Alcoholism and critical illness: A review

Receptor and metabolic insights on the ability of caffeine to prevent alcohol-induced stimulation of mesolimbic dopamine transmission

The consumption of alcohol and caffeine affects the lives of billions of individuals worldwide. Although recent evidence indicates that caffeine impairs the reinforcing properties of alcohol, a characterization of its effects on alcohol-stimulated mesolimbic dopamine (DA) function was lacking. Acting as the pro-drug of salsolinol, alcohol excites DA neurons in the posterior ventral tegmental area (pVTA) and increases DA release in the nucleus accumbens shell (AcbSh). Here we show that caffeine, via antagonistic activity on A2A adenosine receptors (A2AR), prevents alcohol-dependent activation of mesolimbic DA function as assessed, in-vivo, by brain microdialysis of AcbSh DA and, in-vitro, by electrophysiological recordings of pVTA DA neuronal firing. Accordingly, while the A1R antagonist DPCPX fails to prevent the effects of alcohol on DA function, both caffeine and the A2AR antagonist SCH 58261 prevent alcohol-dependent pVTA generation of salsolinol and increase in AcbSh DA in-vivo, as well as alcohol-dependent excitation of pVTA DA neurons in-vitro. However, caffeine also prevents direct salsolinol- and morphine-stimulated DA function, suggesting that it can exert these inhibitory effects also independently from affecting alcohol-induced salsolinol formation or bioavailability. Finally, untargeted metabolomics of the pVTA showcases that caffeine antagonizes alcohol-mediated effects on molecules (e.g. phosphatidylcholines, fatty amides, carnitines) involved in lipid signaling and energy metabolism, which could represent an additional salsolinol-independent mechanism of caffeine in impairing alcohol-mediated stimulation of mesolimbic DA transmission. In conclusion, the outcomes of this study strengthen the potential of caffeine, as well as of A2AR antagonists, for future development of preventive/therapeutic strategies for alcohol use disorder.

Cannabis use disorders and outcome of admission to intensive care: A retrospective multi-centre cohort study

PURPOSE

To identify factors associated with cannabinoid use among patients admitted to ICU and its impact on survival.

METHODS

A cohort of adult patients admitted to four public Australian ICUs was assembled. Individuals with mental and behavioural disorders related to cannabinoids were identified using ICD10-AM codes.

RESULTS

Of a cohort of 34,680 admissions among 28,689 adults, 292 (0.8%) had an associated diagnosis related to cannabinoids, of which 66% were classified as harmful use, 26% as dependence syndrome/withdrawal state, 4% as psychosis/delirium, and 4% as acute intoxication. Patients with cannabinoid-use disorders were more likely to be male (73%), tended to be younger (36 vs 62 years), with fewer comorbidities and lesser severity of disease. ICU LOS was longer for those with cannabinoid-use disorders (2 vs 1 days; p < 0.0001). Patients with cannabinoid-use disorders had lower 90-day case-fatality (6% vs. 10%; p = 0.034), however no significant effect on mortality was present after adjustment for severity of illness, age, and chronic comorbidities (p = 1.0).

CONCLUSION

Cannabinoid-use disorders were present in 0.8% of ICU admissions in our region and were associated with increased ICU length of stay. Further studies are needed to examine cannabinoids as contributors to and modifiers of critical illness.

Meningitis in critically ill patients admitted to intensive care unit for severe community-acquired pneumococcal pneumonia

BACKGROUND

Although it has been reported that patients with pneumococcal pneumonia may develop meningitis, lumbar puncture is not systematically recommended in these patients, even in patients with associated bacteremia or invasive pneumococcal disease. The aim of this study was to determine the characteristics and outcomes of patients admitted to intensive care unit (ICU) for pneumococcal community-acquired pneumonia who developed meningitis.

METHODS

We retrospectively included all consecutive patients admitted to our ICU from January 2006 to December 2020 for severe pneumococcal community-acquired pneumonia according to American Thoracic Society criteria. Meningitis was defined as pleocytosis > 5 cells/mm3 or a positive culture of cerebrospinal fluid for Streptococcus pneumoniae in lumbar puncture. The primary endpoint was the proportion of patients with meningitis during their ICU stay.

RESULTS

Overall, 262 patients [64(52-75) years old] were included: 154(59%) were male, 80(30%) had chronic respiratory disease, 105(39%) were immunocompromised and 6(2%) were vaccinated against S. pneumoniae. A lumbar puncture was performed in 88(34%) patients with a delay from ICU admission to puncture lumbar of 10.5 (2.8-24.1) h and after the initiation of pneumococcal antibiotherapy in 81(92%) patients. Meningitis was diagnosed in 14 patients: 16% of patients with lumbar puncture and 5% of patients in the whole population. Patients with meningitis had more frequently human immunodeficiency virus positive status (29 vs. 5%, p = 0.02), neurological deficits on ICU admission (43 vs. 16%, p = 0.03) and pneumococcal bacteremia (71 vs. 30%, p < 0.01) than those without. The ICU mortality rate (14 vs. 13%, p = 0.73) and the mortality rate at Day-90 (21 vs. 15%, p = 0.83) did not differ between patients with and without meningitis. The proportion of patients with neurological disorders at ICU discharge was higher in patients with meningitis (64 vs. 23%, p < 0.001) than in those without. The other outcomes did not differ at ICU discharge, Day-30 and Day-90 between the two groups of patients.

CONCLUSION

Meningitis was diagnosed in 16% of patients with severe pneumococcal community-acquired pneumonia in whom a lumbar puncture was performed, was more frequent in patients with pneumococcal bacteremia and was associated with more frequent neurological disorders at ICU discharge. Further studies are needed to confirm these results.

Impact of a Rounding Tool and Clinical Champion on Trauma Patient Screening, Brief Intervention, and Referral to Treatment for Alcohol Use Disorder

BACKGROUND

Early identification and treatment of alcohol misuse among trauma patients is the standard of care for trauma centers. Yet, trauma programs face significant barriers in adherence to sustained alcohol misuse screening.

OBJECTIVE

This study aims to evaluate the impact of a rounding tool and clinical champion on screening, brief intervention, and referral to treatment compliance rates for alcohol use disorder in trauma patients.

METHODS

This is a single-center, retrospective cohort design measuring the impact of a nursing rounding tool and clinical champion on screening, brief intervention, and referral to treatment for alcohol use disorder in trauma patients older than 14 years. Retrospective reviews were conducted over a 5-year period from 2017 to 2021 for all admitted trauma patients as defined by the National Trauma Data Standard.

RESULTS

More than 5,000 trauma patients were included during the study period. The nurses' rounding tool and clinical champion intervention led to an increase in the alcohol use disorder screening rate from an average of 59% for the first 3 months of the study (May to July 2017) to 95% for the last 3 months of the study (March to May 2021).

CONCLUSION

Our findings show that a dedicated clinical champion and nurse rounding tool increase compliance for screening, brief intervention, and referral to treatment for alcohol use disorder in trauma patients.

A 3-Year Retrospective Study of the Impact of Integrating an Addiction Liaison Team into an Outpatient Alcoholism Treatment Programme

BACKGROUND

The number of inpatients with alcohol and other substance-related problems (ASRP) in the general hospital population at any time is vast. To meet the needs of those patients, most hospitals have an Addiction Liaison Team (ALT) that diagnoses and initiates the treatment of the addictive disorder. In our hospital, this team is part of a more extensive and intensive Outpatient Alcoholism Treatment Programme that facilitates the continuity of care.

AIM

the main goal of this study is to evaluate the performance and effectiveness of our inpatient ALT.

METHODOLOGY

we carried out an observational cohort study of patients with ASRP admitted to the hospital from 2015 to 2017. We evaluated the performance and effectiveness of our ALT: referrals to the programme, inpatients mortality, readmissions to hospital, hospital length of stay (LOS) and medical or surgical treatment adherence.

RESULTS

out of 133,181 admissions, 17,387 (13.14%) were positive for ASRP, and 615 (3.54%) were referred to the ALT. Referred patients had less in-hospital mortality, shorter LOS and lower risk of readmissions during the first year of follow-up. Subjects treated in the programme had better therapeutic adherence.

CONCLUSIONS

integrating the ALT into an outpatient programme facilitates an earlier detection and initiation of treatment during the hospital stay and the continuity of care. Alcohol misuse conditions affect the patient's prognosis and health outcomes, so appropriate care is needed. Inclusion in the programme was associated with less risk of hospital mortality, fewer readmissions and a lower LOS.

Risk factors for alcohol withdrawal-related hospital transfer in a correctional setting

INTRODUCTION

A major health concern among individuals with alcohol use disorder is alcohol withdrawal syndrome (AWS), where individuals with physical dependence on alcohol may experience withdrawal signs and symptoms upon stopping or reducing alcohol use. AWS has a range of severity, with the most severe cases referred to as complicated AWS, presenting as seizure or signs and symptoms indicative of delirium or new onset of hallucinations. In the general community, risk factors or predictors of complicated AWS among hospitalized patients have been described, but there is no literature that examines such risk factors in a correctional population. The Los Angeles County Jail (LACJ) is the nation's largest jail system and manages 10-15 new patients per day for AWS. Here we aim to identify the risk factors associated with alcohol withdrawal-related hospital transfers among incarcerated patients being managed for AWS in the LACJ.

METHODS

From January 1, 2019, to December 31, 2020, data were gathered about LACJ patients who required transfer to an acute care facility for alcohol withdrawal-related concerns while on the Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) protocol. Log regression analysis was performed to generate an odds ratio for acute care facility transfer for the following variables: race, sex assigned at birth, age, CIWA-Ar scores, highest systolic blood pressure (SBP), and highest heart rate (HR).

RESULTS

Out of 15,658 patients on CIWA-Ar protocol during this 2-year time frame, a total of 269 (1.7%) were transferred to an acute care facility for alcohol withdrawal-related concerns. Of those 269 patients, significant risk factors associated with withdrawal-related hospital transfer included: Other race (OR 2.9, 95% CI 1.5-5.5), male sex assigned at birth (OR 1.6, 95% CI 1.0-2.5), age ≥55 years (OR 2.3, 95% 1.1-4.9), CIWA-Ar score 9-14 (OR 4.1, 95% CI 3.1-5.3), CIWA-Ar score ≥15 (OR 21.0, 95% CI 12.0-36.6), highest SBP ≥150 mmHg (OR 2.3, 95% CI 1.8-3.0), highest HR ≥ 110 bpm (OR 2.8, 95% CI 2.2-3.8).

CONCLUSION

Among patients studied, the higher CIWA-Ar score was the most significant risk factor associated with alcohol withdrawal-related hospital transfer. Other significant risk factors identified are race other than Hispanic, white, and African American; male sex assigned at birth; age ≥55 years; highest SBP ≥150 mmHg; and highest HR ≥ 110 bpm.

Evaluation of phenobarbital based approach in treating patient with alcohol withdrawal syndrome: A systematic review and meta-analysis

BACKGROUND

Alcohol Withdrawal Syndrome (AWS) among patients with chronic and heavy alcohol consumption can range from mild to severe and is associated with high morbidity and mortality. Currently, treating AWS with benzodiazepines is the standard of care, but phenobarbital has also been hypothesized to be an effective first-line treatment due to its pharmacological properties and mechanism of action. We conducted a meta-analysis to review relevant literature and compare the clinical outcomes for patients diagnosed with AWS in ED and ICU settings.

METHODS

We performed a literature search in in the PubMed, Scopus, and Web of Science databases from inception to June 30, 2022. Randomized trials and observational (prospective or retrospective) studies were eligible if they included adult patients who presented in the ED and were treated in the ED and/or the intensive care unit (ICU) with a diagnosis of AWS. The primary outcome was the rate of intubation among patients who received phenobarbital, compared with benzodiazepines. Secondary outcomes such as rates of seizures, hospital, and ICU length of stay (LOS), also were included. The PROSPERO registration is CRD42022318862.

RESULTS

We included twelve studies (1934 patients) in our analysis. Of the 1934 patients in these studies, 765 (41.7%) were treated with phenobarbital and 1169 (58.3%) were treated with other modalities for alcohol withdrawal. Treating AWS patients with phenobarbital did not affect their risk for intubation, as the risk for intubation was similar between the phenobarbital and the control group (RR 0.70, 95% CI 0.36-1.38, P = 0.31). In addition, patients who were treated with phenobarbital were found to have similar rates of seizures (RR 0.73, 95% CI 0.29-1.89) and length of stay in the hospital (Standardized Mean Difference -0.02, 95% CI -0.26, 0.21) or the ICU (SMD -0.02, 95% CI -0.21, 0.25) when compared with patients receiving benzodiazepines.

CONCLUSIONS

Management of patients with AWS with phenobarbital is associated with similar rates of intubation, length of stay in the ICU, or length of stay in the hospital as treatment with benzodiazepines. However, due to the inclusion of mostly observational studies and a significant level of heterogeneity among the studies assessed in this review, additional trials with strong methodology are needed.

Protective Effects of Kefir Against Unpredictable Chronic Stress Alterations in Mice Central Nervous System, Heart, and Kidney

Kefir is a probiotic mixture with anxiolytic and antioxidant properties. Chronic stress can lead to anxiety disorders and increase oxidative damage in organs such as the heart and kidney. In this study, we examined whether kefir ameliorates the anxiety-like behavior of mice submitted to chronic unpredictable stress (CUS) by modulating brain-derived neurotrophic factor (BDNF) and corticosterone levels and whether kefir modifies the oxidative parameters in the heart and kidney of mice. Male Swiss mice received kefir (0.3 mL/100 g/day) or milk for 30 days (gavage). On the 10th day, the mice were submitted to CUS. Behavioral analysis was performed using the elevated plus maze and forced swimming tests. BDNF levels were analyzed in brain tissues. Heart and kidney superoxide dismutase (SOD), catalase, glutathione (GSH), thiobarbituric acid reactive substances (TBARS), 3-nitrotyrosine, metalloproteinase-2 (MMP-2), and plasma corticosterone were evaluated. Kefir reverted the CUS-induced decrease in the time spent in the open arms, the increase in grooming frequency, and decrease in the head dipping frequency, but not the reduced immobility time. CUS decreased the cerebellum BDNF levels and increased corticosterone levels, which were restored by Kefir. Neither catalase and SOD activities nor GSH, TBARS, 3-nitrotyrosine, and MMP-2 were modified by CUS in the heart. In the kidney, CUS increased 3-nitrotyrosine and MMP-2. Kefir increased the antioxidant defense in the heart and kidney of control and CUS mice. These results suggest that kefir ameliorated CUS-induced anxiety-like behavior by modulating brain BDNF and corticosterone levels. Kefir also increased the antioxidant defense of mice heart and kidney.

Impact of Alcohol Misuse on Requirements for Critical Care Services and Development of Hospital Delirium in Patients With COVID-19 pneumonia

Alcohol misuse has been associated with increased morbidity in the setting of pulmonary infections, including the need for critical care resource utilization and development of delirium. How alcohol misuse impacts morbidity and outcomes among patients admitted with COVID-19 pneumonia is not well described. We sought to determine if alcohol misuse was associated with an increased need for critical care resources and development of delirium among patients hospitalized with COVID-19 pneumonia.

DESIGN

Retrospective cohort study.

SETTING

Twelve University of Colorado hospitals between March 2020 and April 2021.

PATIENTS

Adults with a COVID-19 diagnosis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was admission to the ICU. Secondary outcomes included need for mechanical ventilation, development of delirium, and in-hospital mortality. Alcohol misuse was defined by International Classification of Diseases, 10th Revision codes. Of 5,979 patients hospitalized with COVID-19, 26% required ICU admission and 15.4% required mechanical ventilation. Delirium developed in 4.5% and 10.5% died during hospitalization. Alcohol misuse was identified in 4%. In analyses adjusted for age, sex, body mass index, diabetes, and liver disease, alcohol misuse was associated with increased odds of ICU admission (adjusted odds ratio [aOR], 1.46; p < 0.01), mechanical ventilation (aOR, 1.43; p = 0.03), and delirium (aOR, 5.55; p < 0.01) compared with patients without misuse. Mortality rates were not associated with alcohol misuse alone, although the presence of both alcohol misuse and in-hospital delirium significantly increased odds of in-hospital death (aOR, 2.60; p = 0.04).

CONCLUSIONS

Among patients hospitalized with COVID-19, alcohol misuse was associated with increased utilization of critical care resources including ICU admission and mechanical ventilation. Delirium was an important modifiable risk factor associated with worse outcomes in hospitalized patients with alcohol misuse, including increased odds of death.

Association of Plasma Anion Gap with 28-Day Inhospital Mortality and 1-Year Mortality of Patients with Alcohol Use Disorder at ICU Admission: A Retrospective Cohort Study

Background

Alcohol use disorder (AUD) is common in critically ill patients. Plasma anion gap (AG) was known as a feasible parameter and was associated with outcomes of various diseases. This study is intended to explore whether AG is related to 28-day inhospital mortality and 1-year mortality of critically ill patients with AUD.

Method

We extracted data from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The association of plasma AG with 28-day inhospital mortality and 1-year mortality of critically ill AUD patients was assessed using Cox proportional hazard regression models and stratification analyses, allowing AG as a time-varying covariate in the models. To evaluate the accuracy of AG in predicting different endpoints, receiver operator characteristic (ROC) curves were used.

Result

Among the 3993 critically ill patients with AUD, AG was positively associated with 28-day inhospital mortality and 1-year mortality after adjusting confounders (p < 0.001 for all). Compared with lower AG (<12 mmol/L), patients in different groups (12 ≤ AG < 14 mmol/L, 14 ≤ AG < 17 mmol/L, 17 ≤ AG < 20 mmol/L, and AG ≥ 20 mmol/L) had different HRs (95% CIs) for 28-day inhospital mortality (1.105, (0.906, 1.347); 1.171, (0.981, 1.398); 1.320, (1.108, 1.573); and 1.487, (1.254, 1.763), respectively) and 1-year mortality (1.037 (0.898, 1.196); 1.091 (0.955, 1.246); 1.201 (1.052, 1.371); and 1.3093 (1.149, 1.492), respectively).

Conclusion

Increased AG is associated with greater 28-day inhospital mortality and 1-year mortality. The effect of AG on all-cause mortality is linear in critically ill AUD patients.

Rewarding and Antidepressant Properties of Ketamine and Ethanol: Effects on the Brain-Derived Neurotrophic Factor and TrkB and p75NTR Receptors

There is a high level of comorbidity between depression and alcohol use disorder. Subanesthetic doses of ketamine induce short-acting and enduring antidepressant effects after a single or a few administrations. Considering such comorbidity, we assessed, in Swiss male mice, if ketamine-induced antidepressant-like effects would alter ethanol's rewarding effects; and, if ethanol pretreatment would alter the rewarding and antidepressant effects of ketamine. The role of the brain-derived neurotrophic factor (BDNF) and its high and low affinity receptors TrkB and p75NTR, respectively, in both reward and depression-related behaviors is well established. The present study assessed, in outbred Swiss male mice, the expression of these proteins in the prefrontal cortex and hippocampus. Ketamine did not alter the development of ethanol-induced conditioned place preference (CPP), yet ethanol inhibited the expression of CPP induced by 50 mg/kg ketamine. The antidepressant action of 50 mg/kg ketamine was attenuated after repeated treatment (i.e., developed tolerance), an effect blocked by ethanol preexposure; ethanol also inhibited the antidepressant effect of 30 mg/kg ketamine. Ketamine (50 mg/kg) and Ethanol-Ketamine (50 mg/kg) groups showed lower levels of 145 kDa TrkB in the hippocampus than Saline-treated group. Ethanol-Ketamine (50 mg/kg) decreased the hippocampal expression of p75NTR compared to Saline-Saline and Saline-Ethanol groups. Ketamine (50 mg/kg) induced hippocampal downregulation of 145 kDa TrkB may contribute to ketamine-induced antidepressant tolerance. Likewise, a relationship between low hippocampal levels of p75NTR in the Ethanol-Ketamine (50 mg/kg) and ketamine-induced CPP blockade may be considered. The findings underscore potential ethanol-ketamine interactions likely to undermine ketamine putative antidepressant effects.

Idiopathic pyometra and tubo-ovarian abscess in a postmenopausal patient treated conservatively

Background

Pyometra is a rare gynecological condition and is characterized by pus accumulation in the uterine cavity. It occurs more frequently in postmenopausal women than tubo-ovarian abscesses, which constitute a more common gynecological complication among premenopausal women.

Objective

A 72-year-old woman was admitted to our emergency department with lower abdominal pain, diarrhea and fever for the last three days. The laboratory results were indicative to sepsis. The clinical examination revealed sensitivity by palpation of the lower abdomen without any signs of acute abdomen. The gynecological assessment showed pus outflow through the cervix and a pus culture was done. The ultrasound examination found an enlarged uterus, full of hypoechoic fluid, unclear borders between endometrium-myometrium, a mixed echogenicity adnexal mass and no free fluid in the pouch of Douglas. A computed tomography (CT) of the abdomen showed the presence of pyometra and a tubo-ovarian abscess of the right adnexa.

Method

The patient was treated with intravenous antibiotic therapy. When the patient was hemodynamically stable and afebrile, she underwent ultrasound-guided dilatation and curettage of the cervical canal and the endometrium in order to exclude an underlying malignancy, under general anesthesia.

Results

The patient responded promptly to the intravenous antibiotic therapy which was adapted to the pus culture result. The laboratory results withdrew to normal values and the patient was discharged after fifteen days of hospitalization in an afebrile and hemodynamically stable condition.

Conclusion

Pyometra and tubo-ovarian abscess in postmenopausal women could be a lethal complication of pelvic inflammatory disease. The key in treatment is the dilatation of the cervix and drainage of the pyometra. The administration of intravenous antibiotics and drainage through the cervix could be a suitable method of treatment for pyometra in older patients or those with poor performance status if only the histological examination is negative for malignancy.

Analysis of Patients with Alcohol Dependence Treated in Silesian Intensive Care Units

Analysis of patients with alcohol dependence (AD) treated in intensive care units has never been performed in Poland. Data from 25,416 adult patients identified in a Silesian Registry of Intensive Care Units were analysed. Patients with AD were identified, and their data were compared with the remaining population. Preadmission and admission variables that independently influenced ICU death in these patients were identified. Among 25,416 analysed patients, 2285 subjects (9.0%) were indicated to have AD among their comorbidities. Patients with AD were significantly younger (mean age: 53.3 ± 11.9 vs. 62.2 ± 15.5 years, p < 0.001) but had a higher mean APACHE II score at admission and were more frequently admitted to the ICU due to trauma, poisonings, acute pancreatitis, and severe metabolic abnormalities. ICU death and unfavourable outcomes were more frequent in these patients (47.8% vs. 43.0%, p < 0.001 and 54.1% vs. 47.0%, p < 0.001, respectively). Multiorgan failure as the primary cause of ICU admission was among the most prominent independent risk factors for ICU death in these patients (OR: 3.30, p < 0.001). Despite the younger age, ICU treatment of patients with AD was associated with higher mortality and a higher percentage of unfavourable outcomes.

Computational Investigation of Structural Basis for Enhanced Binding of Isoflavone Analogues with Mitochondrial Aldehyde Dehydrogenase

Isoflavone compounds are potent inhibitors against mitochondrial aldehyde dehydrogenase (ALDH2) for the treatment of alcoholism and drug addiction, and an in-depth understanding of the underlying structural basis helps design new inhibitors for enhanced binding. Here, we investigated the binding poses and strengths of eight isoflavone analogues (including CVT-10216 and daidzin) with ALDH2 via computational methods of molecular docking, molecular dynamics (MD) simulation, molecular mechanics Poisson-Boltzmann surface area (MM-PBSA), steered MD, and umbrella sampling. Neither the Vina scoring of docked and MD-sampled complexes nor the nonbonded protein-inhibitor interaction energy from MD simulations is able to reproduce the relative binding strength of the inhibitors compared to experimental IC₅₀ values. Considering the solvation contribution, MM-PBSA and relatively expensive umbrella sampling yield good performance for the relative binding (free) energies. The isoflavone skeleton prefers to form π-π stacking, π-sulfur, and π-alkyl interactions with planar (Phe and Trp) or sulfur-containing (Cys and Met) residues. The enhanced inhibition of CVT-10216 originates from both end groups of the isoflavone skeleton offering strong van der Waals contacts and from the methylsulfonamide group at the 4' position by hydrogen bonding (HB) with neighboring receptor residues. These results indicate that the hydrophobic binding tunnel of ALDH2 is larger than the isoflavone skeleton in length and thus an extended hydrophobic core is likely a premise for potent inhibitors.

Research progress on risk factors of delirium in burn patients: A narrative review

Delirium, an acute brain dysfunction, is a common and serious complication in burn patients. The occurrence of delirium increases the difficulty of patient treatment, is associated with various adverse outcomes, and increases the burden on the patient's family. Many scholars have studied the factors that cause delirium, but the causes, pathogenesis, and treatment of delirium in burn patients have not been fully revealed. There is no effective pharmacological treatment for delirium, but active preventive measures can effectively reduce the incidence of delirium in burn patients. Therefore, it is necessary to study the relevant factors affecting the occurrence of delirium in burn patients. This study was conducted on December 20, 2021 by searching the PubMed database for a narrative review of published studies. The search strategy included keywords related to "burns," "delirium," and "risk factors." We reviewed the characteristics of delirium occurrence in burn patients and various delirium assessment tools, and summarized the risk factors for the development of delirium in burn patients in terms of personal, clinical, and environmental factors, and we found that although many risk factors act on the development of delirium in burn patients, some of them, such as clinical and environmental factors, are modifiable, suggesting that we can estimate the exposure of burn patients to risk factors by assessing their likelihood of delirium occurring and to make targeted interventions that provide a theoretical basis for the prevention and treatment of burn delirium.

Alcohol Use Disorder in Older Adults

As the number of older adults worldwide continues to grow, we observe a proportional growth of substance use. Despite the myriad of complications alcohol use disorder (AUD) has on the body with regards to organ systems and mental health, the topic has been underresearched in the older adult population. Thus, it is important to create awareness about the growing problem of AUD among older adults. In this way, we can mitigate the long-term complications and side effects observed with alcohol abuse in this vulnerable population.

Alcohol Use and the Risk of Communicable Diseases

The body of knowledge on alcohol use and communicable diseases has been growing in recent years. Using a narrative review approach, this paper discusses alcohol's role in the acquisition of and treatment outcomes from four different communicable diseases: these include three conditions included in comparative risk assessments to date-Human Immunodeficiency Virus (HIV)/AIDS, tuberculosis (TB), and lower respiratory infections/pneumonia-as well as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) because of its recent and rapid ascension as a global health concern. Alcohol-attributable TB, HIV, and pneumonia combined were responsible for approximately 360,000 deaths and 13 million disability-adjusted life years lost (DALYs) in 2016, with alcohol-attributable TB deaths and DALYs predominating. There is strong evidence that alcohol is associated with increased incidence of and poorer treatment outcomes from HIV, TB, and pneumonia, via both behavioral and biological mechanisms. Preliminary studies suggest that heavy drinkers and those with alcohol use disorders are at increased risk of COVID-19 infection and severe illness. Aside from HIV research, limited research exists that can guide interventions for addressing alcohol-attributable TB and pneumonia or COVID-19. Implementation of effective individual-level interventions and alcohol control policies as a means of reducing the burden of communicable diseases is recommended.

Alcohol consumption is associated with a later need for ICU admission: a Northern Finland Birth Cohort 1966-study

BACKGROUND

Alcohol-related problems are common in intensive care unit (ICU) admitted patients. The aim of the present study is to assess the impact of alcohol consumption on the need of intensive care in 19 years follow-up period.

METHODS

The study population consists of Northern Finland Birth Cohort 1966 participants, who responded alcohol-related questions at 31 years of age and Intensive Care Unit (ICU admissions from 1997 to 2016.

RESULTS

There were a total of 8379 assessed people and 136 (1.6%) of them were later admitted to ICU. A total of 44 (32.4%) of the ICU-admitted persons had their alcohol consumption at the highest quartile of the cohort (P = 0.047). These patients had a lower number of malignancy-related admissions (3.6% versus 14.0%, P = 0.027), neurological admissions (14.3 versus 30.6%, P = 0.021), and were more often admitted due to poisonings (12.5% versus 5.0%, P = 0.07). There were no differences in 28-day post-ICU mortality but long-term mortality of ICU-admitted patients with lower alcohol consumption was higher than non-ICU-admitted population.

CONCLUSION

Among ICU-admitted population, there was higher alcohol consumption at age of 31 years. People in the lower alcohol consumption quartiles were more often admitted to ICU due to malignancy-related causes and they had higher long-term mortality.

Clinical impact of chronic substance abuse in a Norwegian ICU-population

BACKGROUND

The clinical impact of chronic substance abuse of alcohol and drugs-referred to as substance use disorders (SUD)-is often overlooked in the intensive care (ICU) setting. The aims of the present study were to identify patients with SUD-regardless of cause of admission-in a mixed Norwegian ICU-population, and to compare patients with and without SUD with regard to clinical characteristics and mortality.

METHODS

Cross-sectional prospective study of a mixed medical and surgical ICU-population aged ≥18 years in Oslo, Norway. Data were collected consecutively, using a questionnaire including the AUDIT-C test, medical records and toxicology results. Patients classified with SUD were divided into the subgroups alcohol use disorders (AUD) and drug use disorders (DUD).

RESULTS

Overall, 222 (26%) of the 861 patients included were classified with SUD; 137 (16%) with AUD and 85 (10%) with DUD. 130/222 (59%) of the SUD-patients had substance abuse-related cause of ICU-admission. Compared to non-SUD patients, DUD-patients were younger (median age 42 vs 65 years) and had lower SAPS II scores (41 vs 46), while AUD-patients had higher SOFA scores (8.0 vs 7.3). Overall, age-adjusted logistic regression analysis showed similar hospital mortality for SUD-patients and non-SUD patients, but AUD was associated with increased mortality among medical patients and in patients with sepsis (OR 1.7 (95% CI 1.0-2.8), and OR 2.6 (95% CI 1.1-6.2)).

CONCLUSION

One in four ICU-patients had SUD regardless of cause of admission. Alcohol use disorder was associated with increased mortality in medical patients and in patients with sepsis.

Introduction of an Electronic Mobile Device Version of an Alcohol Impairment Scale (the Hack's Impairment Index Score) Does Not Impair Nursing Assessment of Patients in Emergency Departments

•

Annually, there are up to 5 million visits to EDs across the country of patients with a primary complaint of “Alcohol Intoxication”.

•

ED Health Care Providers are charged with initial assessment, serial evaluations and then deciding when these patients are clinically improved to the point when they are ready for disposition.

•

Previously, there was no widely accepted tool for providers to use to perform a standardized, formal examination of these patients.

•

Hack's Impairment Index (HII Score) is a clinical tool currently being used at the bedside by nurses at select institutions across the United States using paper prompts.

•

An App version of the HII Score for use on mobile devices was developed.

•

This study evaluated the effects on nursing performance with the tool when paper charting was replaced.

Background

There is no formal assessment to determine level of disability in the millions of patients with alcohol-induced impairment who present to emergency departments annually. Hack's Impairment Index (HII) is a standardized, serializable clinical tool designed to quantify ability. Nursing staff members at this center perform the HII and determine a score using paper prompts.

Objective

We developed an HII electronic application and investigated whether or not an electronic version on a mobile device would affect nursing performance.

Methods

A chart review-based quality improvement project compared the number, repetitions, and completeness of HII score documentation performed by nurses over 6.5 months. Group 1: paper-based HII scores for the 90-day period before intervention; group 2: iPad-based HII scores for the 90 days after intervention. There was a 2-week period for staff training and electronic version feedback between groups. Informal, ad hoc interviews were performed with nurses at investigation termination.

Results

Group 1: 476 emergency department patients with alcohol-induced impairment had HII scores ordered; 339 (71.2%; 95% CI, 67.1, 75.3%) had HII assessments with a total of 539 HII scores documented. An average (SD) 1.60 (0.01) serial assessments occurred per patient, 5 (1.1%; 95% CI, (0, 2.2%) scores were incomplete. Group 2: 569 alcohol-induced impairment emergency department patients were seen and had HII scores ordered; 420 (73.8%; 95% CI, (70.2, 77.4%) had HII assessments with a total of 639 HII scores documented. An average (SD) 1.52 (0.03) serial assessments occurred per patient, 4 (0.9%; 95% CI, (0.81, 0.99%) had incomplete HII scores.

Conclusions

Although our study took place at 1 center, was a chart review, and not directly observed, we found that the mobile device-based HII application to determine a score did not interfere with nursing performance. Specifically, the repetition and completeness of nursing assessments of emergency department patients with impairment from alcohol use was not altered when comparing paper chart documentation with electronic format documentation. (Curr Ther Res Clin Exp. 2021; 82:XXX–XXX)

Red Blood Cell Distribution Width as a Predictor of 28-Day Mortality in Critically Ill Patients With Alcohol Use Disorder

BACKGROUND

Patients with alcohol use disorder (AUD) are common attendees of the intensive care unit (ICU). Early assessment of the prognosis for critically ill patients with AUD is conducive for formulating comprehensive treatment measures and improving survival rates. The purpose of this study was to explore the predictive value of red blood cell distribution width (RDW) for 28-day mortality in critically ill patients with AUD.

METHODS

2,884 patients with AUD were recruited retrospectively. Data from the MIMIC-III database were collected and analyzed. A receiver operating characteristic (ROC) curve was used to determine the optimal cutoff value of RDW. The Kaplan-Meier method and Cox regression models were used to evaluate prognostic factors.

RESULTS

Of the 2,884 patients, there were 344 nonsurvivors (11.9%). The nonsurvivors had a higher RDW than the survivors (p < 0.001). According to ROC curve analysis, the area under the curve predicted by RDW for 28-day mortality was 0.728 (95% CI, 0.700 to 0.755) and the optimal cutoff value was 15.45% (sensitivity: 67.2%; specificity: 67.3%). Length of stay in ICU, length of stay in hospital, in-hospital mortality, and 28-day mortality in patients with an RDW > 15.45% were significantly higher than in those with an RDW ≤ 15.45% (p < 0.001). Cox regression analysis showed that an RDW > 15.45% was an independent prognostic indicator for 28-day mortality in critically ill patients with AUD (HR = 1.964, 95% CI: 1.429 to 2.698).

CONCLUSIONS

High RDW was associated with increased short-term mortality risks in critically ill patients with AUD.

The Utility of Carbohydrate-Deficient Transferrin in Identifying Chronic Alcohol Users in the Injured Patient: Expanding the Toolkit

BACKGROUND

Alcohol use remains abundant in patients with traumatic injury. Previous studies have suggested that serum carbohydrate-deficient transferrin (%dCDT) levels, relative to blood alcohol levels (BALs), may better differentiate episodic binge drinkers from sustained heavy consumers in admitted patients with traumatic injury. We characterized %dCDT levels and BAL levels to differentiate binge drinkers from sustained heavy consumers in admitted trauma patients and their associations with outcomes.

METHODS

This prospective, cross-sectional, observational study assessed %dCDT and BAL levels in admitted male and female patients with traumatic injury (≥18 y) at an American College of Surgeons Committee on Trauma level-1 center from July 2014 to June 2016. We designated patients with %dCDT levels ≥1.7% (CDT+) as chronic alcohol users and dichotomized acutely intoxicated patients using three different BAL-level thresholds. Primary outcomes included in-hospital complications, along with prolonged ventilation and intensive care unit length of stay, both defined as the top decile. Secondary outcomes included rates of drug or alcohol withdrawal and all-cause mortality. Analyses were adjusted for clinical factors.

RESULTS

We studied 715 patients (77.5% men, 60.6% ≤ 40 y of age, median Injury Severity Score: 14, 41.7% motor vehicle crashes, 17.9% gunshot wounds, 11.1% falls). While 31.0% were CDT+, 48.7% were BAL>0. After adjusting for CDT levels, BAL levels >0, >100, or >200 were not associated with adverse outcomes. However, CDT+ relative to patients with CDT were associated with complications (adjusted odds ratio: 1.96 [1.24-3.09]), prolonged ventilation days (3.23 [1.08-9.65]), and prolonged intensive care unit stays (2.83 [1.20-6.68]).

CONCLUSIONS

In this 2-year prospective, cross-sectional, and observational study, we found that %dCDT levels, relative to BAL levels, may better stratify admitted patients with traumatic injury into acute versus chronic alcohol users, identifying those at higher risk for in-hospital complications.

Chronic Alcohol Ingestion Worsens Survival and Alters Gut Epithelial Apoptosis and CD8+ T Cell Function After Pseudomonas Aeruginosa Pneumonia-Induced Sepsis

Mortality is higher in septic patients with a history of alcohol use disorder than in septic patients without a history of chronic alcohol usage. We have previously described a model of chronic alcohol ingestion followed by sepsis from cecal ligation and puncture in which alcohol-fed septic mice have higher mortality than water-fed septic mice, associated with altered gut integrity and increased production of TNF and IFNγ by splenic CD4 T cells without alterations in CD8 T cell function. The purpose of this study was to determine whether this represents a common host response to the combination of alcohol and sepsis by creating a new model in which mice with chronic alcohol ingestion were subjected to a different model of sepsis. C57Bl/6 mice were randomized to receive either alcohol or water for 12 weeks and then subjected to Pseudomonas aeruginosa pneumonia. Mice were sacrificed either 24 hours after the onset of sepsis or followed for survival. Alcohol-fed septic mice had significantly higher 7-day mortality than water-fed septic mice (96% vs 58%). This was associated with a 5-fold increase in intestinal apoptosis in alcohol-fed septic animals, accompanied by an increase in the pro-apoptotic protein Bax. Serum IL-6 levels were higher and IL-2 levels were lower in alcohol-fed septic mice. In contrast, CD8 T cell frequency was lower in alcohol-fed mice than water-fed septic mice, associated with increased production of IFNγ and TNF in stimulated splenocytes. No significant differences were noted in CD4 T cells, lung injury or bacteremia. Mice with chronic alcohol ingestion thus have increased mortality regardless of their septic insult, associated with changes in both the gut and the immune system.

Effects of cachaça, a typical Brazilian alcoholic beverage, on submandibular glands of rats: a histomorphometric and biochemical study

OBJECTIVE

This study aimed to evaluate the effects of chronic consumption of cachaça, a Brazilian beverage containing alcohol, on submandibular glands (SM) of rats by using histomorphometric and biochemical parameters.

MATERIALS AND METHODS

Twenty-four male rats (40 days of age) were assigned into the following four groups (n = 6): two control groups for 75 days (C75) and 105 days (C105), and two experimental groups of cachaça ingestion with ascending concentrations for consecutive 75 days (CA75) and 105 days (CA105). On the right SM glands, the striated, granular and acini ducts were processed for histomorphometric analysis. The left SM glands were weighed and stored at - 80 °C, to evaluate through biochemical tests carried out by spectrophotometric methods, the functional activity of total acid phosphatase (TAP), tartrate-resistant acid phosphatase (TRAP), and alkaline phosphatase (ALP) and to determine the mucin levels.

RESULTS

The absolute and relative weights of the SM glands in both experimental groups were reduced in relation to the controls (p < 0.05). The histomorphometric analysis showed a significant reduction of the acini area (p < 0.05) and non-relevant reduction of striated ducts (p > 0.05). The granular ducts did not show a significant increase of the area (p > 0.05). The TAP and TRAP activities were significantly decreased in the experimental groups (p < 0.05), while the ALP functional activity decreased moderately (p > 0.05). Mucin levels also had a significant reduction when compared with the control groups (p < 0.05).

CONCLUSIONS

Chronic consumption of cachaça can cause morphological changes associated with glandular atrophy, loss of biochemical functionality of phosphatases, and the reduction of mucin synthesis.

CLINICAL RELEVANCE

The consumption of cachaça can compromise the functions of the submandibular glands by altering their morphology and enzymatic activity.

Substance abuse-related admissions in a mixed Norwegian intensive care population

BACKGROUND

Alcohol and drug abuse are potentially modifiable risk factors for critical illness. The aims of this study were to describe patients with substance abuse-related admissions (abbreviated SARA) in a mixed intensive care (ICU) population in Oslo, and to compare these patients with patients with non-SARA.

METHODS

Cross-sectional prospective study of a mixed medical and surgical ICU-population in Oslo, Norway. Data were collected consecutively using a questionnaire, medical records, and toxicology results. SARA included admissions due to acute or chronic complications of alcohol or drug abuse, as well as substance abuse-related injuries.

RESULTS

Of the 852 patients included, 168 (20%) had SARA; 102 (12%) alcohol-related and 66 (8%) drug-related. Male patients aged 18-39 had the highest proportion of SARA (47/97, 49%). Among the trauma patients, 69/182 (38%) were influenced by alcohol and drugs at the time of injury. Patients with SARA were significantly younger (median age 48 vs 66), had lower Charlson comorbidity index (mean 1.4 vs 2.5) and shorter length of stay (median days 2.4 vs 4.9), than non-SARA patients. Hospital mortality was similar when adjusting for age (OR 0.8, P = .27, non-SARA as reference).

CONCLUSION

Overall, one in five ICU admissions was associated with substance abuse. For male patients aged 18-39 this ratio was nearly half. More than one third of the trauma patients were influenced by alcohol or drugs at time of injury.

Prevalence of risk-drinking in critically ill patients, screened with carbohydrate-deficient transferrin and AUDIT-C score: A retrospective study

Background Studies demonstrate that up to one-third of intensive care unit (ICU) admissions are directly or indirectly related to alcohol. Screening for alcohol use is not routine. This study examined the prevalence of elevated %CDT (carbohydrate-deficient transferrin) and above risk-level AUDIT-C (Alcohol Use Disorders Identification Test, Consumption) in patients admitted to ICU. Methods We conducted a retrospective analysis of clinical and laboratory data from a single ICU where %CDT and AUDIT-C were included in routine assessment. After excluding readmissions, 2532 adult patients from a 21-month period were included. Admission values of %CDT were available for 2049 patients, and AUDIT-C was available for 1617 patients. The association of %CDT and AUDIT-C with short- and long-term outcome was studied by using univariate and multivariate logistic regression analysis. Results %CDT was above the reference value in 23.7% (486/2048) of patients with available %CDT. Of patients with available AUDIT-C, 33% (544/1617) had a risk-level AUDIT-C score. Patients with a risk-level AUDIT-C score were significantly younger than those with a lower score (51 vs 64 years, P < .0001). Increased %CDT was associated with higher severity of illness. AUDIT-C was associated independently with increased risk of long-term mortality in multivariate analysis (P = .007). Conclusion One in three of ICU patients are risk-level alcohol users as measured with AUDIT-C score, and one in four are analysed with %CDT. The prevalence varies according to the method used and any method alone may be insufficient to detect risk-level consumption reliably. Editorial Comment Alcohol overconsumption is associated with need for ICU admission and with less favorable outcomes. Diagnosis of alcohol overconsumption though is problematic due to low sensitivity in screening. In a pilot study, a biomarker and a screening tool are compared. The finding is that multiple tools are needed to achieve an adequate sensitivity for detection.

Characteristics of Dispensary Patients that Limit Alcohol after Initiating Cannabis

Many patients have reported that they decrease their use of opioids after starting medical cannabis (MC) but less is known for alcohol. The objective of this exploratory study was to identify any factors which differentiate alcohol abaters from those that do not modify their alcohol use after starting MC (non-abaters). Comparisons were made to identify any demographic, dosing, or health history characteristics which differentiated alcohol abaters (N = 47) from non-abaters (N = 65). Respondents selected from among a list of 37 diseases/health conditions (e.g. diabetes, sleep disorders). Abaters and non-abaters were indistinguishable in terms of sex, age, or prior drug history. A greater percentage of abaters (59.6%) than non-abaters (40.6%, p < .05) reported using MC two or more times per day. Abaters were more likely to be employed (68.1%) than non-abaters (51.1%, p < .05). Abaters also reported having significantly more health conditions and diseases (3.3 ± 2.0) than non-abaters (2.4 ± 1.4, p < .05). This small study offers some insights into the profile of patients whose self-reported alcohol intake decreased following initiation of MC. Additional prospective or controlled research into the alcohol abatement phenomenon following MC may be warranted.

Clinical Pharmacist's Role in an Alcohol Detox Unit in a Correctional Setting

INTRODUCTION

Newly incarcerated inmates with chronic alcohol use are at high risk for alcohol withdrawal. This descriptive study aims to describe the role of a clinical pharmacist within an alcohol detoxification unit (ADU) in the Los Angeles County jail that serves nearly 18 000 inmates facility-wide daily.

METHODS

This descriptive analysis was conducted from August 2, 2018 through October 31, 2018 within the jail ADU. The pharmacist attended daily assessments on all alcohol detox patients; identified and assessed patients at high risk of severe withdrawal; and initiated, modified, and discontinued withdrawal medication for selected patients. Patients were determined to be high risk of severe withdrawal if they had history of severe withdrawal, any Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) score ≥15, or polysubstance withdrawal.

RESULTS

A total of 1263 patients were admitted to the ADU during the study (average 97 per week). A total of 282 patients were assessed by the pharmacist. Patient assessments included substance use and medication history, CIWA-Ar score, response to pharmacotherapy, and referral to a substance use counselor. Medications were initiated, modified, or discontinued in 148 patients after discussion with a physician. Transfer to an acute care facility occurred in 48 patients. Zero alcohol detox patient deaths occurred during the study.

CONCLUSION

This is a novel role of a pharmacist in a correctional setting. A pharmacist can aid in an ADU by identifying and assessing patients at high risk of severe withdrawal and managing pharmacotherapy. Future studies can examine pharmacist withdrawal management of additional substances.

Alcohol withdrawal is associated with poorer outcome in acute ischemic stroke

OBJECTIVE

To determine the association between alcohol abuse (AA) and alcohol withdrawal (AW) with acute ischemic stroke (AIS) outcomes.

METHODS

All adult AIS admissions in the United States from 2004 to 2014 were identified from the National Inpatient Sample (weighted n = 4,438,968). Multivariable-adjusted models were used to evaluate the association of AW with in-hospital medical complications, mortality, cost, and length of stay in patients with AIS.

RESULTS

Of the AA admissions, 10.6% of patients, representing 0.4% of all AIS, developed AW. The prevalence of AA and AW in AIS increased by 45.2% and 40.0%, respectively, over time (p for trend <0.001). Patients with AA were predominantly men (80.2%), white (65.9%), and in the 40- to 59-year (44.6%) and 60- to 79-year (45.6%) age groups. After multivariable adjustment, AIS admissions with AW had >50% increased odds of urinary tract infection, pneumonia, sepsis, gastrointestinal bleeding, deep venous thrombosis, and acute renal failure compared to those without AW. Patients with AW were also 32% more likely to die during their AIS hospitalization compared to those without AW (odds ratio 1.32, 95% confidence interval 1.11-1.58). AW was associated with ≈15-day increase in length of stay and ≈$5,000 increase in hospitalization cost (p < 0.001).

CONCLUSION

AW is associated with increased cost, longer hospitalizations, and higher odds of medical complications and in-hospital mortality after AIS. Proactive surveillance and management of AW may be important in improving outcomes in these patients.

Alcohol abuse and disorder of granulopoiesis

Granulocytes are the major type of phagocytes constituting the front line of innate immune defense against bacterial infection. In adults, granulocytes are derived from hematopoietic stem cells in the bone marrow. Alcohol is the most frequently abused substance in human society. Excessive alcohol consumption injures hematopoietic tissue, impairing bone marrow production of granulocytes through disrupting homeostasis of granulopoiesis and the granulopoietic response. Because of the compromised immune defense function, alcohol abusers are susceptible to infectious diseases, particularly septic infection. Alcoholic patients with septic infection and granulocytopenia have an exceedingly high mortality rate. Treatment of serious infection in alcoholic patients with bone marrow inhibition continues to be a major challenge. Excessive alcohol consumption also causes diseases in other organ systems, particularly severe alcoholic hepatitis which is life threatening. Corticosteroids are the only therapeutic option for improving short-term survival in patients with severe alcoholic hepatitis. The existence of advanced alcoholic liver diseases and administration of corticosteroids make it more difficult to treat serious infection in alcoholic patients with the disorder of granulopoieis. This article reviews the recent development in understanding alcohol-induced disruption of marrow granulopoiesis and the granulopoietic response with the focus on progress in delineating cell signaling mechanisms underlying the alcohol-induced injury to hematopoietic tissue. Efforts in exploring effective therapy to improve patient care in this field will also be discussed.

Role of HIF-1α in Alcohol-Mediated Multiple Organ Dysfunction

Excess alcohol consumption is a global crisis contributing to over 3 million alcohol-related deaths per year worldwide and economic costs exceeding $200 billion dollars, which include productivity losses, healthcare, and other effects (e.g., property damages). Both clinical and experimental models have shown that excessive alcohol consumption results in multiple organ injury. Although alcohol metabolism occurs primarily in the liver, alcohol exposure can lead to pathophysiological conditions in multiple organs and tissues, including the brain, lungs, adipose, liver, and intestines. Understanding the mechanisms by which alcohol-mediated organ dysfunction occurs could help to identify new therapeutic approaches to mitigate the detrimental effects of alcohol misuse. Hypoxia-inducible factor (HIF)-1 is a transcription factor comprised of HIF-1α and HIF-1β subunits that play a critical role in alcohol-mediated organ dysfunction. This review provides a comprehensive analysis of recent studies examining the relationship between HIF-1α and alcohol consumption as it relates to multiple organ injury and potential therapies to mitigate alcohol’s effects.

Epidemiology, prognostic factors, and outcome of trauma patients admitted in a Brazilian intensive care unit

Background

Trauma is a major cause of hospital admissions and is associated with manifold complications and high mortality rates. However, data on intensive care unit (ICU) admissions are scarce in developing and low-income countries, where its incidence has been increasing.

Objectives

To analyze epidemiological and clinical factors and outcomes in adult trauma patients admitted to the ICU of a public teaching hospital in a developing country as well as to identify risk factors for complications in the ICU.

Patients and methods

Retrospective cohort of adult trauma patients admitted to the general ICU of a public teaching hospital in southern Brazil in the year 2012. Demographic, clinical, and outcome data from the ICU were analyzed.

Results

During the study period, 144 trauma patients were admitted (83% male, Acute Physiology and Chronic Health Evaluation Score II =18.6±7.2, age =33.3 years, 93% required mechanical ventilation). Of these, 60.4% suffered a traffic accident (52% motorcycle), and 31.2% were victims of violence (aggressions, gunshot wounds, or stabbing); 71% had brain trauma, 37% had chest trauma, and 21% had abdominal trauma. Patients with trauma presented a high incidence of complications, such as infections, acute renal failure, acute respiratory distress syndrome, and thrombocytopenia. The ICU mortality rate was 22.9%.

Conclusion

In a Brazilian public teaching ICU, there was a great variability of trauma etiologies (mainly traffic accidents with motorcycles and victims of violence); patients with trauma had a high incidence of complications and mortality in the ICU.

The impact of alcohol-related admissions on resource use in critically ill patients from 2009 to 2015: an observational study

Excessive alcohol use is associated with increased health care utilisation and increased mortality. This observational study sought to identify the proportion of patients admitted with a critical illness in which alcohol misuse contributed, and to examine the resource use for this group. We performed an observational retrospective database review of all admissions to the Alice Springs Hospital intensive care unit (ICU) between 1 January 2009 and 31 December 2015. The Alice Springs Hospital ICU is a ten-bed unit located in Central Australia, with approximately 600 admissions annually. The per capita consumption of alcohol in Central Australia is approximately 1.5 times the national average. The primary aim was to determine the proportion of admissions to intensive care in which alcohol misuse was identified as a contributing cause. Secondary aims examined resource utilisation including ICU and hospital length of stay, need for and duration of mechanical ventilation, and ICU re-admission. There were 3,768 admissions involving 2,670 individual patients. Of these admissions 947 (25%) were associated with alcohol misuse. Admissions associated with alcohol were significantly more likely to require mechanical ventilation (30% versus 20%, <i>P</i> <0.01), and had a significantly longer ICU length of stay (2.1 versus 1.9 days, <i>P</i> <0.05). The proportion of admissions in which alcohol misuse was implicated is amongst the highest in the published literature. The results of this study should drive further policy change directed at harm minimisation, and warrant more detailed epidemiological work at both a local and national level.

Accesses for alcohol intoxication to the emergency department and the risk of re-hospitalization: An observational retrospective study

BACKGROUND

Alcohol use disorders (AUD) are a frequent cause of admission to emergency departments (EDs) for acute alcohol intoxication (AAI). Patients with AUD present a higher risk of readmission to EDs for AAI than the general population, however, the distinction between sporadic AAI and AAI in the context of AUD in the ED setting is difficult.

AIMS

To analyze the epidemiological characteristics of patients admitted to EDs because of AAI and to identify factors associated with repeated admissions in order to develop a risk stratification system for patients with AUD based on objective data that can be easily applied in an ED setting.

METHODS

An observational retrospective study was performed. All patients with diagnosis of AAI at admission in 2014 were enrolled.

RESULTS

Five hundred and sixty-five patients were enrolled, of which 92 (16%) were admitted more than once to the ED. At multivariate analysis, factors associated with readmission were past episodes of alcohol abuse, social discomfort, previous traumas and psychiatric disorders. Basing on this parameter, a risk-score for re-hospitalization was developed. This score has a high predictive power for the risk of readmission to the ED (AROC 0.837, 95%CI 0.808-0.866), moreover, the cumulative probability of readmission within one year, increased in parallel with score value, being highest in patients presenting 3 or more risk factors.

CONCLUSION

The present study demonstrates that several risk factors stratify the risk of re-hospitalization in patients admitted to EDs for AAI, allowing the identification of those presenting more severe conditions and who would likely benefit from multidisciplinary intervention.

Delirium tremens and alcohol withdrawal nationally in the Veterans Health Administration

BACKGROUND AND OBJECTIVES

Alcohol withdrawal-especially delirium tremens (DT)-is a potentially life-threatening condition. While short-term treatment regimens and factors that predispose to more severe symptomatology have been extensively studied, little attention has been paid to the clinical epidemiology and long-term care of the chronic medical, addictive, psychiatric, and psychosocial problems faced by these patients.

METHODS

National Veterans Health Administration data from fiscal year 2012 were examined to identify veterans diagnosed with DT; with withdrawal but not DT (WNDT); and with Alcohol Use Disorder (AUD) but neither DT nor WNDT. They were compared on sociodemographic characteristics, psychiatric and medical co-morbidities, and health service and psychotropic medication use, first with bivariate analyses and then multiple logistic regression.

RESULTS

Among the 345,297 veterans diagnosed with AUD, 2,341 (0.7%) were diagnosed with DT and 6,738 (2.0%) with WNDT. Veterans diagnosed with either WNDT or DT were more likely to have been homeless, had more comorbid medical and psychiatric disorders, were more likely to be diagnosed with drug use disorders, utilized more health services, received more psychotropic medications, and were more likely to receive naltrexone. They were more likely to receive specialized legal, housing, vocational, and psychosocial rehabilitation services, as well as intensive case management.

CONCLUSIONS

Adults with WNDT and DT suffer from multiple chronic conditions and long-term service models are needed to coordinate the work of multiple specialists and to assure continuity of care.

SCIENTIFIC SIGNIFICANCE

This national study identifies sociodemographic characteristics, comorbidities, and service utilization patterns associated with WNDT and DT.(Am J Addict 2017;26:722-730).

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

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 (p_20min = 0.015 and p_40min = 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.

Effects of alcohol on c-Myc protein in the brain

Alcoholism is a disorder categorized by significant impairment that is directly related to persistent and extreme use of alcohol. The effects of alcoholism on c-Myc protein expression in the brain have been scarcely studied. This is the first study to investigate the role different characteristics of alcoholism have on c-Myc protein in the brain. We analyzed c-Myc protein in the hypothalamus and amygdala from five different animal models of alcohol abuse. c-Myc protein was increased following acute ethanol exposure in a mouse knockout model and following chronic ethanol consumption in vervet monkeys. We also observed increases in c-Myc protein exposure in animals that are genetically predisposed to alcohol and methamphetamine abuse. Lastly, c-Myc protein was increased in animals that were acutely exposed to methamphetamine when compared to control treated animals. These results suggest that in substance abuse c-Myc plays an important role in the brain's response.

High-performance detection and early prediction of septic shock for alcohol-use disorder patients

Background

The presence of Alcohol Use Disorder (AUD) complicates the medical conditions of patients and increases the difficulty of detecting and predicting the onset of septic shock for patients in the ICU.

Methods

We have developed a high-performance sepsis prediction algorithm, InSight, which outperforms existing methods for AUD patient populations. InSight analyses a combination of singlets, doublets, and triplets of clinical measurements over time to generate a septic shock risk score. AUD patients obtained from the MIMIC III database were used in this retrospective study to train InSight and compare performance with the Modified Early Warning Score (MEWS), the Simplified Acute Physiology Score (SAPS II), and the Systemic Inflammatory Response Syndrome (SIRS) for septic shock prediction and detection.

Results

From 4-fold cross validation, InSight performs particularly well on diagnostic odds ratio and demonstrates a relatively high Area Under the Receiver Operating Characteristic (AUROC) metric. Four hours prior to onset, InSight had an average AUROC of 0.815, and at the time of onset, InSight had an average AUROC value of 0.965. When applied to patient populations where AUD may complicate prediction methods of sepsis, InSight outperforms existing diagnostic tools.

Conclusions

Analysis of the higher order correlations and trends between relevant clinical measurements using the InSight algorithm leads to more accurate detection and prediction of septic shock, even in cases where diagnosis may be confounded by AUD.

•

At 93% sensitivity, InSight reduces false alarms by >80% over other detection tools.

•

InSight's diagnostic odds ratio is >30X those of MEWS, SAPS II, SIRS for detection.

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InSight outperforms comparable methods for septic shock prediction hours before onset.