1
|
Baron SW, Wai JM, Aloezos C, Cregin R, Ceresnak J, Dekhtyar J, Southern WN. Improving thiamine prescribing in alcohol use disorder using electronic decision support in a large urban academic medical center: A pre-post intervention study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 166:209485. [PMID: 39153734 DOI: 10.1016/j.josat.2024.209485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 07/03/2024] [Accepted: 08/13/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Thiamine is the only therapy for prevention and treatment of Wernicke Encephalopathy among patients with Alcohol Use Disorder (AUD). Despite this fact, up to 75 % of inpatients with AUD are not prescribed thiamine during hospitalization. Even fewer patients are prescribed high-dose thiamine which many experts recommend should be standard of care. Previous attempts to improve thiamine prescribing for inpatients have had limited success. METHODS We conducted an evaluation of thiamine prescribing in the year before and year after an intervention to increase high-dose thiamine prescribing. Pre-post study analysis occurred on two distinct study cohorts: those with alcohol-related diagnoses and those with elevated alcohol levels. The intervention was new electronic health record-based decision support which encouraged high-dose thiamine when any thiamine order was sought. No educational support was provided. The primary outcome was prescription of high-dose thiamine before versus after intervention. Of those with alcohol-related diagnoses, the monthly percentage of thiamine treatment courses including high-dose thiamine were graphed on a control chart. RESULTS We examined 5307 admissions with alcohol-related diagnoses (2285 pre- and 3022 post-intervention) and 698 admissions with elevated alcohol levels (319 pre- and 379 post-intervention). Among admissions with alcohol-related diagnoses, the intervention was associated with a higher proportion of admissions receiving high-dose thiamine prescriptions in the first 24 h (4.7 % vs. 1.1 %, adjusted odds ratio 4.50, CI 2.93 to 6.89, p < 0.001). A similar difference in high-dose thiamine was seen post-intervention among admissions with elevated alcohol levels (14.3 % vs. 2.5 %, adjusted odds ratio 6.43, CI 3.05 to 13.53, p < 0.001). The control chart among those with an alcohol-related diagnosis demonstrated special cause variation: the median percentage of thiamine treatment courses including high-dose thiamine improved from 8.2 % to 13.0 %. CONCLUSIONS Electronic decision support without educational interventions increased the use of high-dose thiamine among patients with alcohol-related diagnoses and with elevated alcohol levels during hospitalization. This increase occurred immediately in the month after the intervention and was sustained in the year-long study period after.
Collapse
Affiliation(s)
- Sarah W Baron
- Division of Hospital Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Jonathan M Wai
- Department of Psychiatry, Columbia University Irving Medical Center and Division on Substance Use Disorders, New York State Psychiatric Institute, New York, NY, USA
| | | | - Regina Cregin
- Department of Pharmacy, White Plains Hospital, White Plains, New York, USA
| | - Jeffrey Ceresnak
- Division of Hospital Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jessica Dekhtyar
- Division of Hospital Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - William N Southern
- Division of Hospital Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| |
Collapse
|
2
|
Oudman E, Wijnia JW, Bidesie J, Al-Hassaan Z, Laenen S, Jong-Tjien-Fa AV. Young Nonalcoholic Wernicke Encephalopathy Patient Achieves Remission Following Prolonged Thiamine Treatment and Cognitive Rehabilitation. J Clin Med 2023; 12:2901. [PMID: 37109239 PMCID: PMC10143616 DOI: 10.3390/jcm12082901] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023] Open
Abstract
Wernicke encephalopathy (WE), a neurological emergency commonly associated with alcohol use disorder, results from a severe deficiency of vitamin B1. If left untreated, patients either succumb to the illness or develop chronic Korsakoff's syndrome (KS). Recently, an increasing number of nonalcoholic WE case studies have been published, highlighting a lack of understanding of malnutrition-related disorders among high-functioning patients. We present the case of a 26 year old female who developed life-threatening WE after COVID-19-complicated obesity surgery. She experienced the full triad of WE symptoms, including eye-movement disorders, delirium, and ataxia, and suffered for over 70 days before receiving her initial WE diagnosis. Late treatment resulted in progression of WE symptoms. Despite the severity, the patient achieved remission of some of the symptoms in the post-acute phase due to prolonged parenteral thiamine injections and intensive specialized rehabilitation designed for young traumatic brain injury (TBI) patients. The rehabilitation resulted in gradual remission of amnesia symptomatology, mainly increasing her autonomy. The late recognition of this case highlights the importance of early diagnosis and prompt, targeted intervention in the management of nonalcoholic WE, as well as underscores the potential for positive outcomes after delayed treatment through intensive cognitive rehabilitation in specialized treatment centers.
Collapse
Affiliation(s)
- Erik Oudman
- Experimental Psychology, Helmholtz Institute, Utrecht University, 3584 CS Utrecht, The Netherlands
- Slingedael Korsakoff Expertise Center, Lelie Care Group, 3086 EZ Rotterdam, The Netherlands
| | - Jan W. Wijnia
- Experimental Psychology, Helmholtz Institute, Utrecht University, 3584 CS Utrecht, The Netherlands
- Slingedael Korsakoff Expertise Center, Lelie Care Group, 3086 EZ Rotterdam, The Netherlands
| | - Janice Bidesie
- Experimental Psychology, Helmholtz Institute, Utrecht University, 3584 CS Utrecht, The Netherlands
- Slingedael Korsakoff Expertise Center, Lelie Care Group, 3086 EZ Rotterdam, The Netherlands
| | - Zyneb Al-Hassaan
- Daan Theeuwes Center for Intensive Neurorehabilitation, 3447 GN Woerden, The Netherlands
| | - Sascha Laenen
- Daan Theeuwes Center for Intensive Neurorehabilitation, 3447 GN Woerden, The Netherlands
| | - Amy V. Jong-Tjien-Fa
- Daan Theeuwes Center for Intensive Neurorehabilitation, 3447 GN Woerden, The Netherlands
| |
Collapse
|
3
|
Strayer RJ, Friedman BW, Haroz R, Ketcham E, Klein L, LaPietra AM, Motov S, Repanshek Z, Taylor S, Weiner SG, Nelson LS. Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder: A White Paper Prepared for the American Academy of Emergency Medicine. J Emerg Med 2023; 64:517-540. [PMID: 36997435 DOI: 10.1016/j.jemermed.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/06/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Reuben J Strayer
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York.
| | - Benjamin W Friedman
- Department of Emergency Medicine, Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Rachel Haroz
- Cooper Medical School of Rowan University, Cooper University Healthcare, Camden, New Jersey
| | - Eric Ketcham
- Department of Emergency Medicine, Department of Behavioral Health, Addiction Medicine, Presbyterian Healthcare System, Santa Fe & Española, New Mexico
| | - Lauren Klein
- Department of Emergency Medicine, Good Samaritan Hospital, West Islip, New York
| | - Alexis M LaPietra
- Department of Emergency Medicine, Saint Joseph's Regional Medical Center, Paterson, New Jersey
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Zachary Repanshek
- Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Scott Taylor
- Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| |
Collapse
|
4
|
Mateos-Díaz AM, Marcos M, Chamorro AJ. Wernicke-Korsakoff syndrome and other diseases associated with thyamine deficiency. Med Clin (Barc) 2022; 158:431-436. [PMID: 35039171 DOI: 10.1016/j.medcli.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 11/17/2022]
Abstract
Wernicke-Korsakoff syndrome is the best known consequence of thiamine deficiency, frequently associated with patients with chronic and excessive alcohol consumption, but it can be produced by any cause that produces thiamine deficiency. The disease is underdiagnosed so it is essential to have a high clinical suspicion, mainly in patients who do not have alcohol consumption as a risk factor. For this, the diagnosis continues to be eminently clinical, with the difficulty of high clinical variability. Complementary tests are used to support the diagnosis and rule out other causes that can produce similar symptoms, with magnetic resonance imaging being the most cost-effective imaging test. Treatment is based on the administration of thiamine, which should be started early, and parenterally at the appropriate doses, in all patients with compatible symptoms, without waiting to confirm the diagnosis.
Collapse
Affiliation(s)
- Ana-María Mateos-Díaz
- Servicio de Medicina Interna, Hospital Virgen del Puerto, Plasencia, Cáceres, España
| | - Miguel Marcos
- Servicio de Medicina Interna, Hospital Universitario de Salamanca-IBSAL, Universidad de Salamanca, Salamanca, España
| | - Antonio-Javier Chamorro
- Servicio de Medicina Interna, Hospital Universitario de Salamanca-IBSAL, Universidad de Salamanca, Salamanca, España.
| |
Collapse
|
5
|
Columb D, Hussain R, O’Gara C. Addiction psychiatry and COVID-19: impact on patients and service provision. Ir J Psychol Med 2020; 37:164-168. [PMID: 32434597 PMCID: PMC7280151 DOI: 10.1017/ipm.2020.47] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/12/2020] [Accepted: 05/16/2020] [Indexed: 01/18/2023]
Abstract
The Coronavirus Disease 2019 (COVID-19) pandemic has undoubtedly had a major impact on the provision of physical healthcare in Ireland and worldwide. The mental health impact of this pandemic cannot be underestimated, particularly relating to patients suffering from addiction. Heightened public stress and anxiety levels, increasing isolation and the physical consequences of addiction play a large role in the proliferation and ongoing relapse of substance misuse and behavioural addiction. Service provision is an ongoing challenge not only due to the increasing need for services given the increased mental health burden of COVID-19 but also the restrictions in place in clinical areas to achieve social distancing. The necessary adaptations to service provision provide opportunities for the analysis of current processes used in our addiction unit and the introduction of new processes to our service. The current crisis tests the sustainability of the service to provide the high standard of care required for these patients.
Collapse
Affiliation(s)
- D. Columb
- Addiction Department, St. John of God Hospital, Stillorgan, Dublin, Ireland
| | - R. Hussain
- Addiction Department, St. John of God Hospital, Stillorgan, Dublin, Ireland
| | - C. O’Gara
- Addiction Department, St. John of God Hospital, Stillorgan, Dublin, Ireland
- UCD School of Medicine and Medical Specialties, University College Dublin, Dublin, Ireland
| |
Collapse
|
6
|
Thomson A, Guerrini I, Marshall EJ. Incidence of Adverse Reactions to Parenteral Thiamine in the Treatment of Wernicke's Encephalopathy, and Recommendations. Alcohol Alcohol 2019; 54:609-614. [PMID: 31565743 DOI: 10.1093/alcalc/agy091] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 10/07/2018] [Accepted: 01/24/2019] [Indexed: 11/12/2022] Open
Abstract
AIM To offer an estimate of the incidence of anaphylactic reactions to parenteral products containing thiamine used in the treatment of Wernicke's encephalopathy (WE) and make recommendations. METHOD Review of previously released data on some older products and parenteral thiamine use in some other countries; analysis of sales and adverse incident data on anaphylaxis for a contemporary parenteral product used in the UK, Pabrinex. RESULTS It was difficult to estimate the incidence of related anaphylactic reactions to Pabrinex in the UK because the number of doses given is unknown. Sales data are only an approximation to doses given because for products with a limited shelf life not all product sold is administered. However, available data indicate that there have been 10 anaphylactic reactions to Pabrinex from between 5,431,235-6,651,947 patient-days (14,880-16,080 years) of treatment. CONCLUSION It is reasonable to assume that the risk of anaphylaxis is low, and lower than for many other drugs. The risk-benefit ratio for administration is favourable given the potential severity of brain damage in Wernicke-Korsakoff (WK) syndrome. There is a need for international agreement on the reporting of anaphylaxis and on the optimum thiamine therapy for the treatment of WK syndrome. We make recommendations on how this might be achieved.
Collapse
Affiliation(s)
- Allan Thomson
- King's College London, Institute of Psychiatry, Psychology and Neuroscience London SE5 8AF, UK.,Division of Psychiatry, University College London, Rockefeller Building, Gower Street, London WC1E 6BT, UK
| | - Irene Guerrini
- King's College London, Institute of Psychiatry, Psychology and Neuroscience London SE5 8AF, UK.,Bexley Substance Misuse Service, South London and Maudsley NHS Trust, London, UK
| | - Elizabeth Jane Marshall
- King's College London, Institute of Psychiatry, Psychology and Neuroscience London SE5 8AF, UK.,Addictions Clinical Academic Group, South London and Maudsley NHS Foundation Trust, Marina House, 63-65 Denmark Hill, London SE58RS
| |
Collapse
|
7
|
Maguire D, Talwar D, Burns A, Catchpole A, Stefanowicz F, Robson G, Ross DP, Young D, Ireland A, Forrest E, Galloway P, Adamson M, Colgan E, Bell H, Orr L, Kerr JL, Roussis X, McMillan DC. A prospective evaluation of thiamine and magnesium status in relation to clinicopathological characteristics and 1-year mortality in patients with alcohol withdrawal syndrome. J Transl Med 2019; 17:384. [PMID: 31752901 PMCID: PMC6873772 DOI: 10.1186/s12967-019-02141-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 11/15/2019] [Indexed: 12/12/2022] Open
Abstract
Background Alcohol withdrawal syndrome (AWS) is routinely treated with B-vitamins. However, the relationship between thiamine status and outcome is rarely examined. The aim of the present study was to examine the relationship between thiamine and magnesium status in patients with AWS. Methods Patients (n = 127) presenting to the Emergency Department with AWS were recruited to a prospective observational study. Blood samples were drawn to measure whole blood thiamine diphosphate (TDP) and serum magnesium concentrations. Routine biochemistry and haematology assays were also conducted. The Glasgow Modified Alcohol Withdrawal Score (GMAWS) measured severity of AWS. Seizure history and current medications were also recorded. Results The majority of patients (99%) had whole blood TDP concentration within/above the reference interval (275–675 ng/gHb) and had been prescribed thiamine (70%). In contrast, the majority of patients (60%) had low serum magnesium concentrations (< 0.75 mmol/L) and had not been prescribed magnesium (93%). The majority of patients (66%) had plasma lactate concentrations above 2.0 mmol/L. At 1 year, 13 patients with AWS had died giving a mortality rate of 11%. Male gender (p < 0.05), BMI < 20 kg/m2 (p < 0.01), GMAWS max ≥ 4 (p < 0.05), elevated plasma lactate (p < 0.01), low albumin (p < 0.05) and elevated serum CRP (p < 0.05) were associated with greater 1-year mortality. Also, low serum magnesium at time of recruitment to study and low serum magnesium at next admission were associated with higher 1-year mortality rates, (84% and 100% respectively; both p < 0.05). Conclusion The prevalence of low circulating thiamine concentrations were rare and it was regularly prescribed in patients with AWS. In contrast, low serum magnesium concentrations were common and not prescribed. Low serum magnesium was associated more severe AWS and increased 1-year mortality.
Collapse
Affiliation(s)
- Donogh Maguire
- Emergency Medicine Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, Scotland, UK. .,Academic Unit of Surgery, School of Medicine, University of Glasgow, New Lister Building, Royal Infirmary, Glasgow, G31 2ER, Scotland, UK.
| | - Dinesh Talwar
- The Scottish Trace Element and Micronutrient Diagnostic and Reference Laboratory, Department of Biochemistry, Royal Infirmary, Glasgow, G31 2ER, Scotland, UK
| | - Alana Burns
- The Scottish Trace Element and Micronutrient Diagnostic and Reference Laboratory, Department of Biochemistry, Royal Infirmary, Glasgow, G31 2ER, Scotland, UK.,Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, G51 4TF, Scotland, UK
| | - Anthony Catchpole
- The Scottish Trace Element and Micronutrient Diagnostic and Reference Laboratory, Department of Biochemistry, Royal Infirmary, Glasgow, G31 2ER, Scotland, UK
| | - Fiona Stefanowicz
- The Scottish Trace Element and Micronutrient Diagnostic and Reference Laboratory, Department of Biochemistry, Royal Infirmary, Glasgow, G31 2ER, Scotland, UK
| | - Gordon Robson
- Emergency Medicine Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, Scotland, UK
| | - David P Ross
- Emergency Medicine Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, Scotland, UK.,Academic Unit of Surgery, School of Medicine, University of Glasgow, New Lister Building, Royal Infirmary, Glasgow, G31 2ER, Scotland, UK
| | - David Young
- Department of Mathematics and Statistics, University of Strathclyde, 26 Richmond Street, Glasgow, G1 1XH, Scotland, UK
| | - Alastair Ireland
- Emergency Medicine Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, Scotland, UK
| | - Ewan Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, G4 0SF, Scotland, UK
| | - Peter Galloway
- Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, G51 4TF, Scotland, UK
| | - Michael Adamson
- Emergency Medicine Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, Scotland, UK
| | - Eoghan Colgan
- Emergency Medicine Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, Scotland, UK
| | - Hannah Bell
- Emergency Medicine Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, Scotland, UK
| | - Lesley Orr
- Emergency Medicine Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, Scotland, UK
| | - Joanna-Lee Kerr
- Emergency Medicine Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, Scotland, UK
| | - Xen Roussis
- Emergency Medicine Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, Scotland, UK
| | - Donald C McMillan
- Academic Unit of Surgery, School of Medicine, University of Glasgow, New Lister Building, Royal Infirmary, Glasgow, G31 2ER, Scotland, UK
| |
Collapse
|
8
|
Abstract
SUMMARYAlcohol use disorders (AUD) are common, particularly in patients attending mental health services. Clinicians are often hesitant to explore with patients their relationship with alcohol and the role that it has in their presenting complaint, despite being ideally placed to optimise on a ‘teachable moment’ and initiate treatment, where necessary. This article provides an overview of AUD and their identification and management options.
Collapse
|
9
|
Infante MT, Fancellu R, Murialdo A, Barletta L, Castellan L, Serrati C. Challenges in Diagnosis and Treatment of Wernicke Encephalopathy: Report of 2 Cases. Nutr Clin Pract 2016; 31:186-90. [PMID: 26869612 DOI: 10.1177/0884533615621753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Wernicke encephalopathy (WE) is a medical emergency caused by thiamine deficiency, characterized by cerebellar ataxia, ophthalmoplegia, and cognitive disturbances that may progress to Korsakoff amnesia. We describe 2 patients with WE who needed high-dose and long-term treatment with thiamine to obtain neurological improvement and recovery. CASE DESCRIPTION The first patient was a woman diagnosed with non-Hodgkin lymphoma. After a gastrointestinal infection, she developed depression, memory loss, disorientation, behavioral changes, and ataxic paraplegia. Brain magnetic resonance imaging (MRI) showed bilateral alterations in thalamic, frontal, and periaqueductal regions, suggestive of WE. The second patient was a man who lost 10 kg after surgical gastrectomy; he developed diplopia, ophthalmoplegia, cerebellar ataxia, lower limb paresthesias, and amnesia. A brain MRI demonstrated contrast enhancement of mammillary bodies, compatible with WE. OUTCOME The patients were treated with intramuscular (IM) thiamine (1200 mg/d for 2 months and 900 mg/d for a month, respectively) with gradual cognitive and behavioral improvement and brain MRI normalization, while ataxia and oculomotion improved in following months. In both patients, thiamine was gradually reduced to IM 200 mg/d and continued for a year, without clinical relapses. CONCLUSIONS There is no consensus about dosage, frequency, route, and duration of thiamine administration in WE treatment. Based on our cases, we recommend treating patients with WE with higher doses of IM thiamine for a longer time than suggested (900-1200 mg/d for 1-2 months, in our cases) and to gradually reduce dosage after clinical and radiological improvement, maintaining IM 200 mg/d dosage for at least 1 year.
Collapse
Affiliation(s)
- Maria Teresa Infante
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal-Infantile Sciences, University of Genoa, Largo P. Daneo, Genoa, Italy
| | - Roberto Fancellu
- Unit of Neurology, IRCCS San Martino University Hospital IST, Largo R. Benzi, Genoa, Italy
| | - Alessandra Murialdo
- Unit of Neurology, IRCCS San Martino University Hospital IST, Largo R. Benzi, Genoa, Italy
| | - Laura Barletta
- Unit of Neuroradiology, IRCCS San Martino University Hospital IST, Largo R. Benzi, Genoa, Italy
| | - Lucio Castellan
- Unit of Neuroradiology, IRCCS San Martino University Hospital IST, Largo R. Benzi, Genoa, Italy
| | - Carlo Serrati
- Unit of Neurology, IRCCS San Martino University Hospital IST, Largo R. Benzi, Genoa, Italy
| |
Collapse
|
10
|
Abstract
Alcohol-related hospital attendances and admissions continue to escalate despite a fall in alcohol consumption levels in the UK population overall. People with alcohol-related problems pose a significant and often disproportionate burden on acute medical services as their management is often complex and challenging. This article focuses on the management of alcohol intoxication, with particular emphasis on aggressive and possibly violent behaviour; alcohol withdrawal; fitting; and the prevention and treatment of Wernicke's encephalopathy.
Collapse
Affiliation(s)
- Marsha Y Morgan
- UCL Institute for Liver and Digestive Health, Division of Medicine, Royal Free Campus, London, UK
| |
Collapse
|
11
|
Flynn A, Macaluso M, D'Empaire I, Troutman MM. Wernicke's Encephalopathy: Increasing Clinician Awareness of This Serious, Enigmatic, Yet Treatable Disease. Prim Care Companion CNS Disord 2015; 17:14r01738. [PMID: 26644959 PMCID: PMC4578911 DOI: 10.4088/pcc.14r01738] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 01/14/2015] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE Undiagnosed and/or undertreated Wernicke's encephalopathy can result in permanent brain damage, long-term institutionalization, and death. The purpose of this article is to heighten clinical awareness of Wernicke's encephalopathy and shed light on its diagnosis and treatment, which are often inconsistent due to unclear diagnostic criteria and limited practice guidelines. An update on the management of Wernicke's encephalopathy is presented and several case reports and a quality improvement project from our hospital are described. DATA SOURCES PubMed, the Cochrane Database of Systematic Reviews, and PsycINFO were searched for English-language articles published between January 1991 and January 2014 using combinations of the following keywords: Wernicke's encephalopathy, diagnosis, treatment/guideline(s), and thiamine. STUDY SELECTION The automated search identified over 500 articles. A manual review of the related citations and reference lists from articles of interest was also conducted. The articles reviewed were chosen on the basis of author consensus and because they represented expert opinion or the highest quality of evidence available. RESULTS Diagnostic criteria are reviewed in this article and should be used to diagnose Wernicke's encephalopathy with high sensitivity and specificity. The European Federation of Neurologic Societies and the Royal College of Physicians issued national guidelines for the diagnosis, prevention, and treatment of Wernicke's encephalopathy. No benchmark national guidelines for treating Wernicke's encephalopathy exist in the United States. CONCLUSIONS Whenever Wernicke's encephalopathy is suspected, treatment should be initiated immediately with intravenous thiamine because oral thiamine is inadequate for preventing permanent brain damage. An adequate dose of intravenous thiamine administrated in a timely manner is a safe and life-saving treatment for Wernicke's encephalopathy that could preserve brain cells and function.
Collapse
Affiliation(s)
- Alexandra Flynn
- Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita (Drs Flynn, Macaluso, and D'Empaire) and Via Christi Hospitals (Dr Troutman), Wichita, Kansas
| | - Matthew Macaluso
- Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita (Drs Flynn, Macaluso, and D'Empaire) and Via Christi Hospitals (Dr Troutman), Wichita, Kansas
| | - Inna D'Empaire
- Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita (Drs Flynn, Macaluso, and D'Empaire) and Via Christi Hospitals (Dr Troutman), Wichita, Kansas
| | - Megan M Troutman
- Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita (Drs Flynn, Macaluso, and D'Empaire) and Via Christi Hospitals (Dr Troutman), Wichita, Kansas
| |
Collapse
|
12
|
Day GS, Ladak S, Curley K, Farb NAS, Masiowski P, Pringsheim T, Ritchie M, Cheung A, Jansen S, Methot L, Neville HL, Bates D, Lowe D, Fernandes N, Ferland A, Martin del Campo C. Thiamine prescribing practices within university-affiliated hospitals: a multicenter retrospective review. J Hosp Med 2015; 10:246-53. [PMID: 25652810 DOI: 10.1002/jhm.2324] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 12/12/2014] [Accepted: 12/21/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients with suspected thiamine deficiency should receive treatment with parenteral thiamine to achieve the high serum thiamine levels necessary to reverse the effects of deficiency and to circumvent problems with absorption common in the medically ill. OBJECTIVE To quantify rates of parenteral administration of thiamine across university-affiliated hospitals and to identify factors associated with higher rates of parenteral prescribing. DESIGN Multicenter, retrospective observational study of thiamine prescriptions. METHODS Prescriptions for thiamine were captured from computerized pharmacy information systems across participating centers, providing information concerning dose, route, frequency, and duration of thiamine prescribed from January 2010 to December 2011. SETTING Fourteen university-affiliated tertiary care hospitals geographically distributed across Canada, including 48,806 prescriptions for thiamine provided to 32,213 hospitalized patients. RESULTS Parenteral thiamine accounted for a statistically significant majority of thiamine prescriptions (57.6%, P < 0.001); however, oral thiamine constituted a significant majority of the total doses prescribed (68.4%, z = 168.9; P < 0.001). Protocols prioritizing parenteral administration were associated with higher rates of parenteral prescribing (61.3% with protocol, 45.8% without protocol; P < 0.001). Patients admitted under psychiatry services were significantly more likely to be prescribed oral thiamine (P < 0.001). CONCLUSIONS Although parenteral thiamine accounted for a statistically significant majority of prescriptions, oral thiamine was commonly prescribed within academic hospitals. Additional strategies are needed to promote parenteral thiamine prescribing to patients with suspected thiamine deficiency.
Collapse
Affiliation(s)
- Gregory S Day
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Oudman E, Wijnia JW. BNF recommendations for the treatment of Wernicke's encephalopathy: lost in translation? Alcohol Alcohol 2013; 49:118. [PMID: 24334546 DOI: 10.1093/alcalc/agt179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Erik Oudman
- Corresponding author: Slingedael Korsakoff Centre, Slinge 901, 3086 EZ Rotterdam, The Netherlands.
| | | |
Collapse
|
14
|
Donovan A, Perelman M. BNF Recommendations for the Treatment of Wernick's Encephalopathy: Lost in Translation? Alcohol Alcohol 2013; 48:743. [DOI: 10.1093/alcalc/agt145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|