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Ronan MV, Gordon KS, Skanderson M, Krug M, Godwin P, Heppe D, Hoegh M, Boggan JC, Gutierrez J, Kaboli P, Pescetto M, Guidry M, Caldwell P, Mitchell C, Ehlers E, Allaudeen N, Cyr J, Smeraglio A, Yarbrough P, Rose R, Jagannath A, Vargas J, Cornia PB, Shah M, Tuck M, Arundel C, Laudate J, Elzweig J, Rodwin B, Akwe J, Trubitt M, Gunderson CG. Contemporary Management and Outcomes of Veterans Hospitalized With Alcohol Withdrawal: A Multicenter Retrospective Cohort Study. J Addict Med 2024; 18:389-396. [PMID: 38452185 DOI: 10.1097/adm.0000000000001297] [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: 03/09/2024]
Abstract
OBJECTIVES Few studies describe contemporary alcohol withdrawal management in hospitalized settings or review current practices considering the guidelines by the American Society of Addiction Medicine (ASAM). METHODS We conducted a retrospective cohort study of patients hospitalized with alcohol withdrawal on medical or surgical wards in 19 Veteran Health Administration (VHA) hospitals between October 1, 2018, and September 30, 2019. Demographic and comorbidity data were obtained from the Veteran Health Administration Corporate Data Warehouse. Inpatient management and hospital outcomes were obtained by chart review. Factors associated with treatment duration and complicated withdrawal were examined. RESULTS Of the 594 patients included in this study, 51% were managed with symptom-triggered therapy alone, 26% with fixed dose plus symptom-triggered therapy, 10% with front loading regimens plus symptom-triggered therapy, and 3% with fixed dose alone. The most common medication given was lorazepam (87%) followed by chlordiazepoxide (33%), diazepam (14%), and phenobarbital (6%). Symptom-triggered therapy alone (relative risk [RR], 0.68; 95% confidence interval [CI], 0.57-0.80) and front loading with symptom-triggered therapy (RR, 0.75; 95% CI, 0.62-0.92) were associated with reduced treatment duration. Lorazepam (RR, 1.20; 95% CI, 1.02-1.41) and phenobarbital (RR, 1.28; 95% CI, 1.06-1.54) were associated with increased treatment duration. Lorazepam (adjusted odds ratio, 4.30; 95% CI, 1.05-17.63) and phenobarbital (adjusted odds ratio, 6.51; 95% CI, 2.08-20.40) were also associated with complicated withdrawal. CONCLUSIONS Overall, our results support guidelines by the ASAM to manage patients with long-acting benzodiazepines using symptom-triggered therapy. Health care systems that are using shorter acting benzodiazepines and fixed-dose regimens should consider updating alcohol withdrawal management pathways to follow ASAM recommendations.
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Affiliation(s)
- Matthew V Ronan
- From the Medical Service, GIM Section, VA Boston Healthcare System, West Roxbury, MA (MR); Harvard Medical School, Boston, MA (MR); VA Connecticut Healthcare System, West Haven, CT (KSG, M Skanderson, BR, CGG); Yale University School of Medicine, New Haven, CT (KSG, BR, CGG); Medical Service, Boise VA Medical Center, Boise, ID (MK); University of Washington School of Medicine, Seattle, WA (MK, PBC, M Shah); Medical Service, Jesse Brown VA Medical Center, Chicago, IL (PG); University of Illinois, College of Medicine, Chicago, IL (PG); VA Eastern Colorado Health Care System, Aurora, CO (DH, MH); Department of Medicine, University of Colorado School of Medicine, Aurora, CO (DH, MH); Medical Service, Durham VA Medical Center, Durham, NC (JCB); Department of Medicine, Duke University School of Medicine, Durham, NC (JCB); Section of Hospital Medicine, Iowa City VA Healthcare System, Iowa City, IA (JG, PK); Department of Medicine, University of Iowa Health Care, Carver College of Medicine, Iowa City, IA (JG, PK); Medical Service, VA Kansas City Health Care, Kansas City, MO (MP); Medical Service, New Orleans VA Medical Center, New Orleans, LA (MG, PC); Tulane University School of Medicine, New Orleans, LA (MG, PC); Medical Service, Veteran Affairs Nebraska-Western Iowa Health Care System, Omaha, NE (CM, EE); University of Nebraska Medical Center, College of Medicine, Omaha, NE (EE); Medical Service, VA Palo Alto Healthcare System, Palo Alto, CA (NA); Stanford University School of Medicine, Palo Alto, CA (NA); Medical Service, Pittsburgh VA Medical Center, Pittsburgh, PA (JC); Pittsburgh University School of Medicine, Pittsburgh, PA (JC); Medical Service, VA Portland Healthcare System, Portland, OR (AS, AJ); Oregon Health and Science University, School of Medicine, Portland, OR (AS, AJ); Medical Service, Salt Lake City VA Medical Center, Salt Lake City, UT (PY, RR); University of Utah School of Medicine, Salt Lake City, UT (PY, RR); Medical Service, San Diego VA Medical Center, San Diego, CA (JV); Medical Service, VA Puget Sound Healthcare System, Seattle, WA (PBC, M Shah); Medical Service, VA Washington DC Health Care System, Washington, DC (MT, CA); George Washington University School of Medicine and Health Sciences, Washington, DC (MT); Georgetown University School of Medicine, Washington, DC (CA); Medical Service, White River Junction VA Medical Center, White River Junction, VT (JL, JE); Geisel School of Medicine at Dartmouth, Hanover, NH (JL, JE); Medical Service, Atlanta VA Medical Center, Atlanta, GA (JA, MT); Emory University School of Medicine, Atlanta, GA (JA, MT)
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Kádár BK, Gajdics J, Pribék IK, Andó B, Lázár BA. Characterization of alcohol-related seizures in withdrawal syndrome. Epilepsia Open 2024; 9:679-688. [PMID: 38279829 PMCID: PMC10984295 DOI: 10.1002/epi4.12906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 12/14/2023] [Accepted: 01/15/2024] [Indexed: 01/29/2024] Open
Abstract
OBJECTIVE Alcohol-related seizures (ARS) are one of the most important consequences of alcohol withdrawal syndrome (AWS). However, demographic and clinical characteristics, and furthermore, the relationship of ARS with delirium tremens (DT), have not yet been evaluated in detail. Therefore, the aim of the present study was to reveal the correlates of ARS and examine the interaction of ARS with the occurrence of DT and with the severity of AWS. METHODS In the retrospective study (Study 1) 2851 medical charts of inpatient admissions characterized by AWS and DT were listed. Demographic and clinical variables of ARS were assessed. In the follow-up study (Study 2), patients admitted with AWS without (N = 28) and with (N = 18) ARS were enrolled. Study 1 was performed between 2008 and 2023, and Study 2 was performed in 2019 in Hungary. To determine the severity of AWS, the Clinical Institute Withdrawal Assessment Scale for Alcohol, Revised (CIWA-Ar) was used. ARS is a provoked, occasional seizure; therefore, patients with epilepsy syndrome were excluded from the two studies. Statistical analyses were performed by the means of chi-square tests, multinomial logistic regressions, mixed ANOVA, and derivation. RESULTS The occurrence of DT, the history of ARS, and somatic co-morbidities were found to be risk factors for the appearance of ARS. ARS was proved to be a risk factor for the development of DT. In the follow-up study, there was no difference in the decrease of CIWA-Ar scores between the groups. SIGNIFICANCE Our present findings support the likelihood of kindling, which is one of the most important mechanisms underlying the development of ARS, but do not directly prove its presence. Additionally, our results revealed that the severity of AWS is not influenced by the presence of ARS. PLAIN LANGUAGE SUMMARY Provoked, occasional seizures during AWS are defined as ARS. In the present study, predictors and interactions of these seizures with DT-the most severe form of withdrawal-and with the severity of withdrawal were examined in retrospective and follow-up studies. The present study shows that a history of withdrawal seizures, the occurrence of DT, and somatic comorbidities are predictors of the development of seizures. Furthermore, our findings suggest that the presence of seizures does not influence the severity of withdrawal.
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Affiliation(s)
- Bettina Kata Kádár
- Addiction Research Group, Department of Psychiatry, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Janka Gajdics
- Addiction Research Group, Department of Psychiatry, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Ildikó Katalin Pribék
- Addiction Research Group, Department of Psychiatry, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Bálint Andó
- Addiction Research Group, Department of Psychiatry, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Bence András Lázár
- Addiction Research Group, Department of Psychiatry, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
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Ratner JA, Blaney H, Rastegar DA. Management of alcohol withdrawal syndrome in patients with alcohol-associated liver disease. Hepatol Commun 2024; 8:e0372. [PMID: 38251886 PMCID: PMC10805424 DOI: 10.1097/hc9.0000000000000372] [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] [Received: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024] Open
Abstract
Alcohol-associated liver disease is a common and severe sequela of excessive alcohol use; effective treatment requires attention to both liver disease and underlying alcohol use disorder (AUD). Alcohol withdrawal syndrome (AWS) can be dangerous, is a common barrier to AUD recovery, and may complicate inpatient admissions for liver-related complications. Hepatologists can address these comorbid conditions by learning to accurately stage alcohol-associated liver disease, identify AUD using standardized screening tools (eg, Alcohol Use Disorder Identification Test), and assess risk for and symptoms of AWS. Depending on the severity, alcohol withdrawal often merits admission to a monitored setting, where symptom-triggered administration of benzodiazepines based on standardized scoring protocols is often the most effective approach to management. For patients with severe liver disease, selection of benzodiazepines with less dependence on hepatic metabolism (eg, lorazepam) is advisable. Severe alcohol withdrawal often requires a "front-loaded" approach with higher dosing, as well as intensive monitoring. Distinguishing between alcohol withdrawal delirium and HE is important, though it can be difficult, and can be guided by differentiating clinical characteristics, including time to onset and activity level. There is little data on the use of adjuvant medications, including anticonvulsants, dexmedetomidine, or propofol, in this patient population. Beyond the treatment of AWS, inpatient admission and outpatient hepatology visits offer opportunities to engage in planning for ongoing management of AUD, including initiation of medications for AUD and referral to additional recovery supports. Hepatologists trained to identify AUD, alcohol-associated liver disease, and risk for AWS can proactively address these issues, ensuring that patients' AWS is managed safely and effectively and supporting planning for long-term recovery.
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Affiliation(s)
- Jessica A. Ratner
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Hanna Blaney
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Darius A. Rastegar
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Gajdics J, Bagi O, Farkas FF, Andó B, Pribék IK, Lázár BA. The Impact of the COVID-19 Pandemic on the Severity of Alcohol Use Disorder: Significance of Dual Disorders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6939. [PMID: 37887677 PMCID: PMC10606859 DOI: 10.3390/ijerph20206939] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/28/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has been assumed to impact patients diagnosed with alcohol use disorder (AUD). The severity of the influence that the COVID-19 pandemic had on the symptoms of AUD has not yet been revealed in detail. The aim of this study was to examine the impact of the COVID-19 pandemic on patients diagnosed with AUD. This retrospective study was conducted between 11 March 2017 and 31 May 2022 in Hungary. Medical charts (N = 1082) of inpatients with the diagnosis of AUD were reviewed. Based on the dates of admissions, two groups were created: the 'before COVID-19' group (11 March 2017-10 March 2020) and the 'during COVID-19' group (11 March 2020-31 May 2022). Chi-square tests, independent-sample t-tests, and multinomial logistic regressions were performed. The occurrence of delirium tremens (DT) and psychiatric co-morbidities was significantly higher during the pandemic. Our results showed that the occurrence of DT and psychiatric co-morbidities significantly increased during the pandemic. Our results revealed that the pandemic enhanced the severe consequences of AUD, and the development of AUD might have increased in frequency among individuals previously diagnosed with mental illness during the pandemic. These findings indicate the significance of dual disorders in the post-pandemic period.
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Affiliation(s)
| | | | | | | | | | - Bence András Lázár
- Addiction Research Group, Department of Psychiatry, University of Szeged, 6720 Szeged, Hungary; (J.G.); (O.B.); (F.F.F.); (B.A.); (I.K.P.)
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Unlu H, Macaron MM, Ayraler Taner H, Kaba D, Akin Sari B, Schneekloth TD, Leggio L, Abulseoud OA. Sex difference in alcohol withdrawal syndrome: a scoping review of clinical studies. Front Psychiatry 2023; 14:1266424. [PMID: 37810604 PMCID: PMC10556532 DOI: 10.3389/fpsyt.2023.1266424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background We conducted a review of all studies comparing clinical aspects of alcohol withdrawal syndrome (AWS) between men and women. Methods Five databases (PubMed, Cochrane, EMBASE, Scopus and Clinical Trials) were searched for clinical studies using the keywords "alcohol withdrawal syndrome" or "delirium tremens" limited to "sex" or "gender" or "sex difference" or "gender difference." The search was conducted on May 19, 2023. Two reviewers selected studies including both male and female patients with AWS, and they compared males and females in type of AWS symptoms, clinical course, complications, and treatment outcome. Results Thirty-five observational studies were included with a total of 318,730 participants of which 75,346 had AWS. In twenty of the studies, the number of patients presenting with or developing AWS was separated by sex, resulting in a total of 8,159 (12.5%) female patients and a total of 56,928 (87.5%) male patients. Despite inconsistent results, males were more likely than females to develop complicated AWS [delirium tremens (DT) and AW seizures, collective DT in Males vs. females: 1,792 (85.4%) vs. 307 (14.6%), and collective seizures in males vs. females: 294 (78%) vs. 82 (22%)]. The rates of ICU admissions and hospital length of stay did not show sex differences. Although variable across studies, compared to females, males received benzodiazepine treatment at higher frequency and dose. One study reported that the time from first hospitalization for AWS to death was approximately 1.5 years shorter for males and males had higher mortality rate [19.5% (197/1,016)] compared to females [16% (26/163)]. Conclusion Despite the significant heterogeneity of the studies selected and the lack of a focus on investigating potential sex differences, this review of clinical studies on AWS suggests that men and women exhibit different AWS manifestations. Large-scale studies focusing specifically on investigating sex difference in AWS are needed.
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Affiliation(s)
- Hayrunnisa Unlu
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, Phoenix, AZ, United States
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | | | - Hande Ayraler Taner
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | - Duygu Kaba
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | - Burcu Akin Sari
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | - Terry D. Schneekloth
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Lorenzo Leggio
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, Translational Addiction Medicine Branch, National Institute on Drug Abuse, and National Institute on Alcohol Abuse and Alcoholism, Baltimore, MD, United States
| | - Osama A. Abulseoud
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, Phoenix, AZ, United States
- Department of Neuroscience, Graduate School of Biomedical Sciences, Mayo Clinic College of Medicine, Phoenix, AZ, United States
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Affiliation(s)
- Alexander Alexiou
- Barts Health NHS Trust, London, UK
- London's Air Ambulance, Royal London Hospital, London
| | - Thomas King
- Barts Health NHS Trust, London, UK
- London's Air Ambulance, Royal London Hospital, London
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Novak L, Soravia LM, Bünter A, Stöth F, Wopfner A, Weinmann W, Pfeifer P. Alcohol Biomarker Phosphatidylethanol as a Predictor of the Severity of Alcohol Withdrawal Syndrome. Alcohol Alcohol 2023; 58:198-202. [PMID: 36695434 DOI: 10.1093/alcalc/agac071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 12/02/2022] [Accepted: 12/17/2022] [Indexed: 01/26/2023] Open
Abstract
AIMS to investigate the relationship between phosphatidylethanol (PEth) and withdrawal severity in patients with alcohol use disorder (AUD). METHODS in 34 patients with AUD admitted for treatment of acute alcohol withdrawal, data were available for initial blood PEth concentrations and scores throughout detoxification of symptoms of withdrawal assessed by trained medical staff using the alcohol withdrawal syndrome (AWS)-scale, a validated scale consisting of 11 items in the alcohol withdrawal syndrome (two subscales with seven physiological and five psychological symptoms). RESULTS a significant positive correlation between PEth and the severity of alcohol withdrawal was found. When the sample was divided into two groups, according to whether or not AWS score at some point in the treatment reached 6 or more, the median PEth score was higher in those whose peak score had been 6 or more (score of 6 being the suggested cutoff to start medicating the withdrawal syndrome). Although there was a trend for some aspects of the clinical history to be more 'severe' in those with higher AWS, no differences reached significance. CONCLUSION blood PEth on admission could have a role in identifying patients at risk of more severe AWS.
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Affiliation(s)
- Lan Novak
- Suedhang Clinic, Center for Treatment of Addictive Disorders, Kirchlindach 3038, Switzerland
| | - Leila M Soravia
- Suedhang Clinic, Center for Treatment of Addictive Disorders, Kirchlindach 3038, Switzerland.,University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern 3012, Switzerland
| | - Adina Bünter
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern 3012, Switzerland
| | - Frederike Stöth
- Institute of Forensic Medicine, University of Bern, Bern 3012, Switzerland
| | - Alexander Wopfner
- Suedhang Clinic, Center for Treatment of Addictive Disorders, Kirchlindach 3038, Switzerland
| | - Wolfgang Weinmann
- Institute of Forensic Medicine, University of Bern, Bern 3012, Switzerland
| | - Philippe Pfeifer
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern 3012, Switzerland
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Yıldırım YE, Umut G, Evren C, Yeral E, Secerli H. Neutrophil-lymphocyte ratio as a predictor of delirium tremens in hospitalized patients with alcohol withdrawal. Alcohol 2023; 109:43-48. [PMID: 36709009 DOI: 10.1016/j.alcohol.2022.12.004] [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: 06/27/2022] [Revised: 12/11/2022] [Accepted: 12/28/2022] [Indexed: 01/27/2023]
Abstract
Delirium Tremens (DT) is a severe form of alcohol withdrawal that can be fatal if not recognized early and treated appropriately. In our study, we aimed to determine the role of Neutrophil-Lymphocyte ratio (NLR), a marker of systemic inflammation, in predicting the development of DT. This retrospective study was conducted in an alcohol and drug treatment center between March 2017 and March 2020. A total of 212 patients with a diagnosis of alcohol use disorder who were admitted to a special care unit after alcohol withdrawal were included. Blood tests were collected within 24 hours of the patients' admission. Comparisons were made according to whether the patients developed DT during the hospitalization. DT was diagnosed in 24.1% of the patients. It was determined that higher NLR level (odds ratio [OR]: 4.38, 95%CI: 2.58-7.43) and history of DT (OR: 1.33, 95%CI: 1.23-11.73) are independent risk factors for the development of DT in the logistic regression analysis. The optimal cut-off value of NLR in predicting DT was 2.67 (sensitivity: 82.4%, specificity: 88.8%). The ROC curve of NLR showed a larger area under the curve (AUC) than the curves of other systemic inflammation markers. NLR is a simple, practical and inexpensive marker that can predict the development of DT in patients with alcohol withdrawal syndrome.
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Affiliation(s)
- Yusuf Ezel Yıldırım
- Department of Psychiatry, University of Health Sciences, Medicine Faculty, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatric, Neurological and Neurosurgical Diseases, Istanbul, Turkey.
| | - Gökhan Umut
- Department of Psychiatry, University of Health Sciences, Medicine Faculty, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatric, Neurological and Neurosurgical Diseases, Istanbul, Turkey
| | - Cüneyt Evren
- Department of Psychiatry, University of Health Sciences, Medicine Faculty, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatric, Neurological and Neurosurgical Diseases, Istanbul, Turkey
| | - Eylül Yeral
- Department of Psychiatry, University of Health Sciences, Medicine Faculty, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatric, Neurological and Neurosurgical Diseases, Istanbul, Turkey
| | - Hikmet Secerli
- Department of Psychiatry, University of Health Sciences, Medicine Faculty, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatric, Neurological and Neurosurgical Diseases, Istanbul, Turkey
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Yoon JE, Mo H, Kim DW, Im HJ. Quantitative electroencephalographic analysis of delirium tremens development following alcohol-withdrawal seizure based on a small number of male cases. Brain Behav 2022; 12:e2804. [PMID: 36306397 PMCID: PMC9759131 DOI: 10.1002/brb3.2804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/29/2022] [Accepted: 10/08/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Seizures and delirium tremens (DTs) are recognized as severe alcohol-withdrawal symptoms. Prolonged admission and serious complications associated with alcohol withdrawal are responsible for increased costs and use of medical and social resources. This study investigated the predictive value of quantitative electroencephalography (QEEG) for developing alcohol-related DTs after alcohol-withdrawal seizure (AWS). METHODS We compared differences in QEEG in patients after AWS (n = 13). QEEG was performed in the intensive care unit within 48 h of admission, including in age- and sex-matched healthy controls. We also investigated the prognostic value of QEEG for the development of alcohol DTs after AWS in a retrospective, case-control study. The spectral power of each band frequency and the ratio of the theta to alpha band (TAR) in the electroencephalogram were analyzed using iSyncBrain® (iMediSync, Inc., Korea). RESULTS The beta frequency and the alpha frequency band power were significantly higher and lower, respectively, in patients than in age- and sex-matched healthy controls. In AWS patients with DTs, the relative beta-3 power was lower, particularly in the left frontal area, and the TAR was significantly higher in the central channel than in those without DTs. CONCLUSION Quantitative EEG showed neuronal excitability and decreased cognitive activities characteristic of AWS associated with alcohol-withdrawal state, and we demonstrated that quantitative EEG might be a helpful tool for detecting patients at a high risk of developing DTs during an alcohol-dependence period.
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Affiliation(s)
- Jee-Eun Yoon
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Republic of Korea
| | - Heejung Mo
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Dong Wook Kim
- Department of Neurology, School of Medicine, Konkuk University, Seoul, Republic of Korea
| | - Hee-Jin Im
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
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Nath P, Anand AC. Extrahepatic Manifestations in Alcoholic Liver Disease. J Clin Exp Hepatol 2022; 12:1371-1383. [PMID: 36157144 PMCID: PMC9499846 DOI: 10.1016/j.jceh.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/20/2022] [Indexed: 12/12/2022] Open
Abstract
Though liver is the most commonly affected organ in patients with chronic and excessive intake of alcohol, no organ is immune to toxic effects of alcohol and patients with alcohol-related liver disease (ALD) can suffer from a wide list of extrahepatic manifestations involving gastrointestinal tract, central and peripheral nervous systems, cardio vascular system, musculo-skeletal system, disruption of nutritional status, endocrinological abnormalities, hematological abnormalities and immune dysfunction. These extrahepatic organ involvements are usually overlooked by hepatologists and physicians who are mostly focused on managing life threatening complications of ALD. As a result, there is delayed diagnosis, delay in the initiation of appropriate treatment and late referral to other specialists. Some of these manifestations are of utmost clinical importance (e.g. delirium tremans and Wernicke's encephalopathy) because an early diagnosis and treatment can lead to full recovery while delayed or no treatment can result in death. On the other hand, several extrahepatic manifestations are of prognostic significance (such as alcoholic cardiomyopathy and malignancies) in which there is an increased risk of morbidity and mortality. Hence, a clear understanding and awareness of the extrahepatic manifestations of ALD is quintessential for proper management of these patients.
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Key Words
- ACE, Angiotensin-Converting-Enzyme
- ALD, Alcohol related Liver Disease
- AUD, Alcohol Use Disorder
- GAVE, Gastric Antral Vascular Ectasia
- GERD, Gastro-Esophageal Reflux Disease
- HCC, Hepatocellular Carcinoma
- HIV, Human Immunodeficiency Virus
- IARC, International Agency for Research on Cancer
- IL, Interleukin
- NERD, Non-Erosive Reflux Disease
- PPI, Proton Pump Inhibitors
- TNF, Tumour Necrosis Factor
- UGI, Upper Gastrointestinal
- WHO, World Health Organization
- alcohol use disorder
- alcohol withdrawal syndrome
- alcoholic cardiomyopathy
- alcoholic liver disease
- alcoholic myopathy
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Affiliation(s)
- Preetam Nath
- Department of Gastroenterology & Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, 751024, India
| | - Anil C. Anand
- Department of Gastroenterology & Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, 751024, India
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Carlson RW, Girgla N, Davis J, Moradi A, Cooper T. Pneumonia is a common and early complication of the Severe Alcohol Withdrawal Syndrome (SAWS). Heart Lung 2022; 55:42-48. [PMID: 35468360 DOI: 10.1016/j.hrtlng.2022.04.001] [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: 12/08/2021] [Revised: 03/25/2022] [Accepted: 04/03/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pneumonia (PNA) may complicate the Severe Alcohol Withdrawal Syndrome (SAWS), with ICU admission, mechanical ventilation (MV), prolonged length of stay (LOS), and adverse events. OBJECTIVES To examine the onset, features and courses of PNA in patients with SAWS to aid management. METHODS A 33 month contiguous review of SAWS and PNA was conducted at an urban public hospital. RESULTS There were 279 episodes of Alcohol Withdrawal Syndrome (AWS) among 255 patients. Males predominated (91%) with a mean age of 45.8 years (range 23-73), of whom 31% (87/279) developed SAWS with ICU management. Direct ICU admission occurred for 62 patients; 25 were transferred for delirium, seizures, escalating sedation, PNA or other complications. PNA was identified for 34 ICU direct admissions and 13 ward patients. Ten transfers to the ICU also developed PNA for an ICU total of 44/87 (51%), of whom 82% (36/44) required MV. Another 10 ICU patients without PNA received MV for high dose sedation or respiratory failure. Most ICU patients (72/87 (83%)), including all with MV, required IV infusion of sedation. MV prolonged LOS, but LOS for PNA with MV was similar to all MV. ICU transfers had longer LOS with greater use of MV than direct admits (p<0.05). PNA was identified before ICU admission or transfer for 73% (32/44 (p<0.05)), and usually before intubation. Most PNA was Community Acquired Pneumonia (CAP) with P. Pneumoniae frequently cultured. CONCLUSIONS PNA with SAWS is predominately CAP and occurs early. Focused ICU admission with respiratory support are priorities of initial management.
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Affiliation(s)
- Richard W Carlson
- Department of Medicine, Valleywise Medical Center, Phoenix, AZ, United States; College of Medicine, University of Arizona, Phoenix, AZ, United States; Mayo Clinic Alix School of Medicine, Scottsdale, AZ, United States.
| | - Navkaran Girgla
- Department of Medicine, Valleywise Medical Center, Phoenix, AZ, United States; Creighton University Arizona Education Health Alliance, AZ, United States
| | - Jesse Davis
- Department of Medicine, Addiction Medicine Fellowship, University of Washington, Seattle, WA, United States
| | - Ali Moradi
- Department of Medicine, Valleywise Medical Center, Phoenix, AZ, United States; Creighton University Arizona Education Health Alliance, AZ, United States
| | - Tracy Cooper
- Valleywise Medical Center, Phoenix, AZ, United States
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12
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Canales FJ, Davis J, Girgla N, Emami M, Cooper T, Carlson RW. Alcohol Withdrawal Syndrome in Women vs Men: Analysis of 1496 Cases at a Single Site. Am J Crit Care 2022; 31:212-219. [PMID: 35466349 DOI: 10.4037/ajcc2022616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Studies of alcohol withdrawal syndrome indicate a higher prevalence in men than in women. However, it is unknown how the condition differs between the sexes. OBJECTIVE To assess alcohol withdrawal syndrome in women versus men at a single site. METHODS All cases of alcohol withdrawal syndrome at a public hospital from 2010 to 2014 were reviewed retrospectively. For all 1496 episodes, age, sex, and admission to a general care unit (ward) versus the medical intensive care unit were ascertained, along with patient survival. A detailed analysis was performed of 437 cases: all 239 patients admitted to the medical intensive care unit, all 99 female patients admitted to the ward, and 99 randomly selected male patients admitted to the ward. Also analyzed were administration of benzodiazepines, disease course, length of stay, and complications. RESULTS Men accounted for 92% of all cases (1378 of 1496; P < .001) and medical intensive care unit admissions (220 of 239; P < .05). Sixteen percent of both men and women were admitted to the medical intensive care unit. Men were older (mean age, 45.6 vs 43.9 years; P < .01), and women required more benzodiazepines. Similar rates of complications occurred in both sexes, although women had a higher rate of pancreatitis and men had higher rates of pneumonia, higher rates of sepsis, and longer stays. CONCLUSIONS Men and women with alcohol withdrawal syndrome have similar complications, courses, and intensive care unit admission rates, although men are more prone to pneumonia and have longer stays.
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Affiliation(s)
- Francisco J. Canales
- Francisco J. Canales Jr is a resident physician, Department of Emergency Medicine, University of Arizona, Tucson
| | - Jesse Davis
- Jesse Davis is a resident physician, Department of Medicine, Valleywise Medical Center, Phoenix, Arizona, and Creighton University Arizona Education Health Alliance, Phoenix
| | - Navkaran Girgla
- Navkaran Girgla is a resident physician, Department of Medicine, Valleywise Medical Center, and Creighton University Arizona Education Health Alliance
| | - Maryam Emami
- Maryam Emami is a staff physician, Thumb Butte Medical Center, Prescott, Arizona
| | - Tracy Cooper
- Tracy Cooper is a staff nurse in the intensive care unit, Valleywise Medical Center
| | - Richard W. Carlson
- Richard W. Carlson is a professor, College of Medicine, University of Arizona, Phoenix, and Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, and chair emeritus, Department of Medicine, Valleywise Health Medical Center
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Vigouroux A, Garret C, Lascarrou JB, Martin M, Miailhe AF, Lemarié J, Dupeyrat J, Zambon O, Seguin A, Reignier J, Canet E. Alcohol withdrawal syndrome in ICU patients: Clinical features, management, and outcome predictors. PLoS One 2021; 16:e0261443. [PMID: 34928984 PMCID: PMC8687554 DOI: 10.1371/journal.pone.0261443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/01/2021] [Indexed: 12/01/2022] Open
Abstract
Background Alcohol withdrawal syndrome (AWS) is a common condition in hospitalized patients, yet its epidemiology in the ICU remains poorly characterized. Methods Retrospective cohort of patients admitted to the Nantes University Hospital ICU between January 1, 2017, and December 31, 2019, and coded for AWS using ICD-10 criteria. The objective of the study was to identify factors associated with complicated hospital stay defined as ICU length of stay ≥7 days or hospital mortality. Results Among 5,641 patients admitted to the ICU during the study period, 246 (4.4%) were coded as having AWS. Among them, 42 had exclusion criteria and 204 were included in the study. The three main reasons for ICU admission were sepsis (29.9%), altered consciousness (29.4%), and seizures (24%). At ICU admission, median Cushman’s score was 6 [4–9] and median SOFA score was 3 [2–6]. Delirium tremens occurred in half the patients, seizures in one fifth and pneumonia in one third. Overall, 48% of patients developed complicated hospital stay, of whom 92.8% stayed in the ICU for ≥7 days, 36.7% received MV for ≥7 days, and 16.3% died during hospital stay. By multivariable analysis, two factors were associated with complicated hospital stay: a higher number of organ dysfunctions at ICU admission was associated with a higher risk of complicated hospital stay (OR, 1.18; 95CI, 1.05–1.32, P = 0.005), whereas ICU admission for seizures was associated with a lower risk of complicated hospital stay (OR, 0.14; 95%CI, 0.026–0.80; P = 0.026). Conclusions AWS in ICU patients chiefly affects young adults and is often associated with additional factors such as sepsis, trauma, or surgery. Half the patients experienced an extended ICU stay or death during the hospital stay. The likelihood of developing complicated hospital stay relied on the reason for ICU admission and the number of organ dysfunctions at ICU admission.
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Affiliation(s)
- Aliénor Vigouroux
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Charlotte Garret
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Jean-Baptiste Lascarrou
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Maëlle Martin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Arnaud-Félix Miailhe
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Jérémie Lemarié
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Julien Dupeyrat
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Olivier Zambon
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Amélie Seguin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Jean Reignier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Emmanuel Canet
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
- * E-mail:
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Steel TL, Afshar M, Edwards S, Jolley SE, Timko C, Clark BJ, Douglas IS, Dzierba AL, Gershengorn HB, Gilpin NW, Godwin DW, Hough CL, Maldonado JR, Mehta AB, Nelson LS, Patel MB, Rastegar DA, Stollings JL, Tabakoff B, Tate JA, Wong A, Burnham EL. Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 204:e61-e87. [PMID: 34609257 PMCID: PMC8528516 DOI: 10.1164/rccm.202108-1845st] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Severe alcohol withdrawal syndrome (SAWS) is highly morbid, costly, and common among hospitalized patients, yet minimal evidence exists to guide inpatient management. Research needs in this field are broad, spanning the translational science spectrum. Goals: This research statement aims to describe what is known about SAWS, identify knowledge gaps, and offer recommendations for research in each domain of the Institute of Medicine T0-T4 continuum to advance the care of hospitalized patients who experience SAWS. Methods: Clinicians and researchers with unique and complementary expertise in basic, clinical, and implementation research related to unhealthy alcohol consumption and alcohol withdrawal were invited to participate in a workshop at the American Thoracic Society 2019 International Conference. The committee was subdivided into four groups on the basis of interest and expertise: T0-T1 (basic science research with translation to humans), T2 (research translating to patients), T3 (research translating to clinical practice), and T4 (research translating to communities). A medical librarian conducted a pragmatic literature search to facilitate this work, and committee members reviewed and supplemented the resulting evidence, identifying key knowledge gaps. Results: The committee identified several investigative opportunities to advance the care of patients with SAWS in each domain of the translational science spectrum. Major themes included 1) the need to investigate non-γ-aminobutyric acid pathways for alcohol withdrawal syndrome treatment; 2) harnessing retrospective and electronic health record data to identify risk factors and create objective severity scoring systems, particularly for acutely ill patients with SAWS; 3) the need for more robust comparative-effectiveness data to identify optimal SAWS treatment strategies; and 4) recommendations to accelerate implementation of effective treatments into practice. Conclusions: The dearth of evidence supporting management decisions for hospitalized patients with SAWS, many of whom require critical care, represents both a call to action and an opportunity for the American Thoracic Society and larger scientific communities to improve care for a vulnerable patient population. This report highlights basic, clinical, and implementation research that diverse experts agree will have the greatest impact on improving care for hospitalized patients with SAWS.
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15
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Utkin SI. [Clinical and metabolic predictors for delirium tremens]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:64-69. [PMID: 34460159 DOI: 10.17116/jnevro202112107164] [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: 11/17/2022]
Abstract
OBJECTIVE To search for objective diagnostic criteria for the development of delirium tremens (DT) based on physiological and metabolic parameters. MATERIAL AND METHODS The total number of patients was 506, including 393 patients with DT and 113 patients with uncomplicated alcohol withdrawal syndrome (UAWS). Twenty clinical and metabolic indicators were analyzed statistically using comparison of means, logistic regression and ROC-analysis. RESULTS AND CONCLUSION Hyponatremia, thrombocytopenia and tachycardia are most prognostically significant indicators, changes in which are observed in the development of DT. These indicators can serve as the basis for objective diagnosis of alcohol withdrawal syndrome complicated by delirium.
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Affiliation(s)
- S I Utkin
- Moscow Research and Practical Centre for Narcology, Moscow, Russia
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16
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Sanvisens A, Zuluaga P, Short A, Rubio G, Gual A, Torrens M, Fuster D, Bolao F, Rodríguez de Fonseca F, Muga R. Sex-specific Associations of Alcohol Withdrawal in Patients Admitted for the Treatment of Alcohol Use Disorder. J Addict Med 2021; 15:68-73. [PMID: 32769772 DOI: 10.1097/adm.0000000000000704] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES There are sex differences in the pattern of alcohol consumption and in the complications of alcohol use disorder (AUD). We aimed to identify sex-specific differences in the factors associated with alcohol withdrawal syndrome (AWS) among patients that requested a first treatment for AUD. METHODS We enrolled 313 patients (75% men) with a Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) AUD diagnosis that started treatment between 2014 and 2016. We collected socio-demographics, the type and amount of alcohol and other substances consumed, and clinical and laboratory parameters. According to Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) AUD criteria, AWS occurred when patients experienced 2 or more clinical signs/symptoms and/or consumed alcohol to relieve symptoms. Logistic regression models were used to determine factors associated with AWS according to sex. RESULTS The median age of participants was 50 years (interquartile range [IQR]: 43-54 years). The median age of starting alcohol consumption was 16 years (IQR: 14-18 years). Notably, 69% of participants smoked tobacco, and 61% had a family history of AUD; 18% currently used cannabis, and 7.7% used cocaine. Overall, 73% of patients exhibited AWS criteria, and men (76.5%) were more likely than women (64.6%) to report AWS (P = 0.038). In the adjusted analysis, factors associated with AWS were the age at starting alcohol consumption (odds ratio [OR] for every 5 years = 1.89, 95% confidence interval [CI]: 1.69-2.08), and cannabis use (OR = 2.8, 95% CI: 1.04-7.7) in men, and a family history of AUD in women (OR = 2.85 95% CI: 1.07-7.54). CONCLUSIONS factors associated with AWS differ by sex which may have clinical implications for proactive management of AWS during treatment for AUD.
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Affiliation(s)
- Arantza Sanvisens
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol - IGTP, Universitat Autònoma de Barcelona, Spain (AS, PZ, DF, RM); Alcohol Unit, Hospital Universitari Son Espases - IdISPa, Palma de Mallorca, Spain (AS); Department of Psychiatry, Hospital Universitario 12 de Octubre - Instituto i+12, Universidad Complutense de Madrid, Spain (GR); Department of Psychiatry, Hospital Clínic de Barcelona - IDIBAPS, Universitat de Barcelona, Spain (AG); Department of Neuropsychiatry and Addictions, Hospital del Mar - IMIM, Universitat Autònoma de Barcelona, Spain (MT); Department of Internal Medicine, Hospital Universitari de Bellvitge- IDIBELL, L'Hospitalet de Llobregat, Spain (FB); IBIMA Biomedical Research Institut - Málaga, Spain (FRdF)
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Sarkar S, Thakur A, Sood E, Mandal P. Barriers and Facilitators of Addiction Treatment: a Qualitative Study. Int J Ment Health Addict 2020. [DOI: 10.1007/s11469-020-00394-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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18
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Narasimha VL, Shukla L, Mukherjee D, Menon J, Huddar S, Panda UK, Mahadevan J, Kandasamy A, Chand PK, Benegal V, Murthy P. Complicated Alcohol Withdrawal-An Unintended Consequence of COVID-19 Lockdown. Alcohol Alcohol 2020; 55:350-353. [PMID: 32400859 PMCID: PMC7239212 DOI: 10.1093/alcalc/agaa042] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/23/2020] [Accepted: 04/25/2020] [Indexed: 12/04/2022] Open
Abstract
AIM To assess the impact of COVID-19-related lockdown in India on alcohol-dependent persons. METHOD We examined the change in the incidence of severe alcohol withdrawal syndrome presenting to hospitals in the city of Bangalore. RESULTS A changepoint analysis of the time series data (between 01.01.20 to 11.04.20) showed an increase in the average number of cases from 4 to 8 per day (likelihood ratio test: χ2 = 72, df = 2, P < 0.001). CONCLUSION An unintended consequence of the lockdown was serious illness in some patients with alcohol use disorders.
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Affiliation(s)
- Venkata Lakshmi Narasimha
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 560029, India
| | - Lekhansh Shukla
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 560029, India
| | - Diptadhi Mukherjee
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 560029, India
| | - Jayakrishnan Menon
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 560029, India
| | - Sudheendra Huddar
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 560029, India
| | - Udit Kumar Panda
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 560029, India
| | - Jayant Mahadevan
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 560029, India
| | - Arun Kandasamy
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 560029, India
| | - Prabhat K Chand
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 560029, India
| | - Vivek Benegal
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 560029, India
| | - Pratima Murthy
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, 560029, India
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Burkhardt G, Adorjan K, Kambeitz J, Kambeitz-Ilankovic L, Falkai P, Eyer F, Koller G, Pogarell O, Koutsouleris N, Dwyer DB. A machine learning approach to risk assessment for alcohol withdrawal syndrome. Eur Neuropsychopharmacol 2020; 35:61-70. [PMID: 32418843 DOI: 10.1016/j.euroneuro.2020.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 03/04/2020] [Accepted: 03/27/2020] [Indexed: 02/01/2023]
Abstract
At present, risk assessment for alcohol withdrawal syndrome relies on clinical judgment. Our aim was to develop accurate machine learning tools to predict alcohol withdrawal outcomes at the individual subject level using information easily attainable at patients' admission. An observational machine learning analysis using nested cross-validation and out-of-sample validation was applied to alcohol-dependent patients at two major detoxification wards (LMU, n = 389; TU, n = 805). 121 retrospectively derived clinical, blood-derived, and sociodemographic measures were used to predict 1) moderate to severe withdrawal defined by the alcohol withdrawal scale, 2) delirium tremens, and 3) withdrawal seizures. Mild and more severe withdrawal cases could be separated with significant, although highly variable accuracy in both samples (LMU, balanced accuracy [BAC] = 69.4%; TU, BAC = 55.9%). Poor outcome predictions were associated with higher cumulative clomethiazole doses during the withdrawal course. Delirium tremens was predicted in the TU cohort with BAC of 75%. No significant model predicting withdrawal seizures could be found. Our models were unique to each treatment site and thus did not generalize. For both treatment sites and withdrawal outcome different variable sets informed our models' decisions. Besides previously described variables (most notably, thrombocytopenia), we identified new predictors (history of blood pressure abnormalities, urine screening for benzodiazepines and educational attainment). In conclusion, machine learning approaches may facilitate generalizable, individualized predictions for alcohol withdrawal severity. Since predictive patterns highly vary for different outcomes of withdrawal severity and across treatment sites, prediction tools should not be recommended for clinical practice unless adequately validated in specific cohorts.
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Affiliation(s)
- Gerrit Burkhardt
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany.
| | - Kristina Adorjan
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany; Institute of Psychiatric Phenomics and Genomics (IPPG), University Hospital, LMU Munich, Munich, Germany
| | - Joseph Kambeitz
- Department of Psychiatry and Psychotherapy, University of Cologne, Germany
| | - Lana Kambeitz-Ilankovic
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany
| | - Florian Eyer
- Department of Clinical Toxicology, TUM School of Medicine, Technical University of Munich, Germany
| | - Gabi Koller
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany
| | - Oliver Pogarell
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany
| | - Nikolaos Koutsouleris
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany
| | - Dominic B Dwyer
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany
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Derivation and validation of a multivariable model, the alcohol withdrawal triage tool (AWTT), for predicting severe alcohol withdrawal syndrome. Drug Alcohol Depend 2020; 209:107943. [PMID: 32172129 DOI: 10.1016/j.drugalcdep.2020.107943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Alcohol withdrawal and its consequences are a common concern for the large numbers of patients who present to emergency departments (EDs) with alcohol use disorders. While the majority of patients who go on to develop alcohol withdrawal experience only mild symptoms, a small proportion will experience seizures or delirium tremens. The aim of this study was to develop a tool to predict the need for hospital admission in patients at risk for alcohol withdrawal using only objective criteria that are typically available during the course of an ED visit. METHODS We conducted a retrospective study at an academic medical center. Our primary outcome was severe alcohol withdrawal syndrome (SAWS), which we defined as a composite of delirium tremens, seizure, or use of high benzodiazepine doses. All candidate predictors were abstracted from the electronic health record. A logistic regression model was constructed using the derivation dataset to create the alcohol withdrawal triage tool (AWTT). RESULTS Of the 2038 study patients, 408 20.0 %) developed SAWS. We identified eight independent predictors of SAWS. Each of the predictors in the regression model was assigned one point. Summing the points for each predictor generated the AWTT score. An AWTT score of 3 or greater was defined as high risk based on sensitivity of 90 % and specificity of 47 % for predicting SAWS. CONCLUSIONS We were able to identify a set of objective, timely, independent predictors of SAWS. The predictors were used to create a novel clinical prediction rule, the AWTT.
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Wolf C, Curry A, Nacht J, Simpson SA. Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives. Open Access Emerg Med 2020; 12:53-65. [PMID: 32256131 PMCID: PMC7093658 DOI: 10.2147/oaem.s235288] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 02/18/2020] [Indexed: 12/14/2022] Open
Abstract
Alcohol withdrawal syndrome (AWS) is a common, heterogenous, and life-threatening complication of alcohol use disorder (AUD). AUD is a leading cause of worldwide mortality, and many patients with AUD will develop AWS during their ED course. This review summarizes the epidemiology, pathology, and management of AWS and AUD in the emergency setting. The time course of AWS and its impact on ED treatment is emphasized. Once AWS is diagnosed, symptom-triggered benzodiazepine administration remains the most commonly provided treatment but may not be appropriate for patients with significant medical or psychiatric comorbidity or pending discharge. In these cases, ED clinicians may consider short courses of barbiturates or alternative regimens based on novel anticonvulsants. Specific treatment protocols are enumerated for clinical practice. Finally, emergency providers must not only manage acute patients' AWS but also lay the foundation for successful treatment of AUD. An approach to the disposition of the patient with AUD is presented. The authors examine shortcomings in the extant literature and suggest opportunities for further study.
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Affiliation(s)
- Chelsea Wolf
- Denver Health Medical Center, Denver, CO, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ashley Curry
- Denver Health Medical Center, Denver, CO, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jacob Nacht
- Denver Health Medical Center, Denver, CO, USA
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Scott A Simpson
- Denver Health Medical Center, Denver, CO, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Abstract
BACKGROUND The literature lacks consensus to the factors that increase the risk of a patient developing severe alcohol withdrawal syndrome (SAWS). AIM The study set out to identify the variables that increase the risk of SAWS in patients who have alcohol dependence syndrome. METHODS A case-control study was designed to investigate the variables associated with SAWS in an acute hospital setting. Three hundred eighty-two case and 382 control patients were randomly selected retrospectively from referrals to the acute addiction liaison nursing service during a 12-month period (January 1, 2015, to December 31, 2015). Statistical significance (p < .05) and association with SAWS were calculated using chi-square, Cramer's V test, odds ratio, and Levene's test. RESULTS Twenty-four variables have been identified as associated with SAWS development. Five of the 24 variables had a moderate-to-strong association with SAWS risk: Fast Alcohol Screening Test, Glasgow Modified Alcohol Withdrawal Scale score, AWS admission, hours since the last drink, and systolic blood pressure. The study also identified that comorbidity was associated with not developing SAWS. CONCLUSION/RECOMMENDATIONS These findings confirm that noninvasive variables collected in the emergency department are useful in identifying a person's risk of developing SAWS. The results of this study are a useful starting point in the exploration of SAWS and the development of a tool for use in the emergency department that can stratify risk into high and low and is the next stage of this program of work.
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Development of an alcohol withdrawal risk stratification tool based on patients referred to an addiction liaison nursing service in Glasgow. DRUGS AND ALCOHOL TODAY 2019. [DOI: 10.1108/dat-02-2019-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to develop an alcohol withdrawal syndrome risk stratification tool that could support the safe discharge of low risk patients from the emergency department.
Design/methodology/approach
A retrospective cohort study that included all patients referred to the acute addiction liaison nursing service over one calendar month (n=400, 1–30 April 2016) was undertaken. Bivariate and multivariate modelling identified the significant variables that supported the prediction of severe alcohol withdrawal syndrome (SAWS) in the cohort population.
Findings
The Glasgow Modified Alcohol Withdrawal Scale (GMAWS), hours since last drink, fast alcohol screening test (FAST) and systolic blood pressure correctly identified 89 per cent of patients who developed SAWS and 84 per cent of patients that did not. Increasing each component by a score of one is associated with an increase in the odds of SAWS by a factor of 2.76 (95% CI 2.21, 3.45), 1.31 (95% CI 1.24, 1.37), 1.30 (95% CI 1.08, 1.57) and 1.22 (95% CI 1.10, 1.34), respectively.
Research limitations/implications
The research was conducted in a single healthcare system that had a high prevalence of alcohol dependence syndrome (ADS). Second, the developed risk stratification tool was unable to guarantee no risk and lastly, the FAST score previously aligned to severe ADS may have influenced the patients highest GMAWS score.
Practical implications
The tool could help redesign the care pathway for patients who attend the emergency department at risk of SAWS and link low risk patients with community alcohol services better equipped to deal with their physical and psychological needs short and long term supporting engagement, abstinence and prolongation of life.
Originality/value
The tool could help redesign the care pathway for emergency department patients at low risk of SAWS and link them with community alcohol services better equipped to deal with their physical and psychological needs, short and long term, supporting engagement, abstinence and prolongation of life.
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Sørensen HJ, Holst C, Knop J, Mortensen EL, Tolstrup JS, Becker U. Alcohol and delirium tremens: effects of average number of drinks per day and beverage type. Acta Psychiatr Scand 2019; 139:518-525. [PMID: 30697683 DOI: 10.1111/acps.13006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Associations of amount of alcohol intake and beverage type with the risk of delirium tremens (DT) have not been studied. This longitudinal study investigated if the average number of drinks per day and beverage type predict DT. METHODS A cohort of 3 582 alcohol-dependent men and women aged 19-82 without previous DT were interviewed about alcohol intake and beverage type at baseline in 1994-2005 and followed through record linkage in Danish nationwide registers to identify incident DT. Data were analyzed by means of Cox regression models. RESULTS An average number of drinks per day of 20-30 or >30 was associated with hazard ratios (HRs) of 1.38 (95% CI 1.03-1.84) and 1.64 (95% CI 1.19-2.27) relative to the reference category (1-9 drinks). Independently of amount consumed and covariates (age, gender, civil status and work status), beverage type (spirits vs. mixed alcohol) was associated with a HR of 1.63 (95% CI 1.08-2.46). Male gender was robustly associated with increased risk (HR = 1.62 (95% CI 1.25-2.08). CONCLUSIONS In alcohol-dependent men and women, daily alcohol intake above a threshold of 20 beverages or 240 g alcohol and a preference for spirits increase the risk of developing DT.
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Affiliation(s)
- H J Sørensen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.,Mental Health Centre Copenhagen, The Capital Region, Copenhagen, Denmark
| | - C Holst
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - J Knop
- Department of Clinical Epidemiology, Frederiksberg & Bispebjerg Hospital, Copenhagen, Denmark
| | - E L Mortensen
- Department of Public Health and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - J S Tolstrup
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - U Becker
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.,Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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Fritz M, Klawonn AM, Zahr NM. Neuroimaging in alcohol use disorder: From mouse to man. J Neurosci Res 2019; 100:1140-1158. [PMID: 31006907 DOI: 10.1002/jnr.24423] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/15/2019] [Accepted: 03/14/2019] [Indexed: 02/06/2023]
Abstract
This article provides an overview of recent advances in understanding the effects of alcohol use disorders (AUD) on the brain from the perspective of magnetic resonance imaging (MRI) research in preclinical models and clinical studies. As a noninvasive investigational tool permitting assessment of morphological, metabolic, and hemodynamic changes over time, MRI offers insight into the dynamic course of alcoholism beginning with initial exposure through periods of binge drinking and escalation, sobriety, and relapse and has been useful in differential diagnosis of neurological diseases associated with AUD. Structural MRI has revealed acute and chronic effects of alcohol on both white and gray matter volumes. MR Spectroscopy, able to quantify brain metabolites in vivo, has shed light on biochemical alterations associated with alcoholism. Diffusion tensor imaging permits microstructural characterization of white matter fiber tracts. Functional MRI has allowed for elucidation of hemodynamic responses at rest and during task engagement. Positron emission tomography, a non-MRI imaging tool, has led to a deeper understanding of alcohol-induced receptor and neurotransmitter changes during various stages of drinking and abstinence. Together, such in vivo imaging tools have expanded our understanding of the dynamic course of alcoholism including evidence for regional specificity of the effects of AUD, hints at mechanisms underlying the shift from casual to compulsive use of alcohol, and profound recovery with sustained abstinence.
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Affiliation(s)
- Michael Fritz
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Anna M Klawonn
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Natalie M Zahr
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California.,Neuroscience Program, SRI International, Menlo Park, California
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Silczuk A, Habrat B, Lew-Starowicz M. Thrombocytopenia in Patients Hospitalized for Alcohol Withdrawal Syndrome and Its Associations to Clinical Complications. Alcohol Alcohol 2019; 54:503-509. [PMID: 31403690 DOI: 10.1093/alcalc/agz061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 06/24/2019] [Accepted: 06/27/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aim of this study was to assess the predictive value of thrombocytopenia (TP) in alcohol withdrawal syndrome (AWS) as a marker of evolution of non-complicated AWS (nAWS) to severe, complicated AWS (cAWS): delirium tremens (DTs) and withdrawal seizures (wS), and to broaden knowledge about differences between nAWS and cAWS groups in relation to severity of TP. METHODS This study involved 300 people (236 males and 64 females), aged 19-65 years (M = 44.64, SD = 11.32), hospitalized in the detoxification ward with ICD-10 diagnosis of F10.3 (AWS) or F10.4 (DTs), divided into nAWS and cAWS groups, 150 cases each. AWS severity was measured by CIWA-Ar. Available clinical and laboratory data were analyzed. RESULTS TP was found in 139 (46%) of all subjects (nAWS = 32, cAWS = 107). nAWS and cAWS did not differ according to age, gender, length and severity of the last binge. A relationship between the occurrence of TP and cAWS was found (P < 0.001). The lower was the number of PLT, the more AWS incidence was observed. In CIWA-Ar, TP subjects had at least moderate AWS (P < 0.001). nAWS had higher PLT values than cAWS cases (Mrang = 195.96 vs. 105.04, P < 0.001). The predictive value of TP in cAWS was confirmed. CONCLUSIONS The study demonstrates that patients with AWS and TP (in particular <119k/mL) are at higher risk of developing cAWS.
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Affiliation(s)
- Andrzej Silczuk
- Department of Prevention and Treatment of Addictions, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Bogusław Habrat
- Department of Prevention and Treatment of Addictions, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Michał Lew-Starowicz
- Department of Psychiatry, Centre of Postgraduate Medical Education, Warsaw, Poland
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Benson G, Roberts N, McCallum J, McPherson A. Severe alcohol withdrawal syndrome: review of the literature. DRUGS AND ALCOHOL TODAY 2019. [DOI: 10.1108/dat-10-2018-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to identify published literature from a general hospital setting that may highlight variables implicated in the development of severe alcohol withdrawal syndrome (SAWS) in patients who have alcohol dependence syndrome (ADS).
Design/methodology/approach
A systematic literature review was carried out using the electronic databases: MEDLINE, Medline in Process, Cinahl, Embase and PsycINFO from 1989 to 2017. The focus of this search was on English language studies of individuals over 16 years admitted to general hospital with ADS, delirium tremens (DTs), alcohol-related seizure (ARS) or alcohol withdrawal syndrome (AWS).
Findings
Of the 205 studies screened, eight met the criteria for inclusion. Six studies were quantitative retrospective cohort and two were retrospective case-control. Six studies investigated risk factors associated with DTs, one examined SAWS and one alcohol kindling. Descriptive analysis was performed to summarise the empirical evidence from studies were 22 statistically significant risk factors were found; including the reason for admission to hospital, daily alcohol consumption, previous DTs and prior ARS. The last two factors mentioned appeared in two studies.
Research limitations/implications
Further research should consider the quality and completeness of the alcohol history data and competence of staff generating the data in retrospective studies.
Originality/value
The paper suggests that the factors linked to SAWS development from the literature may not fully explain why some individuals who have ADS develop SAWS, and others do not.
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Abstract
Delirium Tremens (DT) falls in the most severe spectrum of alcohol withdrawal, which could potentially result in death, unless managed promptly and adequately. The prevalence of DT in general population is <1% and nearly 2% in patients with alcohol dependence. DT presents with a combination of severe alcohol withdrawal symptoms and symptoms of delirium with agitation and sometimes hallucination. Clinical and laboratory parameters which predict DT have been discussed. Assessment of DT includes assessment of severity of alcohol withdrawal, evaluation of delirium, and screening for underlying medical co-morbidities. Liver disease as a co-morbidity is very common in patients with DT and that could complicate the clinical presentation, determine the treatment choice, and influence the outcome. Benzodiazepines are the mainstay of treatment for DT. Diazepam and lorazepam are preferred benzodiazepine, depending upon the treatment regime and clinical context. In benzodiazepine refractory cases, Phenobarbital, propofol, and dexmedetomidine could be used.
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Benedict NJ, Wong A, Cassidy E, Lohr BR, Pizon AF, Smithburger PL, Falcione BA, Kirisci L, Kane-Gill SL. Predictors of resistant alcohol withdrawal (RAW): A retrospective case-control study. Drug Alcohol Depend 2018; 192:303-308. [PMID: 30308384 DOI: 10.1016/j.drugalcdep.2018.08.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 07/03/2018] [Accepted: 08/10/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Benzodiazepine-resistant alcohol withdrawal (RAW), defined by a requirement of ≥ 40 mg of diazepam in 1 h, represents a severe form of withdrawal without predictive parameters. This study was designed to identify risk factors associated with RAW versus withdrawal without benzodiazepine resistance (nRAW). METHODS A retrospective cohort of adults with severe alcohol withdrawal were screened. Demographic and clinical variables, collected through chart review, underwent logistic regression to select the subset that predicst RAW. RESULTS 736 patients (515 nRAW, 221 RAW) were analyzed. RAW patients were younger (P < 0.001), male (P = 0.008) Caucasians (P = 0.037) with histories of psychiatric illness (P < 0.001), higher serum ethanol concentrations (P < 0.007), and abnormal liver enzymes (P = 0.01). RAW patients had significantly lower platelets (P < 0.001), chloride (P = 0.02), and potassium (P = 0.01) levels; severity of illness (SAPSII) (P < 0.001) and comorbidity scores (P < 0.001). Caucasian race and male gender were found to be 3.6 and 2.6 times more likely to be RAW. For every 1-unit increase in comorbidity and severity of illness scores, patients were 22% [OR(95% CI) 0.78 (0.66-0.90)] and 4% [0.96 (0.93-0.98)] less likely to be RAW. Patients with a psychiatric history or thrombocytopenia were 2 times more likely [2.02 (1.24-3.30); 2.13 (1.31-3.50), respectively] to be RAW. CONCLUSION These data demonstrate the predictive ability of a history of psychiatric illness, thrombocytopenia, gender, race, baseline severity of illness and comorbidity scores for developing RAW. Considering these characteristics in early withdrawal management may prevent progression to RAW outcomes.
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Affiliation(s)
- Neal J Benedict
- Department of Pharmacy, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, United States; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA 15213, United States.
| | - Adrian Wong
- Department of Pharmacy, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, United States; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA 15213, United States
| | - Elizabeth Cassidy
- Department of Pharmacy, UPMC St. Margaret, 815 Freeport Rd, Pittsburgh, PA 15215, United States
| | - Brian R Lohr
- Department of Pharmacy, UPMC Passavant, 9100 Babcock Boulevard, Pittsburgh, PA 15237, United States
| | - Anthony F Pizon
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15213, United States; Division of Medical Toxicology, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15213, United States
| | - Pamela L Smithburger
- Department of Pharmacy, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, United States; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA 15213, United States
| | - Bonnie A Falcione
- Department of Pharmacy, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, United States; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA 15213, United States
| | - Levent Kirisci
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Salk Hall 807, Pittsburgh PA 15261, United States
| | - Sandra L Kane-Gill
- Department of Pharmacy, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, United States; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA 15213, United States
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30
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Wood E, Albarqouni L, Tkachuk S, Green CJ, Ahamad K, Nolan S, Mclean M, Klimas J. Will This Hospitalized Patient Develop Severe Alcohol Withdrawal Syndrome?: The Rational Clinical Examination Systematic Review. JAMA 2018; 320:825-833. [PMID: 30167704 PMCID: PMC6905615 DOI: 10.1001/jama.2018.10574] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Although severe alcohol withdrawal syndrome (SAWS) is associated with substantial morbidity and mortality, most at-risk patients will not develop this syndrome. Predicting its occurrence is important because the mortality rate is high when untreated. OBJECTIVE To assess the accuracy and predictive value of symptoms and signs for identifying hospitalized patients at risk of SAWS, defined as delirium tremens, withdrawal seizure, or clinically diagnosed severe withdrawal. DATA SOURCES MEDLINE and EMBASE (1946-January 2018) were searched for articles investigating symptoms and signs predictive of SAWS in adults. Reference lists of retrieved articles were also searched. STUDY SELECTION Original studies that were included compared symptoms, signs, and risk assessment tools among patients who developed SAWS and patients who did not. DATA EXTRACTION AND SYNTHESIS Data were extracted and used to calculate likelihood ratios (LRs), sensitivity, and specificity. A meta-analysis was performed to calculate summary LR. RESULTS Of 530 identified studies, 14 high-quality studies that included 71 295 patients and 1355 relevant cases of SAWS (1051 cases), seizure (53 cases), or delirium tremens (251 cases) were analyzed. A history of delirium tremens (LR, 2.9 [95% CI 1.7-5.2]) and baseline systolic blood pressure 140 mm Hg or higher (LR, 1.7 [95% CI, 1.3-2.3) were associated with an increased likelihood of SAWS. No single symptom or sign was associated with exclusion of SAWS. Six high-quality studies evaluated combinations of clinical findings and were useful for identifying patients in acute care facilities at high risk of developing SAWS. Of these combinations, the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) was most useful, with an LR of 174 (95% CI, 43-696; specificity, 0.93) when patients had 4 or more individual findings and an LR of 0.07 (95% CI, 0.02-0.26; sensitivity, 0.99) when there were 3 or fewer findings. CONCLUSIONS AND RELEVANCE Assessment tools that use a combination of symptoms and signs are useful for identifying patients at risk of developing severe alcohol withdrawal syndrome. Most studies of these tools were not fully validated, limiting their generalizability.
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Affiliation(s)
- Evan Wood
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Stacey Tkachuk
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Carolyn J. Green
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Keith Ahamad
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Seonaid Nolan
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mark Mclean
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jan Klimas
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Tait RJ, Kirkman JJL, Schaub MP. A Participatory Health Promotion Mobile App Addressing Alcohol Use Problems (The Daybreak Program): Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2018; 7:e148. [PMID: 29853435 PMCID: PMC6002672 DOI: 10.2196/resprot.9982] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/17/2018] [Accepted: 04/17/2018] [Indexed: 11/15/2022] Open
Abstract
Background At-risk patterns of alcohol use are prevalent in many countries with significant costs to individuals, families, and society. Screening and brief interventions, including with Web delivery, are effective but with limited translation into practice to date. Previous observational studies of the Hello Sunday Morning approach have found that their unique Web-based participatory health communication method has resulted in a reduction of at-risk alcohol use between baseline and 3 months. The Hello Sunday Morning blog program asks participants to publicly set a personal goal to stop drinking or reduce their consumption for a set period of time, and to record their reflections and progress on blogs and social networks. Daybreak is Hello Sunday Morning’s evidence-based behavior change program, which is designed to support people looking to change their relationship with alcohol. Objective This study aims to systematically evaluate different versions of Hello Sunday Morning’s Daybreak program (with and without coaching support) in reducing at-risk alcohol use. Methods We will use a between groups randomized control design. New participants enrolling in the Daybreak program will be eligible to be randomized to receive either (1) the Daybreak program, including peer support plus behavioral experiments (these encourage and guide participants in developing new skills in the areas of mindfulness, connectedness, resilience, situational strategies, and health), or (2) the Daybreak program, including the same peer support plus behavioral experiments, but with online coaching support. We will recruit 467 people per group to detect an effect size of f=0.10. To be eligible, participants must be resident in Australia, aged ≥18 years, score ≥8 on the alcohol use disorders identification test (AUDIT), and not report prior treatment for cardiovascular disease. Results The primary outcome measure will be reduction in the AUDIT-Consumption (AUDIT-C) scores. Secondary outcomes include mental health (Kessler’s K-10), days out of role (Kessler), alcohol consumed (measured with a 7-day drinking diary in standard 10 g drinks), and alcohol-related harms (CORE alcohol and drug survey). We will collect data at baseline and 1, 3, and 6 months and analyze them with random effects models, given the correlated data structure. Conclusions A randomized trial is required to provide robust evidence of the impact of the online coaching component of the Daybreak program, including over an extended period. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12618000010291; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373110 (Archived by WebCite at http://www.webcitation.org/6zKRmp0aC) Registered Report Identifier RR1-10.2196/9982
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Affiliation(s)
- Robert J Tait
- National Drug Research Institute, Faculty of Health Sciences, Curtin University, Perth, Australia
| | | | - Michael P Schaub
- Swiss Research Institute for Public Health and Addiction, University of Zurich, Zurich, Switzerland
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The "Forgotten" Treatment of Alcohol Withdrawal Delirium With Electroconvulsive Therapy: Successful Use in a Very Prolonged and Severe Case. Clin Neuropharmacol 2018. [PMID: 28622209 DOI: 10.1097/wnf.0000000000000224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Alcohol withdrawal delirium (AWD) is a notorious complication in alcohol withdrawal. Usually, the symptomatic treatment is efficacious; however, some patients show treatment resistance or a prolonged course of AWD. METHOD We report the case of a patient with a prolonged and severest form of AWD. Even 11 weeks after admission, he received approximately 100 mg diazepam per week to manage the symptoms of withdrawal delirium. RESULTS A treatment course of electroconvulsive therapy was initiated, which allowed a complete tapering off of benzodiazepines during electroconvulsive therapy without adverse effects. CONCLUSIONS The reported case might contribute to alternative approaches reserved for severest forms of prolonged AWD.
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da Costa E Silva LD, Pereira P, Regner GG, Boaretto FBM, Hoffmann C, Pflüger P, da Silva LL, Steffens LR, Morás AM, Moura DJ, Picada JN. DNA damage and oxidative stress induced by seizures are decreased by anticonvulsant and neuroprotective effects of lobeline, a candidate to treat alcoholism. Metab Brain Dis 2018; 33:53-61. [PMID: 29032429 DOI: 10.1007/s11011-017-0130-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 10/09/2017] [Indexed: 12/28/2022]
Abstract
The alkaloid lobeline (Lob) has been studied due to its potential use in treatment of drug abuse. This study evaluates the possible anticonvulsant and neuroprotective activities of Lob to obtain new information on its properties that could confirm it as a candidate in the treatment of alcohol addiction. The anticonvulsant effect of Lob was evaluated using a pilocarpine-induced seizure model. In addition, possible neuroprotective effects were investigated measuring DNA damage using the comet assay, assessing free radical levels by dichlorofluorescein diacetate (DCF) oxidation, and measuring the antioxidant potential using the α, α-diphenyl-β-picrylhydrazyl (DPPH) scavenging assay, besides measuring superoxide dismutase (SOD) and catalase (CAT) enzyme activities in brain tissues. Lobeline increased the latency to the first seizure and decreased the percentage of seizures in a similar way as diazepam, used as control. DNA damage induced by Pil and hydrogen peroxide were decreased in hippocampus and cerebral cortex from mice treated with Lob. The levels of free radicals and CAT activity increased in cortex and hippocampus, respectively, in mice treated with Pil. Lobeline decreased CAT in hippocampus, leading to similar values as in the saline negative control. In conclusion, Lob has anticonvulsant and neuroprotective actions that may be mediated by antioxidant-like mechanisms, indicating its potential as candidate drug in alcoholism therapy.
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Affiliation(s)
- Liana Dantas da Costa E Silva
- Laboratory of Toxicological Genetics, Lutheran University of Brazil (ULBRA), Farroupilha Avenue, 8001, Canoas, RS, 2425-900, Brazil
| | - Patrícia Pereira
- Laboratory of Neuropharmacology and Preclinical Toxicology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Gabriela Gregory Regner
- Laboratory of Neuropharmacology and Preclinical Toxicology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Fernanda Brião Menezes Boaretto
- Laboratory of Toxicological Genetics, Lutheran University of Brazil (ULBRA), Farroupilha Avenue, 8001, Canoas, RS, 2425-900, Brazil
| | - Cleonice Hoffmann
- Laboratory of Toxicological Genetics, Lutheran University of Brazil (ULBRA), Farroupilha Avenue, 8001, Canoas, RS, 2425-900, Brazil
| | - Pricila Pflüger
- Laboratory of Neuropharmacology and Preclinical Toxicology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Lucas Lima da Silva
- Laboratory of Neuropharmacology and Preclinical Toxicology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Luiza Reinhardt Steffens
- Laboratory of Genetic Toxicology, Federal University of Health Science of Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Ana Moira Morás
- Laboratory of Genetic Toxicology, Federal University of Health Science of Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Dinara Jaqueline Moura
- Laboratory of Genetic Toxicology, Federal University of Health Science of Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Jaqueline Nascimento Picada
- Laboratory of Toxicological Genetics, Lutheran University of Brazil (ULBRA), Farroupilha Avenue, 8001, Canoas, RS, 2425-900, Brazil.
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Mendoza RL. Is medical treatment of Alcohol Withdrawal Syndrome a Stag Hunt? Challenges and opportunities in managing risk and uncertainty in addiction cessation. Risk Manag Healthc Policy 2017; 11:1-14. [PMID: 29317849 PMCID: PMC5743126 DOI: 10.2147/rmhp.s144831] [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: 11/23/2022] Open
Abstract
PURPOSE While the individual and social costs of alcoholism or alcohol use disorder are well established, few are aware that medical problems can arise during detoxification, some of which can be life-threatening. This study determines if sustained treatment for Alcohol Withdrawal Syndrome (AWS) might be based on the strategic choices and expectations of patients and health care providers alike, as well as the risk mitigation options available to them. DESIGN/APPROACH AWS was modeled as a Stag Hunt to explain both risk and decision-making in medical treatments for detoxification, since it can deduce a set of equilibrium strategies available to both patient and provider. Modeling was based on a review of juried literature gathered from search engines with the use medical subject heading terms. MAIN FINDINGS While there is little evidence that decision-making is shared between patient and physician in AWS treatments, the outcomes of their interactions depend on utility-maximizing choices each makes in anticipation of the other. Payoff-dominant and risk-dominant treatment outcomes are equally likely and equally cost-efficient, as conditioned by the presence (or absence) of mutual trust and assurance in reciprocal transactions. CONCLUSION/VALUE Simulation games, such as the Stag Hunt, offer a viable framework to understand patient and provider incentives and health-affecting behaviors during treatments for addiction cessation. If both anticipate indefinitely interacting in the absence of any predetermined or foreseeable final visit, they can maximize future payoffs from mutual cooperation and accountability, which fosters health promotion. However, this study suggests that the effect of cooperation is distinct from the effect of time in AWS and other addiction-cessation programs.
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Ram D, Raman R, Gowdappa B. Lorazepam precipitated alcohol withdrawal delirium - Two case report. Asian J Psychiatr 2017; 30:98-99. [PMID: 28846885 DOI: 10.1016/j.ajp.2017.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 08/05/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Dushad Ram
- Department of Psychiatry, JSS Medical College, JSS University, Mysore, Karnataka, 570004, India.
| | - Rajesh Raman
- Department of Psychiatry, JSS Medical College, JSS University, Mysore, Karnataka, 570004, India
| | - Basawanna Gowdappa
- Department of Psychiatry, JSS Medical College, JSS University, Mysore, Karnataka, 570004, India
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Heo K, Cho YJ, Eun SH, Lim SC, Lee J, Song P. Management of Alcohol Withdrawal Syndrome and Alcohol Withdrawal Seizure. ACTA ACUST UNITED AC 2017. [DOI: 10.17340/jkna.2017.3.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Harshe DG, Thadasare H, Karia SB, De Sousa A, Cholera RM, Kale SS, Mate OS, Shah N. A Study of Patterns of Platelet Counts in Alcohol Withdrawal. Indian J Psychol Med 2017; 39:441-444. [PMID: 28852237 PMCID: PMC5559991 DOI: 10.4103/0253-7176.211766] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
AIMS This study aimed to evaluate the patterns of platelet counts during the course of alcohol withdrawal and its relationship if any with liver enzymes. METHODOLOGY Forty consecutive patients, with alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders-fourth edition, Text Revision criteria, willing for a 10-day inpatient detoxification program and presenting within 12 h of the last consumption of alcohol were recruited in the study. Details about the diagnosis and alcohol consumption patterns were assessed with a detailed psychiatric interview. After admission, routine investigations (complete blood counts [CBCs] and liver function tests) were sent and records were kept. CBC was sent for platelet counts on the 2nd, 4th, 6th, 8th, and the 10th day of alcohol withdrawal. RESULTS Nearly 40% of the patients developed delirium tremens (DT group) and rest had an uncomplicated alcohol withdrawal (ND group). Platelet counts at baseline and all the 4 days of collection were significantly lower in DT group than the ND group. Platelet counts increased gradually from baseline till 10th day of alcohol withdrawal, mean increase in platelet counts being 88.61 ± 11.60% (median: 61.11%, range [23.41-391.23%]). Platelet counts in 63% of the patients showed a drop on the 4th day of withdrawal before rising till the 10th day of alcohol withdrawal. Platelet counts were not affected by liver enzymes or other alcohol consumption patterns. CONCLUSIONS Transient thrombocytopenia and reverse thrombocytosis during alcohol withdrawal are associated with an initial drop in platelet counts. The synchrony between the drop and the onset of DT needs to be evaluated.
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Affiliation(s)
- Devavrat G Harshe
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Kolhapur, Maharashtra, India
| | - Harshal Thadasare
- Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Navi Mumbai, Maharashtra, India
| | - Sagar B Karia
- Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Navi Mumbai, Maharashtra, India
| | - Avinash De Sousa
- Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Navi Mumbai, Maharashtra, India
| | - Rashmin M Cholera
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Navi Mumbai, Maharashtra, India
| | - Sanjiv S Kale
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Navi Mumbai, Maharashtra, India
| | - Omkar S Mate
- Department of Psychiatry, Dr. D. Y. Patil Medical College, Navi Mumbai, Maharashtra, India
| | - Nilesh Shah
- Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Navi Mumbai, Maharashtra, India
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Sarkar S, Choudhury S, Ezhumalai G, Konthoujam J. Risk factors for the development of delirium in alcohol dependence syndrome: Clinical and neurobiological implications. Indian J Psychiatry 2017; 59:300-305. [PMID: 29085088 PMCID: PMC5659079 DOI: 10.4103/psychiatry.indianjpsychiatry_67_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Alcohol withdrawal delirium (AWD) or delirium tremens (DT) is associated with severe complications and high mortality. Prospectively identifying patients with increased risk of developing DT would have important preventive and therapeutic implications. Thus, the present study aimed to identify clinical risk factors predicting the development of DT. MATERIALS AND METHODS The study was a cross-sectional quasi-experimental one with equivalent control group, conducted at a tertiary hospital from August 2014 to May 2015. Forty adult male inpatients, diagnosed with DT, were compared with forty age- and sex-matched inpatients in alcohol withdrawal state without delirium. Assessments were done using confusion assessment method, Clinical Institute Withdrawal Assessment of Alcohol Scale, and Mini-Mental Status Examination. For group comparisons, Pearson's Chi-square test and independent sample t-test were used; logistic regression was applied to identify predictors followed by receiver operating characteristic curve analysis. RESULTS Heavy drinking (P = 0.005; odds ratio [OR]: 1.17, confidence interval [CI]: 1.05-1.31), continuous pattern of drinking (P = 0.027; OR: 4.67, CI: 1.19-18.33), past history of delirium (P = 0.009; OR: 552.8, CI: 4.88-625.7), alcohol-induced psychosis (P = 0.002; OR: 74.6, CI: 4.68-1190), and presence of cognitive deficits (P = 0.044; OR: 12.5, CI: 1.07-147.3) emerged as strong predictors of AWD. CONCLUSION The risk factors found can be easily evaluated in a clinical setting for physicians to readily identify patients at risk for developing DT and plan intensive therapies for them. At a neurobiological level, patients with preexisting brain neurotransmitter disturbances are at greater risk for developing DT.
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Affiliation(s)
- Sukanto Sarkar
- Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - Sunayana Choudhury
- Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - Gem Ezhumalai
- Department of Allied Health Sciences, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - Janet Konthoujam
- Department of Psychiatry, Jawaharlal Nehru Institute of Medical Sciences, Imphal, India
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Occurrence, Predictors, and Prognosis of Alcohol Withdrawal Syndrome and Delirium Tremens Following Traumatic Injury. Crit Care Med 2017; 45:867-874. [DOI: 10.1097/ccm.0000000000002371] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Sutton LJ, Jutel A. Alcohol Withdrawal Syndrome in Critically Ill Patients: Identification, Assessment, and Management. Crit Care Nurse 2017; 36:28-38. [PMID: 26830178 DOI: 10.4037/ccn2016420] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Management of alcohol withdrawal in critically ill patients is a challenge. The alcohol consumption histories of intensive care patients are often incomplete, limiting identification of patients with alcohol use disorders. Abrupt cessation of alcohol places these patients at risk for alcohol withdrawal syndrome. Typically benzodiazepines are used as first-line therapy to manage alcohol withdrawal. However, if patients progress to more severe withdrawal or delirium tremens, extra adjunctive medications in addition to benzodiazepines may be required. Sedation and mechanical ventilation may also be necessary. Withdrawal assessment scales such as the Clinical Institute of Withdrawal Assessment are of limited use in these patients. Instead, general sedation-agitation scales and delirium detection tools have been used. The important facets of care are the rapid identification of at-risk patients through histories of alcohol consumption, management with combination therapies, and ongoing diligent assessment and evaluation. (Critical Care Nurse. 2016;36[1]:28-39).
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Affiliation(s)
- Lynsey J Sutton
- Lynsey Sutton is an associate charge nurse manager of a level 3 intensive care unit, Capital and Coast District Health Board, Wellington Regional Hospital, Riddiford, Wellington, New Zealand. She is a guest teaching assistant in the postgraduate nursing program at Victoria University of Wellington, New Zealand.Annemarie Jutel works at Victoria University of Wellington. She is also a locum emergency nurse in Central Otago, New Zealand.
| | - Annemarie Jutel
- Lynsey Sutton is an associate charge nurse manager of a level 3 intensive care unit, Capital and Coast District Health Board, Wellington Regional Hospital, Riddiford, Wellington, New Zealand. She is a guest teaching assistant in the postgraduate nursing program at Victoria University of Wellington, New Zealand.Annemarie Jutel works at Victoria University of Wellington. She is also a locum emergency nurse in Central Otago, New Zealand
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Long D, Long B, Koyfman A. The emergency medicine management of severe alcohol withdrawal. Am J Emerg Med 2017; 35:1005-1011. [PMID: 28188055 DOI: 10.1016/j.ajem.2017.02.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 01/31/2017] [Accepted: 02/03/2017] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Alcohol use is widespread, and withdrawal symptoms are common after decreased alcohol intake. Severe alcohol withdrawal may manifest with delirium tremens, and new therapies may assist in management of this life-threatening condition. OBJECTIVE To provide an evidence-based review of the emergency medicine management of alcohol withdrawal and delirium tremens. DISCUSSION The underlying pathophysiology of alcohol withdrawal syndrome (AWS) is central nervous system hyperexcitation. Stages of withdrawal include initial withdrawal symptoms, hallucinations, seizures, and delirium tremens. Management focuses on early diagnosis, resuscitation, and providing medications with gamma-aminobutyric acid (GABA) receptor activity. Benzodiazepines with symptom-triggered therapy have been the predominant medication class utilized and should remain the first treatment option with rapid escalation of dosing. Treatment resistant withdrawal warrants the use of phenobarbital or propofol, both demonstrating efficacy in management. Propofol can be used as an induction agent to decrease the effects of withdrawal. Dexmedetomidine does not address the underlying pathophysiology but may reduce the need for intubation. Ketamine requires further study. Overall, benzodiazepines remain the cornerstone of treatment. Outpatient management of patients with minimal symptoms is possible. CONCLUSIONS Alcohol withdrawal syndrome can result in significant morbidity and mortality. Physicians must rapidly diagnose these conditions while evaluating for other diseases. Benzodiazepines are the predominant medication class utilized, with adjunctive treatments including propofol or phenobarbital in patients with withdrawal resistant to benzodiazepines. Dexmedetomidine and ketamine require further study.
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Affiliation(s)
- Drew Long
- Vanderbilt University School of Medicine, 1161 21st Ave S # T1217, Nashville, TN 37232, United States.
| | - Brit Long
- San Antonio Military Medical Center, Department of Emergency Medicine, Fort Sam Houston, 3841 Roger Brooke Dr, TX 78234, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States.
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Seidemann T, Spies C, Morgenstern R, Wernecke KD, Netzhammer N. Influence of Volatile Anesthesia on the Release of Glutamate and other Amino Acids in the Nucleus Accumbens in a Rat Model of Alcohol Withdrawal: A Pilot Study. PLoS One 2017; 12:e0169017. [PMID: 28045949 PMCID: PMC5207639 DOI: 10.1371/journal.pone.0169017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 12/09/2016] [Indexed: 01/29/2023] Open
Abstract
Background Alcohol withdrawal syndrome is a potentially life-threatening condition, which can occur when patients with alcohol use disorders undergo general anesthesia. Excitatory amino acids, such as glutamate, act as neurotransmitters and are known to play a key role in alcohol withdrawal syndrome. To understand this process better, we investigated the influence of isoflurane, sevoflurane, and desflurane anesthesia on the profile of excitatory and inhibitory amino acids in the nucleus accumbens (NAcc) of alcohol-withdrawn rats (AWR). Methods Eighty Wistar rats were randomized into two groups of 40, pair-fed with alcoholic or non-alcoholic nutrition. Nutrition was withdrawn and microdialysis was performed to measure the activity of amino acids in the NAcc. The onset time of the withdrawal syndrome was first determined in an experiment with 20 rats. Sixty rats then received isoflurane, sevoflurane, or desflurane anesthesia for three hours during the withdrawal period, followed by one hour of elimination. Amino acid concentrations were measured using chromatography and results were compared to baseline levels measured prior to induction of anesthesia. Results Glutamate release increased in the alcohol group at five hours after the last alcohol intake (p = 0.002). After 140 min, desflurane anesthesia led to a lower release of glutamate (p < 0.001) and aspartate (p = 0.0007) in AWR compared to controls. GABA release under and after desflurane anesthesia was also significantly lower in AWR than controls (p = 0.023). Over the course of isoflurane anesthesia, arginine release decreased in AWR compared to controls (p < 0.001), and aspartate release increased after induction relative to controls (p20min = 0.015 and p40min = 0.006). However, amino acid levels did not differ between the groups as a result of sevoflurane anesthesia. Conclusions Each of three volatile anesthetics we studied showed different effects on excitatory and inhibitory amino acid concentrations. Under desflurane anesthesia, both glutamate and aspartate showed a tendency to be lower in AWR than controls over the whole timecourse. The inhibitory amino acid arginine increased in AWR compared to controls, whereas GABA levels decreased. However, there were no significant differences in amino acid concentrations under or after sevoflurane anesthesia. Under isoflurane, aspartate release increased in AWR following induction, and from 40 min to 140 min arginine release in controls was elevated. The precise mechanisms through which each of the volatile anesthetics affected amino acid concentrations are still unclear and further experimental research is required to draw reliable conclusions.
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Affiliation(s)
- Thomas Seidemann
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Berlin, Germany
- * E-mail:
| | - Rudolf Morgenstern
- Institute of Pharmacology, Campus Charité Mitte, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | - Nicolai Netzhammer
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Berlin, Germany
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Jesse S, Bråthen G, Ferrara M, Keindl M, Ben-Menachem E, Tanasescu R, Brodtkorb E, Hillbom M, Leone M, Ludolph A. Alcohol withdrawal syndrome: mechanisms, manifestations, and management. Acta Neurol Scand 2017; 135:4-16. [PMID: 27586815 PMCID: PMC6084325 DOI: 10.1111/ane.12671] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2016] [Indexed: 12/26/2022]
Abstract
The alcohol withdrawal syndrome is a well‐known condition occurring after intentional or unintentional abrupt cessation of heavy/constant drinking in patients suffering from alcohol use disorders (AUDs). AUDs are common in neurological departments with patients admitted for coma, epileptic seizures, dementia, polyneuropathy, and gait disturbances. Nonetheless, diagnosis and treatment are often delayed until dramatic symptoms occur. The purpose of this review is to increase the awareness of the early clinical manifestations of AWS and the appropriate identification and management of this important condition in a neurological setting.
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Affiliation(s)
- S. Jesse
- Department of Neurology; University Ulm; Ulm Germany
| | - G. Bråthen
- Department of Neurology and Clinical Neurophysiology; Trondheim University Hospital; Trondheim Norway
- Department of Neuroscience; Norwegian University of Science and Technology; Trondheim Norway
| | - M. Ferrara
- Unit of Neurology; IRCCS Casa Sollievo della Sofferenza; San Giovanni Rotondo Italy
| | - M. Keindl
- Danube University Krems; Krems Austria
| | - E. Ben-Menachem
- Institute of Clinical Neuroscience and Neurophysiology; SU/Sahlgrenska Hospital; Gothenburg Sweden
| | - R. Tanasescu
- Department of Neurology; Neurosurgery and Psychiatry; University of Medicine and Pharmacy Carol Davila; Colentina Hospital; Bucharest Romania
- Academic Clinical Neurology; Division of Clinical Neuroscience; University of Nottingham; Nottingham UK
| | - E. Brodtkorb
- Department of Neurology and Clinical Neurophysiology; Trondheim University Hospital; Trondheim Norway
- Department of Neuroscience; Norwegian University of Science and Technology; Trondheim Norway
| | - M. Hillbom
- Department of Neurology; Oulu University Hospital; Oulu Finland
| | - M.A. Leone
- Unit of Neurology; IRCCS Casa Sollievo della Sofferenza; San Giovanni Rotondo Italy
| | - A.C. Ludolph
- Department of Neurology; University Ulm; Ulm Germany
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Leuenberger DL, Fierz K, Hinck A, Bodmer D, Hasemann W. A systematic nurse-led approach to withdrawal risk screening, prevention and treatment among inpatients with an alcohol use disorder in an ear, nose, throat and jaw surgery department-A formative evaluation. Appl Nurs Res 2016; 33:155-163. [PMID: 28096011 DOI: 10.1016/j.apnr.2016.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 11/14/2016] [Accepted: 11/19/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Among patients with head and neck cancer comorbid alcohol use disorder is frequent which contributes to higher risk of developing perioperative alcohol withdrawal syndrome/delirium or delirium due to medical conditions. Although guidelines emphasize prevention and treatment of alcohol withdrawal in hospitalized patients, a validated systematic approach for management of these patients is still lacking. Our aim was to formatively evaluate our newly developed systematic approach in view of nurses' adherence to screening patients for regular alcohol consumption and managing their withdrawal symptoms using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised. METHODS We conducted a formative evaluation to improve the project's design and performance and used a retrospective chart review in a consecutive sample of all adult inpatients with head and neck cancer being assigned for surgery in a university hospital. Our bundle of interventions consisted of nurses' screenings for regular alcohol consumption, withdrawal risk assessment, offering patients a substitution therapy, nurses' assessments of withdrawal symptoms and symptom oriented withdrawal management. Proximate endpoints were analyzed descriptively at each component of the bundle in terms of frequencies and severity of withdrawal symptoms, frequencies of nurses' and doctors' screenings and nurses' assessments performed as required. RESULTS Between 2013 and 2014, 87 inpatients met inclusion criteria and screenings by doctors/ nurses revealed 49 alcohol consumers, where six screenings were omitted by nurses and six by doctors. Twenty-one consumers were at risk and six of them developed an alcohol withdrawal syndrome. None of the 87 showed an alcohol withdrawal delirium, but five developed a delirium due to medical conditions. Nurses correctly conducted all preventive elements of the intervention bundle in 14 (58%) patients at risk but overall, only performed 50% of the required assessments. CONCLUSIONS Although nurses safely managed patients' symptoms, nurses' adherence to the interventions was suboptimal and requires stronger leadership.
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Affiliation(s)
- Deborah Linda Leuenberger
- Department of Orthopaedic and Traumatology, Clinical Nurse Specialist, Inselspital, University Hospital Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.
| | - Katharina Fierz
- Institute of Nursing Science, Scientific Collaborator, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland.
| | - Andreas Hinck
- Clinic for Otolaryngology, Head and Neck Surgery, University Hospital Basel, Basel, Switzerland; University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
| | - Daniel Bodmer
- Clinic for Otolaryngology, Head and Neck Surgery, University Hospital Basel, Basel, Switzerland; University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
| | - Wolfgang Hasemann
- Department of Nursing and Allied Health Professions, Practice Development Unit Nursing, University Hospital Basel, Hebelstrasse 2, CH-4031 Basel, Switzerland; University Hospital Basel, Hebelstrasse 2, CH-4031 Basel, Switzerland.
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Yoshimura A, Komoto Y, Higuchi S. Exploration of Core Symptoms for the Diagnosis of Alcohol Dependence in the ICD-10. Alcohol Clin Exp Res 2016; 40:2409-2417. [PMID: 27716976 PMCID: PMC5108416 DOI: 10.1111/acer.13225] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 08/21/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND The classification of alcohol use disorder has changed over the past century. Now, the conceptualization of alcohol dependence is still controversial. Accumulating evidence has shown the reliability and validity for the diagnosis of alcohol dependence in the ICD-10 and DSM-IV. However, the meaning and association of the respective diagnostic items, which are descriptive of representative symptoms, have hardly been examined. The core symptom of substance use disorder has been debated in various situations, but has never been elucidated logically. METHODS We consecutively registered 192 patients with alcohol-related problems who visited our hospital for the first time during a certain period. The relations and principal components among the checked items of the ICD-10 diagnostic criteria were examined statistically. RESULTS Three diagnostic items in the ICD-10 were strongly correlated with each other and were thought to form the core symptoms of alcohol dependence: "strong desire," "difficulties in controlling," and "neglect of pleasures." One major physical phenomenon, "withdrawal," seemed to complement the core symptoms in the diagnosis of alcohol dependence. Another physical phenomenon, "tolerance," was demonstrated to be a relatively independent item. The principal component analysis also demonstrated that the diagnostic item "difficulties in controlling" had the maximum component loading value, followed by 2 items, "neglect of pleasures" and "strong desire." CONCLUSIONS The core symptomatic elements in the diagnosis of alcohol dependence were statistically suggested in this study. Knowledge of the relations and components among the diagnostic items of alcohol dependence might also be applicable to other forms of substance use dependence and behavioral addiction.
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Affiliation(s)
- Atsushi Yoshimura
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Kanagawa, Japan. .,Department of Psychiatry, Tohoku Medical and Pharmaceutical University, Sendai, Japan.
| | - Yasunobu Komoto
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Kanagawa, Japan
| | - Susumu Higuchi
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Kanagawa, Japan
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Zahr NM. Structural and microstructral imaging of the brain in alcohol use disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 125:275-90. [PMID: 25307581 DOI: 10.1016/b978-0-444-62619-6.00017-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Magnetic resonance imaging (MRI), by enabling rigorous in vivo study of the longitudinal, dynamic course of alcoholism through periods of drinking, sobriety, and relapse, has enabled characterization of the effects of chronic alcoholism on the brain in the human condition. Importantly, MRI has distinguished alcohol-related brain effects that are permanent versus those that are reversible with abstinence. In support of postmortem neuropathologic studies showing degeneration of white matter, MRI has shown a specific vulnerability of brain white matter to chronic alcohol exposure by demonstrating white-matter volume deficits, yet not leaving selective gray-matter structures unscathed. Diffusion tensor imaging (DTI), by permitting microstructural characterization of white matter, has extended MRI findings in alcoholics. This review focuses on MRI and DTI findings in common concomitants of alcoholism, including Wernicke's encephalopathy, Korsakoff's syndrome, hepatic encephalopathy, central pontine myelinolysis, alcoholic cerebellar degeneration, alcoholic dementia, and Marchiafava-Bignami disease as a framework for findings in so-called "uncomplicated alcoholism," and also covers findings in abstinence and relapse.
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Affiliation(s)
- Natalie M Zahr
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; Neuroscience Program, SRI International, Menlo Park, CA, USA.
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Czynniki ryzyka majaczenia alkoholowego u osób leczonych stacjonarnie w Polsce z powodu uzależnienia od alkoholu. ALCOHOLISM AND DRUG ADDICTION 2016. [DOI: 10.1016/j.alkona.2016.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Sachdeva A, Choudhary M, Chandra M. Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. J Clin Diagn Res 2015; 9:VE01-VE07. [PMID: 26500991 DOI: 10.7860/jcdr/2015/13407.6538] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 07/03/2015] [Indexed: 11/24/2022]
Abstract
Alcohol dependence is an increasing and pervasive problem. Alcohol withdrawal symptoms are a part of alcohol dependence syndrome and are commonly encountered in general hospital settings, in most of the departments. Alcohol withdrawal syndrome ranges from mild to severe. The severe complicated alcohol withdrawal may present with hallucinations, seizures or delirium tremens. Benzodiazepines have the largest and the best evidence base in the treatment of alcohol withdrawal, and are considered the gold standard. Others, such as anticonvulsants, barbiturates, adrenergic drugs, and GABA agonists have been tried and have evidence. Supportive care and use of vitamins is essential in the management. Symptom triggered regime is favoured over fixed tapering dose regime, although monitoring through scales is cumbersome. This article aims to review the evidence base for appropriate clinical management of the alcohol withdrawal syndrome. We searched Pubmed for articles published in English on 'Alcohol withdrawal syndrome' in humans during the last 10 years. A total of 1182 articles came up. Articles not relevant to clinical utility and management were excluded based on the titles and abstract available. Full text articles, meta-analyses, systematic reviews and randomized controlled trials were obtained from this list and were considered for review.
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Affiliation(s)
- Ankur Sachdeva
- Assistant Professor, Department of Psychiatry, ESIC Medical College and Hospital , Faridabad, Haryana, India
| | - Mona Choudhary
- Senior Resident, Department of Psychiatry and Drug De-addiction, Post Graduate Institute of Medical Education and Research, Dr Ram Manohar Lohia Hospital , New Delhi, India
| | - Mina Chandra
- Chief Medical Officer (NFSG), Department of Psychiatry and Drug De-addiction, Post Graduate Institute of Medical Education and Research, Dr Ram Manohar Lohia Hospital , New Delhi, India
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Shu JE, Lin A, Chang G. Alcohol Withdrawal Treatment in the Medically Hospitalized Patient: A Pilot Study Assessing Predictors for Medical or Psychiatric Complications. PSYCHOSOMATICS 2015; 56:547-55. [DOI: 10.1016/j.psym.2014.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 11/28/2014] [Accepted: 12/01/2014] [Indexed: 10/24/2022]
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Wong A, Smithburger PL, Kane-Gill SL. Review of adjunctive dexmedetomidine in the management of severe acute alcohol withdrawal syndrome. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2015; 41:382-91. [DOI: 10.3109/00952990.2015.1058390] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Adrian Wong
- Department of Pharmacy, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, PA and
| | - Pamela L. Smithburger
- Department of Pharmacy, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, PA and
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Sandra L. Kane-Gill
- Department of Pharmacy, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, PA and
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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