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Caputo F, Penitenti F, Bergonzoni B, Lungaro L, Costanzini A, Caio G, DE Giorgio R, Ambrosio MR, Zoli G, Testino G. Alcohol use disorders and liver fibrosis: an update. Minerva Med 2024; 115:354-363. [PMID: 38727709 DOI: 10.23736/s0026-4806.24.09203-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Alcoholic liver disease (ALD) is currently, worldwide, the second most common cause of human fatalities every year. Alcohol use disorders (AUDs) lead to 80% of hepatotoxic deaths, and about 40% of cases of cirrhosis are alcohol-related. An acceptable daily intake (ADI) of ethanol is hard to establish and studies somewhat controversially recommend a variety of dosages of ADI, whilst others regard any intake as dangerous. Steatohepatitis should be viewed as "the rate limiting step": generally, it can be overcome by abstinence, although in some patients, abstinence has little effect, with the risk of fibrosis, leading in some cases to hepatocellular carcinoma (HCC). Chronic alcoholism can also cause hypercortisolism, specifically pseudo-Cushing Syndrome, whose diagnosis is challenging. If fibrosis is spotted early, patients may be enrolled in detoxification programs to achieve abstinence. Treatment drugs include silybin, metadoxine and adenosyl methionine. Nutrition and the proper use of micronutrients are important, albeit often overlooked in ALD treatment. Other drugs, with promising antifibrotic effects, are now being studied. This review deals with the clinical and pathogenetic aspects of alcohol-related liver fibrosis and suggests possible future strategies to prevent cirrhosis.
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Affiliation(s)
- Fabio Caputo
- Center for the Study and Treatment of Alcohol-Related Diseases, Department of Translational Medicine, University of Ferrara, Ferrara, Italy -
- Department of Internal Medicine, SS. Annunziata Hospital, University of Ferrara, Cento, Ferrara, Italy -
| | - Francesco Penitenti
- Section of Endocrinology, Internal Medicine and Geriatrics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Barbara Bergonzoni
- Department of Internal Medicine, SS. Annunziata Hospital, University of Ferrara, Cento, Ferrara, Italy
| | - Lisa Lungaro
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Anna Costanzini
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Giacomo Caio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Roberto DE Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Maria R Ambrosio
- Section of Endocrinology, Internal Medicine and Geriatrics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Giorgio Zoli
- Center for the Study and Treatment of Alcohol-Related Diseases, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Internal Medicine, SS. Annunziata Hospital, University of Ferrara, Cento, Ferrara, Italy
| | - Gianni Testino
- Unit of Addiction and Hepatology, ASL3, San Martino Polyclinic Hospital, Genoa, Italy
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Hagan SR, Crilly J, Ranse J. The Impact of Alcohol-Related Presentations to Emergency Departments on Days with a Public Holiday or Sporting Event: A Retrospective Cohort Study. Prehosp Disaster Med 2024:1-7. [PMID: 38693885 DOI: 10.1017/s1049023x24000232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
INTRODUCTION The consumption of alcohol within the Australian community continues to rise, impacting care delivery in already over-burdened emergency departments (EDs). STUDY OBJECTIVE This study aimed to examine the impact of alcohol-related presentations (ARPs) to EDs on days with a public holiday or sporting event. METHODS A retrospective cohort study was undertaken using routinely collected health data pertaining to patient presentations diagnosed with an alcohol-related disorder (ICD-10-AM code F10) to two EDs in Queensland, Australia from January 1, 2016 - December 31, 2020. Descriptive and inferential statistics were used to describe and compare ARPs on event days versus non-event days and uncomplicated versus other ARPs on event days only. RESULTS Of all 5,792 ARPs, nine percent (n = 529) occurred on public holidays or sporting event days. When compared by day type, type of presentation, mode of arrival, and day of week differed between event and non-event days. On event days, uncomplicated ARPs differed to other ARPs, with uncomplicated ARPs being younger, having shorter median length-of-stay (LOS), and less likely to be admitted to hospital. CONCLUSIONS In this multi-site study, public holidays and sporting events had a noteworthy impact on ARPs to EDs. Focused refinement on the clinical management of uncomplicated ARPs is warranted to inform future resource allocation, including on event days.
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Affiliation(s)
- Stephanie Rae Hagan
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
- Department of Emergency Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Julia Crilly
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
- Department of Emergency Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Jamie Ranse
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia
- Department of Emergency Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
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3
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Qu L, Ma XP, Simayi A, Wang XL, Xu GP. Comparative efficacy of various pharmacologic treatments for alcohol withdrawal syndrome: a systematic review and network meta-analysis. Int Clin Psychopharmacol 2024; 39:148-162. [PMID: 38170803 DOI: 10.1097/yic.0000000000000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
This study was to compare multiple classes of medications and medication combinations to find alternatives or additives for patients not applicable to benzodiazepines (BZDs). We performed a network meta-analysis to assess the comparative effect of 11 pharmacologic treatments in patients with alcohol withdrawal syndrome. Forty-one studies were included, comprising a total sample size of 4187 participants. The pooled results from the randomized controlled trials showed that there was no significant difference in the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) reduction with other medications or medication combinations compared to BZDs. Compared to BZDs, the mean difference in ICU length of stay of anticonvulsants + BZDs was -1.71 days (95% CI = -2.82, -0.59). Efficacy rankings from cohort studies showed that anticonvulsant + BZDs were superior to other treatments in reducing CIWA-Ar scores and reducing the length of stay in the ICU. Synthesis results from randomized controlled trials indicate that there are currently no data suggesting that other medications or medication combinations can fully replace BZDs. However, synthetic results from observational studies have shown that BZDs are effective in the context of adjuvant anticonvulsant therapy, particularly with early use of gabapentin in combination with BZDs in the treatment of alcohol withdrawal syndrome, which represents a promising treatment option.
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Affiliation(s)
- Li Qu
- Department of Anesthesia, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, China
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Watanabe M, Atagi N, Makino Y, Kooguchi K, Ohta B. Acute alcohol intoxication presenting acquired lesion of the corpus callosum in a young healthy woman: A case of possible Marchiafava-Bignami disease. Acute Med Surg 2024; 11:e960. [PMID: 38699411 PMCID: PMC11063720 DOI: 10.1002/ams2.960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 05/05/2024] Open
Abstract
Background Marchiafava-Bignami disease is a rare neurological disease characterized by acquired lesions of the corpus callosum. Although the major causative etiology is chronic alcoholism, a case caused by acute alcohol intoxication has not yet been reported. Case Presentation A 19-year-old female with no known medical history or a history of chronic alcohol consumption was brought to the emergency department in a coma after binge alcohol consumption. Even after an overnight observation, she remained comatose. After a thorough examination including magnetic resonance imaging, which showed lesions of the corpus callosum, she was treated with thiamine for Marchiafava-Bignami disease. She recovered completely and at the follow-up, the callosum lesion had resolved. Conclusion This is a rare case within the spectrum of Marchiafava-Bignami disease caused by acute consumption of alcohol. Clinicians should be aware of this potentially devastating critical condition among patients with severe alcohol intoxication, which might have been overlooked.
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Affiliation(s)
- Makoto Watanabe
- Department of Emergency MedicineKyoto Prefectural University of MedicineKyotoJapan
| | - Nobuhito Atagi
- Department of Emergency MedicineKyoto Prefectural University of MedicineKyotoJapan
| | - Yosuke Makino
- Department of Emergency MedicineKyoto Prefectural University of MedicineKyotoJapan
| | - Kunihiko Kooguchi
- Department of Critical Care MedicineKyoto Prefectural University of MedicineKyotoJapan
| | - Bon Ohta
- Department of Emergency MedicineKyoto Prefectural University of MedicineKyotoJapan
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Balbinot P, Pellicano R, Testino G. Burden of caregiving of alcohol related liver disease patients: a possible role of training and caregiver groups frequency. Proposal of a method, preliminary results. Minerva Gastroenterol (Torino) 2023; 69:486-493. [PMID: 36255285 DOI: 10.23736/s2724-5985.22.03288-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND The patient with alcohol related liver disease (ALD) is an extremely complex patient who can be affected by various problems: alcohol use disorders (AUDs) (intoxication or withdrawal syndrome), psychopathological manifestations, hepatic encephalopathy (HE), family and social discomfort. Burden of caregiving for this type of patient is particularly severe. For this reason we propose our own working model. METHODS Thirty-one informal caregivers (ICs) of patients with ALD (28 females; mean age: 51±11) recruited in the period September-November 2021 followed prospectively were evaluated retrospectively. Those who completed all the steps (initial information/ training meeting), participation in support groups for caregivers and participation in self-help groups for AUD (club of alcoholics in treatment, anonymous family members, other realities) were selected (31/71: 43%). ICs underwent Zarit Burden Interview and a semi-structured interview. RESULTS From the semi-structured interview, emotional, organizational, but also constructive reflections emerge. Zarit Score (ZS) was found to be light or nil in the 13% (4/31), moderate in the 22.5% (7/31), severe in the 32% (10/31) and very serious in the 32% (10/31). The parameters that most influenced initial ZS are the presence of HE and primitive psychiatric comorbidity (PC). By dividing the caregivers into two groups (40) odds ratio is 2.4231 (95% CI: 0.4059-14.4637) in the presence of HE and odds ratio is 5.3846 (95% CI: 0.5666 to 51.1738) in the presence of PC. After the frequency to the caregiver groups (CGs) (at least 4) the ZS is significantly decreased (49.9±18 vs. 34±11; t=4.1966; P<0.0001) and this regardless of the presence of HE, PC or active alcohol consumption. CONCLUSIONS While waiting to increase the number of cases and to submit it to a more in-depth verification, we suggest to other health organizations to use and verify this organizational/ relational method for primary ICs, in an attempt to optimize the health and social health activity in a complex medical sector (ALD) in constant growth.
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Affiliation(s)
- Patrizia Balbinot
- Unit of Addiction and Hepatology/Alcohological Regional Centre, ASL3 Liguria, Polyclinic San Martino Hospital, Genoa, Italy
- Centro Studi Mutual-self-help, Community Programs and Caregiver Training, ASL3 Liguria, Genoa, Italy
| | | | - Gianni Testino
- Unit of Addiction and Hepatology/Alcohological Regional Centre, ASL3 Liguria, Polyclinic San Martino Hospital, Genoa, Italy
- Centro Studi Mutual-self-help, Community Programs and Caregiver Training, ASL3 Liguria, Genoa, Italy
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Testino G, Bottaro LC, Andorno E, Bandini F, Balbinot P, Beltramini S, Bottino S, Caltabellotta M, Caputo F, Caviglia E, Curone P, DI Biagio A, Gagliano C, Gandolfo N, Pestarino L, Rollero A, Romairone E, Sampietro L, Torre E, Zuccarelli S, Pellicano R. Hepatic encephalophathy: management and diagnostic therapeutic assistance path of Ligurian Local Health Company 3 (ASL3). Minerva Med 2023; 114:698-718. [PMID: 36952221 DOI: 10.23736/s0026-4806.22.08408-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Hepatic encephalophathy (HE) is a neuropsychiatric syndrome with a prevalence in the cirrhotic population ranging from 20 to 80%. HE is a cause of inappropriate hospitalization, caregiver burdening and increased social costs. There is need to create dedicated care pathways to better manage patients and support family caregivers. The data used for the preparation of this diagnostic therapeutic assistance path (DTAP) are based on a detailed analysis of the scientific literature published before June 30, 2022 (PubMed, Web of Science, Scopus, Google Scholar). Furthermore, in the process of developing this work, we consulted in particular the guidelines/ position papers of International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN), Italian Association for the Study of the Liver (AISF), European Association for the Study of the Liver (EASL), American Association for the Study of Liver Diseases (AASLD), Italian Society on Alcohol (Società Italiana di Alcologia [SIA]) and other relevant papers. DTAP was created based on the most recent recommendations of the international scientific literature. The present DTAP highlight the need for a multidisciplinary activity integrated with territorial medicine in close connection with caregivers. This guarantees improved therapeutic adherence, hospital readmission reduction, improved quality of life for patients and caregivers and a significant reduction in costs.
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Affiliation(s)
- Gianni Testino
- Addiction and Hepatology Unit/Alcohological Regional Centre and Study Centre "Self Help, Community Program and Caregiver Training" ASL3, Genoa, Italy -
| | | | - Enzo Andorno
- Liver Transplantation Unit, San Martino Polyclinic Hospital, Genoa, Italy
| | | | - Patrizia Balbinot
- Addiction and Hepatology Unit/Alcohological Regional Centre and Study Centre "Self Help, Community Program and Caregiver Training" ASL3, Genoa, Italy
| | | | | | | | - Fabio Caputo
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Center for the Study and Treatment of Chronic Inflammatory Intestinal Diseases (IBD) and Gastroenterological Manifestations of Rare Diseases, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Center for the Study and Treatment of Alcohol-Related Diseases, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Internal Medicine, Santissima Annunziata Hospital, University of Ferrara, Ferrara, Italy
| | | | | | - Antonio DI Biagio
- Department of Health Sciences, Infectious Diseases Clinic, IRCCS San Martino Polyclinic Hospital, University of Genoa, Genoa, Italy
| | | | | | | | | | | | | | - Enrico Torre
- Unit of Endocrinology, Metabolic Diseases and Diabetology, ASL3 Liguria, Genoa, Italy
| | | | - Rinaldo Pellicano
- Unit of Gastroenterology, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
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Mayer M, Masoud A. Blood Alcohol Level as a Predictor of Withdrawal Severity. Cureus 2023; 15:e44463. [PMID: 37791217 PMCID: PMC10544183 DOI: 10.7759/cureus.44463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Few studies have explored the correlation between the severity of alcohol withdrawal and blood alcohol level at the time of admission. Specifying prognostic factors for life-threatening withdrawal necessitating inpatient pharmacologic management over the course of days would be useful to identify at-risk patients at the time of admission. Hence, we present the case of a 34-year-old Caucasian male with a past medical history of poly-substance abuse who has presented to our emergency department 11 times over the past four years with a mean blood alcohol level (BAL) of 287 mg/dL upon withdrawal. BAL at the time of withdrawal is highly variable depending on the chronicity of abuse; however, a BAL this elevated is highly unusual and indicative of severe and long-term use. While in the unit at this admission, the patient's BAL was 437 and his withdrawal symptoms were severe, necessitating ICU admission and strong sedating medications to control his symptoms. Even after these interventions, he still demonstrated severe withdrawal symptoms including full body tremors, vital sign instability, and continuous visual, auditory, and tactile hallucinations. This patient presents an interesting case of severe alcohol withdrawal at an abnormally elevated blood alcohol level progressing to a prolonged withdrawal course in the ICU. Alcohol level at the time of withdrawal could be a helpful predictor of the course of severity of alcohol withdrawal; however, more studies are required to prove this relationship.
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Affiliation(s)
- Megan Mayer
- Department of Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Amgad Masoud
- Department of Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
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Liontos A, Samanidou V, Athanasiou L, Filippas-Ntekouan S, Milionis C. Acute Ethanol Intoxication: Αn Overlooked Cause of High Anion Gap Metabolic Acidosis With a Marked Increase in Serum Osmolal Gap. Cureus 2023; 15:e37292. [PMID: 37168210 PMCID: PMC10166247 DOI: 10.7759/cureus.37292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2023] [Indexed: 05/13/2023] Open
Abstract
Measurement of serum osmolal gap is a useful tool in suspected toxic alcohol ingestion. Normal levels of osmolal gap are typically <10 mOsm/kg). Osmolal gap >20 mOsm/kg is usually caused by ingestion of methanol, ethylene glycol, isopropanol, propylene glycol, diethylene glycol, or organic solvents such as acetone but rarely of ethanol alone. Herein, we describe the case of a severe ethanol intoxication presenting with a marked increase in the osmolal gap. An 18-year-old male was referred to the emergency department of our hospital, in a comatose state, following binge drinking. blood gas analysis revealed a high anion gap metabolic acidosis. In addition, it was found an extremely elevated osmolal gap of 91 mOsm/kg. The increment of the osmolal gap and the high anion gap acidosis could not be attributed to methanol/ethylene glycol intoxication, alcoholic ketoacidosis, or other cause of acidosis. The calculated osmolal concentration of ethanol was 91 mOsm/kg (osmolal concentration of ethanol is equal to the serum ethanol levels (mg/dL) divided by 3.7). Thus, the increase in the osmolal gap was a result of ethanol intoxication solely. Acute, isolated, ethanol intoxication may be a rare cause of a marked increase of osmolal gap with high anion gap metabolic acidosis. Clinicians should be alerted to the possibility of acute ethanol intoxication in a patient presenting with high anion gap metabolic acidosis and an extremely elevated osmolal gap. Toxicologic screen tests should be performed to identify the aetiology of the gap rise and proper therapy should be administered.
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Affiliation(s)
- Angelos Liontos
- 1st Department of Internal Medicine, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, GRC
| | - Valentini Samanidou
- 1st Department of Internal Medicine, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, GRC
| | - Lazaros Athanasiou
- 1st Department of Internal Medicine, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, GRC
| | - Sebastien Filippas-Ntekouan
- 1st Department of Internal Medicine, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, GRC
| | - Charalambos Milionis
- 1st Department of Internal Medicine, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, GRC
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Faustmann TJ, Paschali M, Kojda G, Schilbach L, Kamp D. [Antipsychotic Treatment of Alcohol Withdrawal Syndrome with Focus on Delirium Tremens: a Systematic Review]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2023. [PMID: 36958342 DOI: 10.1055/a-2029-6387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND Delirium tremens (DT) is a common complication of alcohol withdrawal. Pharmacological treatment of hospitalized patients with DT is important in addiction medicine but also in other medical disciplines where DT can occur as a complication of hospitalization. Patients suffering from DT require treatment with benzodiazepines (short-acting benzodiazepines for elderly patients to reduce accumulation), and in cases of psychotic symptoms, treatment with antipsychotics. Benzodiazepines are a first-line treatment for DT. A specific guideline for the use of antipsychotics has yet to be developed. This review discusses the current guidelines and literature on the antipsychotic treatment options in DT. AIM Systematic presentation of relevant antipsychotics for the treatment of DT. METHODS A systematic literature search was conducted using Scopus and PubMed. The last search was conducted on May 22nd 2022. Original articles and reviews on antipsychotic treatment in alcohol withdrawal and DT were included in this review. Further, international guidelines were also considered. The review was registered using the PROSPERO database (https://www.crd.york.ac.uk/prospero/); CRD42021264611. RESULTS Haloperidol is mainly recommended for use in the intensive care unit. There is little literature on the use of atypical antipsychotics to treat DT. Treatment with antipsychotics always should be combined with benzodiazepines, and physicians should watch out for complications like neuroleptic malignant syndrome, QTc interval prolongation, extrapyramidal symptoms and withdrawal seizures resulting from lowering the threshold for seizures. CONCLUSION Antipsychotic treatment should depend on the experience of the physician. Beside haloperidol, no other clear recommendations are available.
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Affiliation(s)
- Timo Jendrik Faustmann
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
- Abteilung für Allgemeine Psychiatrie 2, LVR-Klinikum Düsseldorf, Düsseldorf, Germany
| | - Myrella Paschali
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
- Abteilung für Gerontopsychiatrie, LVR-Klinikum Düsseldorf, Düsseldorf, Germany
| | - Georg Kojda
- Institut für Pharmakologie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Leonhard Schilbach
- Abteilung für Allgemeine Psychiatrie 2, LVR-Klinikum Düsseldorf, Düsseldorf, Germany
- Klinik für Psychiatrie und Psychotherapie, Ludwig-Maximilians-Universität München, München, Germany
| | - Daniel Kamp
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
- Abteilung für Allgemeine Psychiatrie 2, LVR-Klinikum Düsseldorf, Düsseldorf, Germany
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Cholerzyńska H, Zasada W, Kłosiewicz T, Konieczka P, Mazur M. The Burden of Alcohol-Related Emergency Department Visits in a Hospital of a Large European City. Healthcare (Basel) 2023; 11:healthcare11060786. [PMID: 36981443 PMCID: PMC10099728 DOI: 10.3390/healthcare11060786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/26/2023] [Accepted: 03/03/2023] [Indexed: 03/30/2023] Open
Abstract
(1) Alcohol consumption contributes to the development of numerous diseases and is a big organizational burden on emergency departments (EDs). (2) We examined data on alcohol-related ED admissions in Poznan, Poland between 1 April 2019 and 31 March 2022. A total of 2290 patients' records were collected and analysed. The main goal was to determine the impact that these visits had on the functioning of the ED and the hospital. (3) The alcohol-related admission rate was significantly higher in males (78.95% vs. 21.05%), and the median blood alcohol concentration (BAC) level was 2.60 (1.78-3.38) ‱. Most of the visits took place at weekends and in the evening. Patients with higher BAC tended to stay longer in the ED, but had a lower chance of being admitted. A majority of patients required radiology and laboratory testing, 20.44% needed psychiatric examination, and 19.69% suffered trauma, mainly to the head. (4) Injuries and mental problems were the most common medical emergencies. This study presents trends in alcohol-related ED attendances, examines reasons for visits, and makes an attempt to assess overall burden on EDs.
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Affiliation(s)
- Hanna Cholerzyńska
- Students' Scientific Circle of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Wiktoria Zasada
- Students' Scientific Circle of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Tomasz Kłosiewicz
- Department of Medical Rescue, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Patryk Konieczka
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Mateusz Mazur
- Department of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
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11
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Mirijello A, Sestito L, Antonelli M, Gasbarrini A, Addolorato G. Identification and management of acute alcohol intoxication. Eur J Intern Med 2023; 108:1-8. [PMID: 35985955 DOI: 10.1016/j.ejim.2022.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/03/2022] [Accepted: 08/11/2022] [Indexed: 02/07/2023]
Abstract
Acute alcohol intoxication (AAI) is a harmful clinical condition, potentially life-threatening, secondary to the intake of large amounts of alcohol. Clinical manifestations of AAI are characterized by behavioural and neurological symptoms, even if its effects involve several organs and apparatus. Moreover, severe alcohol intoxication can produce a global neurological impairment leading to autonomic dysfunction, respiratory depression, coma and cardiac arrest. The evaluation of blood alcohol concentrations (BAC) is useful to confirm the suspicion of intoxication, both for clinical and legal reasons. Most of patients with AAI are referred to Emergency Departments due to behavioural, social, traumatic or clinical complications. Patient's stabilization is the first step in the management of AAI, in order to support vital functions and to prevent complications. Metadoxine represents a useful drug to increase ethanol metabolism and elimination. Given that AAI could represent a sentinel event of chronic alcohol abuse, patients presenting with acute intoxication should be screened for the presence of an underlying alcohol use disorder and referred to and an alcohol addiction unit to start a multidisciplinary treatment to achieve long term alcohol abstinence. The present review will focus on clinical features, diagnostic criteria and treatment strategies of AAI.
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Affiliation(s)
- Antonio Mirijello
- Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Luisa Sestito
- Department of Medical Sciences, Hepatology and Gastroenterology Unit, Catholic University of Rome, Italy
| | - Mariangela Antonelli
- Department of Medical Sciences, Hepatology and Gastroenterology Unit, Catholic University of Rome, Italy
| | - Antonio Gasbarrini
- Department of Medical Sciences, Hepatology and Gastroenterology Unit, Catholic University of Rome, Italy
| | - Giovanni Addolorato
- Department of Medical Sciences, Hepatology and Gastroenterology Unit, Catholic University of Rome, Italy.
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12
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Petrolini VM, Locatelli CA. Pharmacological treatment of acute alcohol intoxication: More doubts than certainties. Eur J Intern Med 2023; 108:25-27. [PMID: 36693776 DOI: 10.1016/j.ejim.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 01/23/2023]
Affiliation(s)
- Valeria M Petrolini
- Toxicology Unit, Pavia Poison Centre and National Toxicology Information Centre, Laboratories of Clinical and Experimental Toxicology, IRCCS Hospital of Pavia, Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Carlo A Locatelli
- Toxicology Unit, Pavia Poison Centre and National Toxicology Information Centre, Laboratories of Clinical and Experimental Toxicology, IRCCS Hospital of Pavia, Istituti Clinici Scientifici Maugeri, Pavia, Italy.
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13
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Gallus S, Lugo A, Borroni E, Vignoli T, Lungaro L, Caio G, De Giorgio R, Zoli G, Caputo F. Symptoms of Protracted Alcohol Withdrawal in Patients with Alcohol Use Disorder: A Comprehensive Systematic Review. Curr Neuropharmacol 2023; 21:409-416. [PMID: 35794766 PMCID: PMC10190151 DOI: 10.2174/1570159x20666220706105253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 03/31/2022] [Accepted: 04/29/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Alcohol withdrawal syndrome (AWS) is characterized by different phases (acute, early and protracted). Protracted alcohol withdrawal (PAW) presents some symptoms, which may persist for several weeks, months or even years after drinking cessation. METHODS We conducted a systematic review of the literature in major scientific databases on selected AWS symptoms (craving, sleep disorders, and anhedonia) in patients with alcohol use disorder. RESULTS Of the 102 eligible publications (70 RCTs and 32 cohort studies), 88 provided data on craving, 21 on sleep disorders, and 1 on anhedonia. Overall, 37 studies assessed craving using the Obsessive Compulsive Drinking Scale (OCDS). Pooled OCDS decreased from 24.2 at baseline to 18.8 at 1 week, 10.3 at 1 month and 9.7 at 3 months. The corresponding estimates for treated individuals were 23.9, 18.8, 8.7, and 8.8, and for non-treated subjects, they were 25.3, 13.9, 13.2, and 11.4, respectively. In 4 studies assessing sleep disorders using the Epworth Sleeping Scale (ESS), the scale remained stable in time, i.e., 7.3 at baseline, 7.3 at 1 week, 7.2 at 1 month, and 7.1 at 3 months. CONCLUSION This study confirms the presence of PAW after the resolution of the acute phase of AWS. The pharmacological approach to managing PAW may ensure a more rapid reduction of symptoms in three weeks. We highlight the importance of studying PAW and the ability of pharmacological treatment to reduce its symptoms. This review protocol is registered in Prospero (registration number: CRD42020211265). SUMMARY This systematic review summarizes literature on major symptoms of protracted alcohol withdrawal in patients with alcohol use disorder. The pharmacological approach to manage protracted alcohol withdrawal ensures a more rapid reduction of symptoms (craving in particular), achieving in three weeks similar results obtained only after almost 6 months without treatment.
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Affiliation(s)
- Silvano Gallus
- Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Alessandra Lugo
- Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Elisa Borroni
- Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Teo Vignoli
- Department of Addiction and Mental Health, Romagna Healthcare Service, Lugo Addiction Unit, Bologna, Emilia- Romagna, Italy
| | - Lisa Lungaro
- Department of Translational Medicine, Centre for the Study and Treatment of Alcohol-Related Diseases, University of Ferrara, Ferrara, Italy
| | - Giacomo Caio
- Department of Translational Medicine, Centre for the Study and Treatment of Alcohol-Related Diseases, University of Ferrara, Ferrara, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, Centre for the Study and Treatment of Alcohol-Related Diseases, University of Ferrara, Ferrara, Italy
| | - Giorgio Zoli
- Centre for the Study and Treatment of Alcohol-Related Diseases, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Internal Medicine, SS Annunziata Hospital, University of Ferrara, Cento (Ferrara), Italy
| | - Fabio Caputo
- Department of Translational Medicine, Centre for the Study and Treatment of Alcohol-Related Diseases, University of Ferrara, Ferrara, Italy
- Department of Internal Medicine, SS Annunziata Hospital, University of Ferrara, Cento (Ferrara), Italy
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14
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Palmese F, Bonavita ME, Pompili E, Migliano MT, Reggidori N, Di Stefano C, Grieco M, Colazzo S, Tufoni M, Baldassarre M, Caraceni P, Foschi FG, Giostra F, Farina G, Del Toro R, Bedogni G, Domenicali M. Mortality and its association with chronic alcohol-related diseases in patients admitted to the emergency department for acute alcoholic intoxication: retrospective cohort study. Intern Emerg Med 2023; 18:257-263. [PMID: 36199001 PMCID: PMC9883355 DOI: 10.1007/s11739-022-03114-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/25/2022] [Indexed: 02/01/2023]
Abstract
We assessed long-term mortality and its association with chronic alcohol-related diseases in patients admitted to the emergency department (ED) because of acute alcoholic intoxication (AAI). A retrospective cohort study was performed at the ED of Sant'Orsola-Malpighi Hospital, Bologna, Italy. 3304 patients, corresponding to 6415 admissions for AAI, who accessed the ED from January 1, 2005, to December 31, 2017, were studied. The ED electronic registry system was used to assess living status on 08 May 2020 and to obtain the prespecified potential predictors, i.e., age at first admission, sex, alcohol use disorder (AUD), substance use disorder (SUD), more than 1 admission to ED for trauma, mental and behavioral disorders, neurological disorders, and cardiovascular disease. The median follow-up time was 9.3 years and the time on risk was 30,053 person years (PY) with a death rate corresponding to 4.42 (95% CI 3.74-5.26) per 1000 PY (n = 133 deaths). The death rate was higher in patients with AUD (17.30) than in those without AUD (1.98) and in those with SUD (13.58) than in those without SUD (3.80). Lastly, there was a clearly higher death rate among AUD+ SUD+ (20.89) compared to AUD-SUD-patients (1.74). At multivariable Cox regression, AUD, SUD, and liver cirrhosis were strong and independent predictors of time-to-death. Using standardized mortality ratios, a clear excess of mortality was evident for all the age bands from (40-45] to (60-65] years. Mortality is higher in AAI than in the general population and chronic alcohol-related diseases are strongly associated with it.
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Affiliation(s)
- Francesco Palmese
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
- Department of Primary Health Care, Internal Medicine Unit Addressed to Frailty and Aging, "S. Maria Delle Croci" Hospital, AUSL Romagna, Ravenna, Italy.
| | - Maria Elena Bonavita
- Department of Internal Medicine, "Degli Infermi" Hospital, AUSL Romagna, Faenza, Italy
| | - Enrico Pompili
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | - Maria Teresa Migliano
- Department of Internal Medicine, "Degli Infermi" Hospital, AUSL Romagna, Faenza, Italy
| | - Nicola Reggidori
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | - Cecilia Di Stefano
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | - Marta Grieco
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | - Stefano Colazzo
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | - Manuel Tufoni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | - Maurizio Baldassarre
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Center for Applied Biomedical Research-CRBA, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | | | - Fabrizio Giostra
- Emergency Department-Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | - Gabriele Farina
- Emergency Department-Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | - Rossella Del Toro
- Department of Primary Health Care, Internal Medicine Unit Addressed to Frailty and Aging, "S. Maria Delle Croci" Hospital, AUSL Romagna, Ravenna, Italy
| | - Giorgio Bedogni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit Addressed to Frailty and Aging, "S. Maria Delle Croci" Hospital, AUSL Romagna, Ravenna, Italy
| | - Marco Domenicali
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit Addressed to Frailty and Aging, "S. Maria Delle Croci" Hospital, AUSL Romagna, Ravenna, Italy
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15
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Seshadri A, Appelbaum R, Carmichael SP, Farrell MS, Filiberto DM, Jawa R, Kodadek L, Mandell S, Miles MVP, Paul J, Robinson B, Michetti CP. Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2022; 7:e001010. [PMCID: PMC9680182 DOI: 10.1136/tsaco-2022-001010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022] Open
Abstract
Alcohol withdrawal syndrome is a common and challenging clinical entity present in trauma and surgical intensive care unit (ICU) patients. The screening tools, assessment strategies, and pharmacological methods for preventing alcohol withdrawal have significantly changed during the past 20 years. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews the best practices for screening, monitoring, and prophylactic treatment of alcohol withdrawal in the surgical ICU.
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Affiliation(s)
- Anupamaa Seshadri
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rachel Appelbaum
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Samuel P Carmichael
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | | | - Dina M Filiberto
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Randeep Jawa
- Department of Surgery, Stony Brook University, Stony Brook, New York, USA
| | - Lisa Kodadek
- Surgery, Yale University School of Medicine, New Haven, Connecticut, USA,Department of Surgery, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Samuel Mandell
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - M Victoria P Miles
- College of Medicine Chattanooga, The University of Tennessee Health Science Center, Chattanooga, Tennessee, USA
| | - Jasmeet Paul
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Bryce Robinson
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
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16
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Zangani C, Giordano B, Stein HC, Bonora S, Ostinelli EG, D'Agostino A. Efficacy of tiapride in the treatment of psychiatric disorders: A systematic review. Hum Psychopharmacol 2022; 37:e2842. [PMID: 35313032 DOI: 10.1002/hup.2842] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 02/22/2022] [Accepted: 03/08/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Tiapride is an atypical antipsychotic used to treat alcohol withdrawal, aggressiveness and agitation, headache, dyskinesias, tic and Tourette's disorder. More recently, it has been proposed for the treatment of delirium and agitation in hospitalised patients with COVID-19. Although its safety profile makes it suitable for use in vulnerable populations, the use of tiapride for psychiatric disorders is limited. This work aims to systematically review the available evidence on the efficacy and tolerability of tiapride in individuals with a psychiatric disorder. METHODS We searched PubMed, Embase, PsycINFO, GreyLit, OpenGrey, and ProQuest up to March 2020 for randomised controlled trials focussing on the use of tiapride in the treatment of individuals with a psychiatric disorder (e.g., mood disorder, schizophrenia spectrum, substance use disorder). The Risk of Bias 2 was performed for the quality assessment of the included studies. RESULTS We identified 579 records. Of them, six studies (published between 1982 and 2010) were included in the review. Four studies referred to alcohol withdrawal, and two to the management of agitation in elderly patients with dementia. None of the studies reported significant differences between tiapride and other active comparators in terms of efficacy and tolerability. The overall risk of bias was moderate to high. CONCLUSION Tiapride may be considered as a relatively safe treatment option for selected patients with alcohol withdrawal or agitation in dementia. However, solid evidence of its efficacy in the scientific literature is lacking. High-quality trials remain necessary to fully sustain its use in clinical practice.
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Affiliation(s)
- Caroline Zangani
- Department of Psychiatry, University of Oxford, Oxford, UK.,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK.,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Barbara Giordano
- Department of Health Sciences, University of Milan, Milan, Italy
| | | | - Stefano Bonora
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Edoardo Giuseppe Ostinelli
- Department of Psychiatry, University of Oxford, Oxford, UK.,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK.,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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17
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Knapen FMFM, Laumer SJM, Van Osch FHM, Barten DG. The impact of the COVID-19 pandemic on alcohol-related emergency department visits in the Netherlands: The ALCOVID study. Drug Alcohol Rev 2021; 41:476-483. [PMID: 34806251 PMCID: PMC9011601 DOI: 10.1111/dar.13410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 10/17/2021] [Accepted: 10/20/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The ongoing COVID-19 pandemic has a profound impact on society and healthcare utilisation. Some studies found that alcohol consumption increased. While declines in non-COVID emergency department (ED) visits have been observed worldwide, little is known about the impact of the COVID-19 pandemic on the number of alcohol-related ED visits. We aimed to examine the changes in alcohol-related ED utilisation during the first year of the pandemic in the Netherlands. We assessed whether lockdowns, closure of the catering industry and alcohol bans were associated with changes in ED utilisation for alcohol-related emergencies. METHODS We performed a retrospective analysis of alcohol-related ED visits in a Dutch trauma level 2 centre, comparing the pandemic year 2020 and using the year 2019 as a reference. Alcohol-related ED visits were categorised as alcohol intoxication, alcohol-related trauma or a combination of both. RESULTS There was an absolute decline of 23.3% in alcohol-related ED visits during 2020 compared to 2019. The decline was most distinct during the second lockdown period (-60%, P ≤ 0.001), which included an alcohol ban. No significant differences were found in the type of alcohol-related ED visits. The proportion of alcohol-related ED visits remained similar (2.2% vs. 2%). DISCUSSION AND CONCLUSIONS Despite reports of higher alcohol consumption, we observed a reduction of alcohol-related ED visits during the COVID-19 pandemic. The decline was most distinct during the second lockdown period, which included an alcohol ban. Further prospective studies are warranted to examine this possible association.
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Affiliation(s)
- Femke M F M Knapen
- Department of Emergency Medicine, VieCuri Medical Centre, Venlo, Netherlands
| | - Susanne J M Laumer
- Department of Emergency Medicine, VieCuri Medical Centre, Venlo, Netherlands
| | - Frits H M Van Osch
- Department of Clinical Epidemiology, VieCuri Medical Centre, Venlo, Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands
| | - Dennis G Barten
- Department of Emergency Medicine, VieCuri Medical Centre, Venlo, Netherlands
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18
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Costa E, Sterzi E, Tedeschi F, Casari R, Marini P, Lugoboni F. Can oral formulation increase the risk of lormetazepam abuse? Intern Emerg Med 2021; 16:785-788. [PMID: 33095413 DOI: 10.1007/s11739-020-02538-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/30/2020] [Indexed: 02/07/2023]
Abstract
The slowness of dripping and the presence of alcohol have been offered/suggested as possible causes for the increased risk of developing dependence to the oral formulation of lormetazepam rather than to other anxiolytic and hypnotic drugs. We hence assessed the time of dripping of the most used benzodiazepines and z-drugs oral solution products under experimental conditions and the different employed excipients through a comparative analysis of the Summaries of Product Characteristics. A wide range of the median overall dispensing time was found across the eight products included in the analysis. Among the products containing LMZ, Minias® ranked in the fourth position, while LMZ Mylan Generics® and Noctamid® in the sixth and third, respectively. Our data suggest that the pace of dripping and the presence of alcohol cannot be considered themselves the cause that triggered the abuse of lormetazepam. More precisely, the quantity of alcohol per bottle has been found negligible at therapeutic doses; however, when these are exceeded, they may have clinical implications for patients. Further studies are needed to assess them. Meanwhile, the public-health problem remains and some improvements should be carried out at different levels, to guarantee the appropriate prescription and use of lormetazepam oral solution.
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Affiliation(s)
- Enrico Costa
- Department of Pharmacy, Azienda Ospedaliera Universitaria Integrata Verona,, P. le L.A. Scuro, 10, 37134, Verona, Italy.
| | - Enrico Sterzi
- Department of Pharmacy, Azienda Ospedaliera Universitaria Integrata Verona,, P. le L.A. Scuro, 10, 37134, Verona, Italy
| | - Federico Tedeschi
- Section of Psychiatry and Clinical Psychology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Rebecca Casari
- Addiction Medicine Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Paola Marini
- Department of Pharmacy, Azienda Ospedaliera Universitaria Integrata Verona,, P. le L.A. Scuro, 10, 37134, Verona, Italy
| | - Fabio Lugoboni
- Addiction Medicine Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
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19
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Caputo F, Cibin M, Loche A, De Giorgio R, Zoli G. The recognition and management of protracted alcohol withdrawal may improve and modulate the pharmacological treatment of alcohol use disorder. J Psychopharmacol 2020; 34:1171-1175. [PMID: 32648800 DOI: 10.1177/0269881120936483] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
About 50% of persons with an alcohol use disorder may have symptoms of alcohol withdrawal syndrome (AWS) when they reduce or discontinue their alcohol consumption. Protracted alcohol withdrawal (PAW), an underestimated and not yet clearly defined clinical condition that follows the acute stage of AWS, is characterized by the presence of substance-specific signs and symptoms (i.e. anxiety, irritability, mood instability, insomnia, craving) common to acute AWS, but persisting beyond the generally expected acute AWS time frames. Considering that PAW symptoms are mainly related to the neuro-adaptive changes of gamma-aminobutyric acid (GABA) and N-methyl-d-aspartate (NMDA) systems, naltrexone, nalmefene, and disulfiram may not be able to suppress the symptoms of PAW. After treatment of the acute phase of AWS, a more specifically pharmacological therapy able to suppress PAW symptoms could perhaps be used earlier and may be more helpful in preventing the risk of alcohol relapse, which remains higher during the first months of treatment. In light of this, medications acting on GABA and NMDA neurotransmitter systems to counterbalance the up-regulation of NMDA and the down-regulation of GABA could be employed in combination and started as soon as possible.
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Affiliation(s)
- Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, University of Ferrara, Ferrara, Italy.,Italian Society on Alcohol (SIA), Bologna, Italy
| | - Mauro Cibin
- Italian Society of Substance Abuse (SITD), Dolo (Venezia), Italy
| | | | - Roberto De Giorgio
- Department of Morphology, Surgery, Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Giorgio Zoli
- Department of Morphology, Surgery, Experimental Medicine, University of Ferrara, Ferrara, Italy
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20
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Driscoll D, Bleecker G, Francis J, Jaberi A. Acute Hemodialysis for Treatment of Severe Ethanol Intoxication. Kidney Med 2020; 2:793-796. [PMID: 33319202 PMCID: PMC7729238 DOI: 10.1016/j.xkme.2020.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
A male college student presented to the emergency department with altered mental status and a serum ethanol level higher than the hospital laboratory assay. His course was complicated by mechanical ventilation, vasopressors, and cardiotoxicity. Thirteen hours into admission and despite aggressive supportive measures, the patient remained obtunded off sedation with serum ethanol level elevated at 428 mg/dL. A decision was made to initiate hemodialysis to expedite ethanol clearance and prevent further end-organ damage. Two hours into hemodialysis, mental status improved and serum ethanol level had decreased to 264 mg/dL. A total of 4 hours of hemodialysis were completed and serum ethanol level continued to downtrend. Dialysis increased the rate of ethanol elimination by a factor of 4 and prevented further cardiotoxicity or electrolyte level abnormalities. This case supports the use of hemodialysis for adult patients who meet the criteria of severe ethanol toxicity requiring critical care resources and having evidence of organ toxicity to 1 or more organ.
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Affiliation(s)
| | | | | | - Aala Jaberi
- Boston University Medical Center, Boston, MA
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21
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Chouhan D, Uniyal A, Gadepalli A, Akhilesh, Tiwari V, Agrawal S, Roy TK, Shaw S, Purohit N, Tiwari V. Probing the Manipulated Neurochemical Drive in Alcohol Addiction and Novel Therapeutic Advancements. ACS Chem Neurosci 2020; 11:1210-1217. [PMID: 32243128 DOI: 10.1021/acschemneuro.0c00073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Alcohol addiction is one of the highly prevalent neurological disorders and a major threat to public health in the 21st century. Alcohol addiction affects people from all age groups and often leads to other serious comorbidities. The pathophysiology of alcohol addiction involves imbalance between the excitatory and inhibitory neurotransmitters in the brain. These changes occur in various regions of the brain including reward circuit such as the ventral tegmental area (VTA), nucleus accumbens (NAc), and prefrontal cortex. In this review, we have discussed several neurochemical circuitries which get manipulated and maladapted during alcohol addiction. To date there is no effective therapeutic intervention in clinics devoid of side effects that can successfully treat the patients suffering from alcohol addiction. Understanding the neurobiological intricacies of alcohol addiction is critical for the development of novel anti-addiction therapeutics. Apart from this, we have also discussed the recent therapeutic milestones for the management of alcohol addiction including vasopressin receptors, corticotrophin-releasing factor, GABA receptors, glucocorticoid receptors, brain stimulation and mindfulness-oriented recovery enhancement.
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Affiliation(s)
- Deepak Chouhan
- Neuroscience and Pain Research Lab, Department of Pharmaceutical Engineering & Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh 221005, India
| | - Ankit Uniyal
- Neuroscience and Pain Research Lab, Department of Pharmaceutical Engineering & Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh 221005, India
| | - Anagha Gadepalli
- Neuroscience and Pain Research Lab, Department of Pharmaceutical Engineering & Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh 221005, India
| | - Akhilesh
- Neuroscience and Pain Research Lab, Department of Pharmaceutical Engineering & Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh 221005, India
| | - Vineeta Tiwari
- Neuroscience and Pain Research Lab, Department of Pharmaceutical Engineering & Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh 221005, India
| | - Somesh Agrawal
- Neuroscience and Pain Research Lab, Department of Pharmaceutical Engineering & Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh 221005, India
| | - Tapas Kumar Roy
- Neuroscience and Pain Research Lab, Department of Pharmaceutical Engineering & Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh 221005, India
| | - Sneha Shaw
- Neuroscience and Pain Research Lab, Department of Pharmaceutical Engineering & Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh 221005, India
| | - Narendra Purohit
- Neuroscience and Pain Research Lab, Department of Pharmaceutical Engineering & Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh 221005, India
| | - Vinod Tiwari
- Neuroscience and Pain Research Lab, Department of Pharmaceutical Engineering & Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh 221005, India
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22
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Glahn A, Proskynitopoulos PJ, Bleich S, Hillemacher T. Pharmacotherapeutic management of acute alcohol withdrawal syndrome in critically Ill patients. Expert Opin Pharmacother 2020; 21:1083-1092. [PMID: 32281894 DOI: 10.1080/14656566.2020.1746271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Alcohol withdrawal syndrome is a common and life-threatening condition in patients suffering from alcohol use disorder. Treatment of this syndrome is challenging, especially in patients that are critically ill, either because of withdrawal symptoms or underlying conditions. For the treatment, several pharmacological agents exist, such as benzodiazepines, barbiturates, or dexmedetomidine. Nonetheless, as alcohol withdrawal syndromes can occur in every clinical setting, it is necessary to provide a guideline for clinicians confronted with this syndrome in varying clinical contexts. AREAS COVERED The authors provide a systematic review of the literature found in PubMed and Embase following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. EXPERT OPINION For the treatment of alcohol withdrawal syndrome, medications targeting the GABA system are preferred. Benzodiazepines are regarded as the gold standard. However, as many adjunct therapeutic options exist, it is essential to find symptom-triggered approaches and treatment protocols for the variety of clinical contexts. Apart from that, it is necessary to compare protocols toward clinical variables rather than investigating medications that are in use for the treatment of alcohol withdrawal syndrome.
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Affiliation(s)
- A Glahn
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - P J Proskynitopoulos
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - S Bleich
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - T Hillemacher
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany.,Department of Psychiatry and Psychotherapy, Paracelcus Medical University , Nuremberg, Germany
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23
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Abstract
OBJECTIVES In contrast with other developed nations, life expectancy is decreasing in the United States, in part due to increasing mortality from alcohol-associated liver disease (ALD). Up-to-date estimates of ALD mortality are necessary for setting public health priorities to reverse this concerning trend. We therefore aimed to assess current (2017) estimates of ALD mortality and temporal trends from 1999 to 2017. METHODS Using national data from the Centers for Disease Control and Prevention, we analyzed stratified ALD mortality rates between 1999 and 2017. We determined the age-adjusted death rates, stratified by sex and categorized by age, race/ethnicity, urbanization, and census region. We also identified statistically significant changes in the annual rate difference (ARD), annual percentage change (APC), and average APC in ALD mortality. RESULTS In 2017, mortality from ALD was higher than any other year since 1999 with age-adjusted rates of 13.1 per 100,000 (95% confidence interval [CI] 12.9-13.3) in men and 5.6 per 100,000 (95% CI 5.4-5.7) in women. Mortality was highest among men and women who were middle aged, Native American, and from rural areas. Since 2006, ALD mortality has increased in almost every age group and race with the exception of non-Hispanic black men. Absolute increases in mortality rates have been particularly pronounced in Native American women (2005-2017 ARD 0.8, 95% CI 0.6-0.9), non-Hispanic/white men (2006-2017 ARD 0.4, 95% CI 0.3-0.4), and non-Hispanic/white women (2013-2017 ARD 0.4, 95% CI 0.3-0.5). DISCUSSION Mortality from ALD is increasing over time in most demographic groups. Increased effort is needed to develop targeted public health strategies to address high and increasing ALD mortality.
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24
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Testino G, Vignoli T, Patussi V, Scafato E, Caputo F. Management of end-stage alcohol-related liver disease and severe acute alcohol-related hepatitis: position paper of the Italian Society on Alcohol (SIA). Dig Liver Dis 2020; 52:21-32. [PMID: 31757596 DOI: 10.1016/j.dld.2019.09.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/28/2019] [Accepted: 09/23/2019] [Indexed: 02/07/2023]
Abstract
Worldwide, the prevalence of alcohol use disorder (AUD) is 20-30% in men and 10-15% in women, and cirrhosis due to alcohol-related liver disease (ALD) is responsible for 0.9% of global deaths and 47.9% of cirrhosis-related deaths. End-stage ALD (ESALD) is the final condition of alcohol-related cirrhosis, and severe acute alcohol-related hepatitis (SAAH) is a distinct clinical syndrome associated with the consumption of large amounts of alcohol. In some cases, ESALD, and SAAH may need liver transplantation (LT). Thus, the management of ESALD and SAAH in patients affected by AUD may be an essential part of the clinical skills for hepatologists. For these reasons, the national board of the Italian Society on Alcohol have reviewed the most recent data on the management of ESALD, SAAH and LT for ALD in patients with AUD, formulating a position paper with related recommendations regarding four issues of specific clinical interest in this field: (a) the management of hepatic encephalopathy in patients with AUD, and LT in patients with ESALD; (b) the management of SAAH; (c) the management of AUD in patients with ESALD and SAAH; (d) special populations: polydrug addicts.
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Affiliation(s)
- Gianni Testino
- Unit of Addiction and Hepatology ASL3 Liguria, San Martino Hospital, Genova, Italy
| | - Teo Vignoli
- Unit of Addiction Treatment, Lugo, Ravenna, Italy
| | | | - Emanuele Scafato
- National Observatory on Alcohol, National Institute of Health, Roma, Italy
| | - Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, Cento, Ferrara, Italy; "G. Fontana" Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, Department of Medical and Surgical Sciences, University of Bologna, Italy.
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25
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Cosci F, Nardi AE, Starcevic V, Chouinard G, Balon R. Lormetazepam in oral solution: a formulation at risk of high-dose use. Intern Emerg Med 2019; 14:1203-1204. [PMID: 31270679 DOI: 10.1007/s11739-019-02143-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 12/30/2022]
Affiliation(s)
- Fiammetta Cosci
- Department of Health Sciences, University of Florence, via di San Salvi, 12, 50135, Florence, Italy.
- Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands.
| | - Antonio Egidio Nardi
- Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Vladan Starcevic
- Faculty of Medicine and Health, Sydney Medical School, Nepean Clinical School, University of Sydney, Sydney, Australia
| | - Guy Chouinard
- Clinical Pharmacology and Toxicology Program, McGill University and Mental Health Institute of Montreal Fernand Seguin Research Centre, Montreal, Canada
| | - Richard Balon
- Department of Psychiatry and Behavioral Neurosciences and Anesthesiology, Wayne State University, Detroit, MI, USA
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26
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Pavarin RM, Domenicali M, Marani S, Caputo F, Mazzoni M. Visits of adolescents for acute alcohol intoxication to emergency departments in Northern Italy: natives and non-natives. JOURNAL OF SUBSTANCE USE 2019. [DOI: 10.1080/14659891.2019.1664665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Raimondo Maria Pavarin
- Epidemiological Monitoring Center on Addiction, Mental Health DSM-DP, Ausl Bologna, Bologna, Italy
| | - Marco Domenicali
- Department of Medical and Surgical Sciences G. Fontana, Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, University of Bologna, Bologna, Italy
| | - Silvia Marani
- Epidemiological Monitoring Center on Addiction, Mental Health DSM-DP, Azienda USL Bologna, Bologna, Italy
| | - Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, Cento (Ferrara), Italy
| | - Monica Mazzoni
- Department of statistics, Città Metropolitana of Bologna, Italy
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27
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Pezzilli R, Caputo F, Testino G, Patussi V, Greco G, Macciò L, Rossin MR, Mioni D, Balbinot P, Gandin C, Zanesini F, Frulloni L, Aricò S, Bottaro LC, Pellicano R, Scafato E. Alcohol-related chronic exocrine pancreatic insufficiency: diagnosis and therapeutic management. A proposal for treatment by the Italian Association for the Study of the Pancreas (AISP) and the Italian Society of Alcohology (SIA). Minerva Med 2019; 110:425-438. [PMID: 30938130 DOI: 10.23736/s0026-4806.19.06043-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Current estimates of the prevalence of chronic pancreatitis, one of the most common causes of exocrine pancreatic insufficiency, are in the range of 3-10 per 100,000 people in many parts of the world. Alcohol consumption is a very important risk factor for exocrine pancreatic insufficiency and is involved in nearly half of all cases. The main hypothesis regarding the role of chronic alcohol consumption in pancreatitis is that there must be additional environmental or genetic risk factors involved for ongoing damage to occur. Treatment of patients with alcohol-related exocrine pancreatic insufficiency is complex, as the patient has two concomitant pathologies, alcohol-use disorder (AUD) and exocrine pancreatic insufficiency/chronic pancreatitis. Alcohol abstinence is the starting point for treatment, although even this along with the most advanced therapies allow only a slowdown in progression rather than restoration of function. This position paper of the Italian Association for the Study of the Pancreas and the Italian Society of Alcohology provides an overview of the pathogenesis of alcohol-related pancreatitis and discuss diagnostic issues. Treatment options for both exocrine pancreatic insufficiency/chronic pancreatitis (with a focus on pancreatic enzyme replacement therapy) and AUD (acamprosate, disulfiram, oral naltrexone, long-acting injectable naltrexone, sodium oxybate, nalmefene, baclofen, and psychosocial interventions) are also reviewed.
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Affiliation(s)
- Raffaele Pezzilli
- Pancreas Unit, Department of Gastroenterology, Polyclinic of Sant'Orsola, Bologna, Italy - .,Italian Association for the Study of the Pancreas, Rome, Italy -
| | - Fabio Caputo
- Department of Internal Medicine, SS. Annunziata Hospital, Cento, Ferrara, Italy.,G. Fontana Center for the Study and Multidisciplinary Treatment of Alcohol Addiction, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Gianni Testino
- Regional Alcohol Center of Liguria Region, ASL3, San Martino Hospital, Genoa, Italy
| | | | - Giovanni Greco
- Department of Mental Health and Pathological Dependency, AUSL Romagna, SerT Ravenna, Ravenna, Italy
| | | | | | - Davide Mioni
- Casa di Cura Parco dei Tigli, Villa Di Teolo, Padua, Italy
| | - Patrizia Balbinot
- Regional Alcohol Center of Liguria Region, ASL3, San Martino Hospital, Genoa, Italy
| | - Claudia Gandin
- National Observatory on Alcohol, National Institute of Health, Rome, Italy
| | | | - Luca Frulloni
- Department of Medicine, Pancreas Institute, University of Verona, Verona, Italy
| | - Sarino Aricò
- Unit of Gastroenterology, Mauriziano Hospital, Turin, Italy
| | | | | | - Emanuele Scafato
- National Observatory on Alcohol, National Institute of Health, Rome, Italy
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28
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Knapp B, Tito E, Espiridion ED. Delusional Parasitosis in a Patient with Alcohol-induced Psychotic Disorder. Cureus 2019; 11:e4344. [PMID: 31187009 PMCID: PMC6541158 DOI: 10.7759/cureus.4344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Alcohol-induced psychotic disorder is a rare complication of chronic alcohol abuse following abrupt alcohol cessation that is characterized by visual, auditory, or tactile hallucinations paired with intact orientation and stable vital signs, distinguishing the condition from delirium tremens and psychotic disorders. The condition, first termed alcoholic hallucinosis, has been described in medical literature for over a century, however, its nosologic classification and psychopathologic characteristics are less well-documented. One such case of alcohol-induced psychotic disorder with multimodal hallucinations of four months duration is described here.
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Affiliation(s)
- Blayne Knapp
- Family Medicine, West Virginia School of Osteopathic Medicine, Lewisburg, USA
| | - Emmanuel Tito
- Internal Medicine, West Virginia School Osteopathic Medicine, Lewisburg, USA
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