nations or classes that cause physical, emotional, moral and/or spiritual harm to oneself or to others".a A multicenter study with victims of non-fatal external causes involving 10 countries revealed that 18.1% of these victims had consumed alcoholic beverages during the six hours that preceded the event; the lowest frequency was found in Canada (6%) and the highest in New Zealand (38.5%). 1 In Europe, alcohol is believed to be associated with 40-60% of unintentional injury cases and those of violence. 22Some studies have been performed in Brazil to assess the relationship between alcohol abuse and the occurrences of external causes, usually in metropolitan areas or state capitals.In the city of São Paulo, Southeastern Brazil, positive blood alcohol content (BAC) was observed among 11% of patients, victims of non-fatal traumas, who were cared for in an emergency room; 21 among 28.9% of patients cared for in a trauma care center, victims of transportation accidents, falls, aggressions and others; 11 and among approximately 50% of fatal victims of external causes in 1994. 4coholic beverage abuse has an important impact on violence rates.In the city of São Paulo, 42.5% of homicide victims, submitted to a toxicology test, had consumed alcohol, 10 and in the city of Curitiba, Southern Brazil, 50.2% of victims of interpersonal aggression by fi rearm or bladed weapon, cared for in an emergency room, were under the infl uence of alcohol. 12e present study aimed to estimate the frequency of prior alcoholic beverage consumption among victims of injuries from external causes cared for in a hospital.

METHODS
The study was performed in a regional reference university general hospital, which is in partnership with the Sistema Único de Saúde -SUS (Unifi ed Health System), in the city of Uberlândia, located in a countryside of Southeastern Brazil, between February and August 2004.The population was 600,369 inhabitants, as estimated by the Instituto Brasileiro de Geografi a e Estatística -IBGE (Brazilian Institute of Geography and Statistics) for 2006, with a substantial urban expansion.According to data from the Brazilian Ministry of Health, in 2005, a total of R$ 4,605,089.59were spent on 3,494 hospitalizations due to external causes.
Patients included in this study were victims of injuries from external causes, aged 18 or older, and cared for in the emergency room or hospitalized in the surgery or trauma outpatient clinics.
A total of 85 patients were assessed in the emergency room upon admission.They were interviewed with a questionnaire about their socioeconomic conditions and characteristics, such as sex, age, level of education, marital status, family income and information related to the event that led them to seek a hospital.The Cutdown, Annoyed by criticism, Guilty and Eye-opener (CAGE) questionnaire was also applied to each patient to diagnose chronic abuse of or dependence on alcohol.CAGE was positive when two or more affi rmative responses were given to its four questions. 9Blood samples were subsequently collected from each patient who agreed to participate in the study to have their BAC determined.In addition, the progress of each case was assessed: discharge, hospitalization or death.
Interviews were conducted by authors in 6-hour day shifts, from 6:30am to 12:30pm, or from 12:30pm to 6:30pm, and 12-hour night shifts, that is, from 6:30pm to 6:30am.The day and night shifts were performed every other day and, after a random choice, the fi rst shift fell on a Tuesday morning.The weekend was the period between 6:00pm on Friday and 6:00am on Monday.
Blood samples were collected in glass tubes with separating gel and, after centrifugation, the serum was stored at -20°C.The TDx/TDxFLx-Ethanol reagent kit (Abbott, Abbott Park, IL, USA) was used to determine BAC; samples were considered positive when BAC was equal to or above 0.1 g/l of blood, in accordance with the maker's recommendations.To maintain patient confi dentiality, the samples, as well as the interviews, were only identifi ed with cardinal numbers.A total of 301 patients, hospitalized due to injuries from external causes, were consecutively assessed in the general surgery or trauma outpatient clinics.Those who had already been interviewed in the emergency room were excluded and none of the patients approached refused to participate in the study.Patients were asked: about their socioeconomic conditions, about the trauma that led to their hospitalization, and whether they had a history of alcohol use prior to this event.The CAGE questionnaire was also applied to all patients studied.History of alcoholic beverage use was positive when one reported consuming at least one beer bottle (660ml) or two shots of distilled spirits (100ml) (whiskey, vodka, or cachaça, a type of Brazilian distilled spirit), equivalent to 25g and 32g of ethanol, respectively, 18 until six hours before trauma.Consumption of approximately 44g produces concentrations between 0.4g/l and 0.9g/l of blood, depending on the type of drink and previous consumption of food or not. 19tients under 18 years of age were not included in the study.Other two patients were also excluded in the emergency room, once they had orotracheal intubation and were not accompanied, thus unable to communicate, and three others who did not agree to participate.The doctor in charge of the patient was the one responsible for diagnosing the type of injury of external cause.
The chi-square test or Fisher's exact test were employed to compare the frequencies analyzed, and p<0.05 was considered signifi cant.This project was approved by the institutional research ethics committee.An informed consent form was signed by each patient or family member for their participation.

RESULTS
Table 1 shows data from the 85 patients assessed in the emergency room: 67 (78.8%) were male and 18 (21.2%)were female, with a mean age and standard deviation (SD) of 34.8±13.1; the predominant age group was from 18 to 25 years (30.6%).The majority of patients had completed up to elementary school (62.4%), were not married (62.3%), and had a monthly income of up to three minimum wages (77.6%).The most frequent type of external cause was traffi c accident (68.2%), followed by physical aggression (16.5%), falls (12.9%) and others (2.4%).
BAC was positive among 27 patients (31.8%), of which 24 (28.2%) had more than 0.6g/l.The predominant age group was between 31 and 40 years (37%), most of which were male (85.2%) and not married (63%), had completed up to elementary school (81.5%), and whose monthly income was up to three minimum wages (96.3%).The frequency of patients who had completed high-school or university, or with a family income above three minimum wages was higher (p<0.05)among negative BAC patients (31.8% and 21.2%, respectively) than those with positive BAC (5.9% and 1.2%, respectively).The frequency of positive BAC was, proportionately, similar among men (34.3%) and women (22.2%), and among those who were married (32.1%) and not married (31.2%).
Positive BAC was proportionately more frequent (p<0.05)among victims of physical aggression (57.1%) than those of fall (18.2%),and also tended (p>0.05) to be more frequent than those of traffi c accidents (29.3%) (Table 3).
Among positive BAC patients, the most frequent types of injuries were the cut-contusion injuries (30.2%) and fractures (25.6%); head trauma was observed among 34.5% and the only case of amputation (left lower limb) was found among these.In addition, the frequency of accidents on weekends (63%; p<0.01) and at night (59.3%; p<0.05) was higher among positive BAC patients than those with negative BAC, where accidents happened more frequently during the day (62.1%), on weekdays (70.7%).
The frequency of high-school or university levels and family income above three minimum wages were higher (p<0.01) in the subgroup of negative CAGE patients (29.4%) than those with positive CAGE (8.2%).Among positive CAGE patients, the type of external cause that was proportionately more frequent (p<0.05) was physical aggression (64.3%) in relation to traffi c accidents (34.5%); there were no signifi cant differences between the frequencies of fall (63.6%)and aggression, or between fall and traffi c accidents (  Of all the 301 patients hospitalized in the outpatient clinics because of injuries from external causes, the majority were male (80.4%), had completed up to elementary school (72.8%), had a monthly family income of up to three minimum wages (62.8%), but with none of the age groups assessed predominating (Table 2).Among all these patients, 90 (29.9%) reported alcohol consumption before trauma, and the minimum amount consumed was two beer bottles of 660ml and two shots of distilled spirits.Of all patients who reported alcohol consumption, the majority (93.3%) were male (p<0.01) and not married (55.4%), had completed elementary school (81.1%), and had a family income of up to three minimum wages (63.3%).The frequency of high-school and university levels was higher (p<0.05)among patients who reported no alcohol consumption (30.8%) than those who reported positively (18.9%).Proportionately, alcoholic consumption was more frequent (p<0.01)among victims of physical aggression (67.4%) than those of traffi c accident (27.8%) or falls (19.3%).(Table 3) Spinal cord injuries or head trauma were more frequent (p<0.05)among patients who reported alcoholic consumption (66.6% and 37.6%, respectively) than those with negative history (33.3% and 10.9%, respectively).
Among patients who reported previous alcoholic consumption, the frequency of accidents on weekends (57.8%; p<0.01) and at night (57.8%; p<0.05) was higher than among those who reported no alcoholic consumption, when the majority of accidents occurred during the day (69.2%) and on weekdays (64%).

DISCUSSION
Despite the different assessment methods employed to diagnose alcoholic consumption among victims of external causes in outpatient clinics and emergency rooms, the results obtained were comparable.The frequency of positive BAC observed in the emergency room was similar to that found among victims of external causes admitted to an urban trauma care center in the city of São Paulo (28.9%). 11However, a higher frequency was observed among fatal victims of external causes, also in the metropolitan area of São Paulo (48.3%). 4he BAC frequencies above 0.6g/l found in this study were comparable to those observed in an emergency hospital in the city of Porto Alegre, Southern Brazil, where BAC above 0.8g/l was observed among 24.5% of victims of traffi c accidents. 5Lower frequency of alcoholic consumption (18.9%) was observed among victims of external causes in an emergency room in the city of Curitiba, when clinical evidence and reports of alcohol consumption were used for diagnosis. 12gh frequency of serum levels above 0.6g/l was observed among positive BAC patients in this study; BACs from 0.5g/l may cause lack of motor coordination, mood swings, and changes in behavior and personality, and may compromise routine activities.These manifestations can intensify with the increase in serum concentration of ethanol, 16,19 predisposing one to accidents or violence.
There was higher prevalence of positive BAC, as well as of the history of alcoholic consumption prior to trauma, among those who were male, not married and with low levels of education and family income.This same patients' profi le was observed in studies performed in other Brazilian cities.In these studies, people involved in accidents, including those resulting from alcohol consumption, are usually male 10,11,13,15 and in the economically active age group, and have low level of education. 11A national survey revealed that men are three times more exposed to physical risks under the effect of alcohol than women. 3Another study showed that the frequency of drinking and driving was 7.4 times higher among men than women.a The predominance of individuals with low levels of education and family income, as observed in this study, may also be related to the fact that the hospital where the study was performed is a local and regional reference service for the public health care network, serving the portion of the population that does not have access to any other type of health care.
Positive BAC, history of alcohol consumption prior to trauma, or positive CAGE was proportionately more frequent among patients who are victims of aggression.This observation shows that people under the infl uence of alcohol and/or chronic drinkers are more predisposed to violence.These results are comparable to those observed in a study performed in the city of São Paulo, which revealed higher frequency of positive BAC among victims of aggression (46.2%) than among those of transportation accidents (24.2%) or of fall (20.2%). 11Other studies also revealed high frequencies of alcohol consumption among victims of violence: in the city of São Paulo, positive BAC was found among 42.5% of homicide victims in the second semester of 2001 10 and among 52.3% of homicide victims in 1994. 4In the city of Curitiba, 50.2% of victims of interpersonal aggression by fi rearms or bladed weapons were under the infl uence of alcohol, 12 based on clinical evidence (alcohol breath, agitation, and lack of motor coordination) and on patients' reports.Moreover, in the city of Belo Horizonte, Southeastern Brazil, among the 207 victims of trauma caused by bladed weapons who were cared for in an emergency room, 59.4% had consumed alcoholic beverages. 14e CAGE questionnaire has good sensitivity and specifi city to detect chronic alcoholism when used in the emergency room. 20Among patients with positive BAC and those with positive history of alcoholic consumption prior to trauma, 81.5% and 82.2%, respectively, revealed a positive CAGE questionnaire.This shows that the majority of patients, victims of external causes after alcohol use, were not occasional drinkers, but probably chronic drinkers or alcohol-dependent.
The methodology used in this study did not track the harmful use of alcoholic beverages among patients assessed, thus constituting a limitation.
A multicenter study, involving seven cities in Latin America (Salvador and Rio de Janeiro, in Brazil) and Madrid, in Spain, revealed that people who are most frequently victimized by urban violence are male and younger, and consume alcohol. 6One example of how alcohol abuse can increase the frequency of violence was observed in the city of Diadema, Southeastern Brazil, which was considered, in 1999, one of the cities with highest homicide rates in Brazil.After the implementation of Alcohol Prohibition (also known as "Dry Law"), which established that bars in that city should be closed by 11:00pm, a reduction of 44% in homicide rates was recorded. 8This can be justifi ed by the fact that loss of self-control and release of aggressive impulses are among the effects of alcohol in the central nervous system, thus posing risk to the physical integrity of the individual and those around him. 19e highest frequency of need for hospitalization among positive BAC patients, cared for in the emergency room, shows that accidents involving people under the infl uence of alcohol tend to be more serious.This fact has already been described by, at least, two other studies, one from Brazil, performed in the city of São Paulo, 11 and the other one from Los Angeles, US. 7 The predominance of the head (skull and face) as the most affected body part among positive BAC patients or those with history of alcohol consumption prior to trauma may be associated, at least in part, with the proportionately higher frequency of physical aggression observed among them.Victims of physical aggression and/or homicides show many head injuries. 10The highest frequency of spinal cord injuries among those with positive history of alcohol use prior to trauma also shows the severity of trauma is potentially greater among people who are under the infl uence of alcohol.
Among positive BAC patients, as well as among those with previous history of alcohol consumption, the highest frequency of accidents occurred on weekends and at night, comparable to fi ndings from other studa Laranjeira R, Pinsky I, Zaleski M, Caetano R. I levantamento nacional sobre os padrões de consumo de álcool na população brasileira [internet] Brasília: Secretaria Nacional Antidrogas; 2007 [cited 2008 Aug 3].Available from: http://www.senad.gov.br/relatorio_padroes_consumo_alcool.pdfies. 5,10,11This is probably due to the fact that informal get-togethers with alcoholic beverage consumption are more frequent during these periods.
In conclusion, among patients victims of external causes, about one third consumed alcoholic beverages prior to trauma, the majority were chronic drinkers, male, young, and had low level of education and family income.The most frequent external cause was traffi c accidents.Proportionately, previous consumption of alcoholic beverages was more usual among patients victims of violence.Victims with positive BAC showed injuries with greater severity more frequently.The occurrence of accidents associated with previous alcohol consumption was more usual on weekends and at night.

Table 1 .
Characteristics of patients cared for in the emergency room, according to BAC positivity and CAGE questionnaire.

Table 3
In terms of the patients' progress after care in the emergency room, the frequency of need for hospitalization was higher (p<0.05)among positive BAC patients (19/27; 70.4%) than among those with negative BAC (22/58; 37.9%), and none of the patients assessed died.

Table 3 .
Type of occurrence of external cause among patients cared for in the emergency room and surgery and trauma outpatient clinics, according to BAC positivity, alcohol consumption and CAGE questionnaire results.
CAGE: Cut-down, Annoyed by criticism, Guilty and Eye-opener BAC: blood alcohol content