Acute ethanol poisoning and the ethanol withdrawal syndrome

The effects of alcohol on testosterone synthesis in men: a review

INTRODUCTION

Testosterone concentrations in men decline with advancing age, with low testosterone concentrations being associated with multiple morbidities, an increased risk of early mortality, and a reduced quality of life. The purpose of this study was to examine the effects of alcohol on testosterone synthesis in men by investigating its effects on each level of the hypothalamic-pituitary-gonadal axis.

AREAS COVERED

Acute consumption of a low-to-moderate amount of alcohol increases testosterone concentrations in men, while consumption of a large volume of alcohol is associated with a reduction in serum testosterone concentrations. Elevated testosterone concentrations result from the increased activity of detoxification enzymes in the liver. Conversely, the primary mechanisms of action involved in the reduction of testosterone are increased hypothalamic-pituitary-adrenal axis activity, inflammation, and oxidative stress. When alcohol is consumed in excess, particularly chronically, it negatively affects testosterone production in men.

EXPERT OPINION

Since testosterone is an important component of men's health and wellbeing, current levels of alcohol consumption in many countries of the world require urgent attention. Elucidating the relationship between alcohol consumption and testosterone may be useful in identifying strategies to attenuate the testosterone-reducing effects of excessive or chronic alcohol consumption.

Identification and management of acute alcohol intoxication

Acute alcohol intoxication (AAI) is a harmful clinical condition, potentially life-threatening, secondary to the intake of large amounts of alcohol. Clinical manifestations of AAI are characterized by behavioural and neurological symptoms, even if its effects involve several organs and apparatus. Moreover, severe alcohol intoxication can produce a global neurological impairment leading to autonomic dysfunction, respiratory depression, coma and cardiac arrest. The evaluation of blood alcohol concentrations (BAC) is useful to confirm the suspicion of intoxication, both for clinical and legal reasons. Most of patients with AAI are referred to Emergency Departments due to behavioural, social, traumatic or clinical complications. Patient's stabilization is the first step in the management of AAI, in order to support vital functions and to prevent complications. Metadoxine represents a useful drug to increase ethanol metabolism and elimination. Given that AAI could represent a sentinel event of chronic alcohol abuse, patients presenting with acute intoxication should be screened for the presence of an underlying alcohol use disorder and referred to and an alcohol addiction unit to start a multidisciplinary treatment to achieve long term alcohol abstinence. The present review will focus on clinical features, diagnostic criteria and treatment strategies of AAI.

A Sarcina bacterium linked to lethal disease in sanctuary chimpanzees in Sierra Leone

Human and animal infections with bacteria of the genus Sarcina (family Clostridiaceae) are associated with gastric dilation and emphysematous gastritis. However, the potential roles of sarcinae as commensals or pathogens remain unclear. Here, we investigate a lethal disease of unknown etiology that affects sanctuary chimpanzees (Pan troglodytes verus) in Sierra Leone. The disease, which we have named "epizootic neurologic and gastroenteric syndrome" (ENGS), is characterized by neurologic and gastrointestinal signs and results in death of the animals, even after medical treatment. Using a case-control study design, we show that ENGS is strongly associated with Sarcina infection. The microorganism is distinct from Sarcina ventriculi and other known members of its genus, based on bacterial morphology and growth characteristics. Whole-genome sequencing confirms this distinction and reveals the presence of genetic features that may account for the unusual virulence of the bacterium. Therefore, we propose that this organism be considered the representative of a new species, named "Candidatus Sarcina troglodytae". Our results suggest that a heretofore unrecognized complex of related sarcinae likely exists, some of which may be highly virulent. However, the potential role of "Ca. S. troglodytae" in the etiology of ENGS, alone or in combination with other factors, remains a topic for future research.

Assessment of Ethanol-Induced Toxicity on iPSC-Derived Human Neurons Using a Novel High-Throughput Mitochondrial Neuronal Health (MNH) Assay

Excessive ethanol exposure can cause mitochondrial and cellular toxicity. In order to discover potential counteracting interventions, it is essential to develop assays capable of capturing the consequences of ethanol exposure in human neurons, and particularly dopaminergic neurons that are crucial for the development of alcohol use disorders (AUD). Here, we developed a novel high-throughput (HT) assay to quantify mitochondrial and neuronal toxicity in human dopaminergic neuron-containing cultures (DNs) from induced pluripotent stem cells (iPSCs). The assay, dubbed mitochondrial neuronal health (MNH) assay, combines live-cell measurement of mitochondrial membrane potential (MMP) with quantification of neuronal branching complexity post-fixation. Using the MNH assay, we demonstrated that chronic ethanol exposure in human iPSC-derived DNs decreases MMP and neuronal outgrowth in a dose-dependent manner. The toxic effect of ethanol on DNs was already detectable after 1 h of exposure, and occurred similarly in DNs derived from healthy individuals and from patients with AUD. We next used the MNH assay to carry out a proof-of-concept compound screening using FDA-approved drugs. We identified potential candidate compounds modulating acute ethanol toxicity in human DNs. We found that disulfiram and baclofen, which are used for AUD treatment, and lithium caused neurotoxicity also in the absence of ethanol, while the spasmolytic drug flavoxate positively influenced MNH. Altogether, we developed an HT assay to probe human MNH and used it to assess ethanol neurotoxicity and to identify modulating agents. The MNH assay represents an effective new tool for discovering modulators of MNH and toxicity in live human neurons.

Hemodialysis as a Treatment of Severe Ethanol Poisoning

A 64-year-old woman presented with coma and shock due to severe ethanol intoxication. Her initial, markedly elevated blood alcohol level of 136.5 mM fell only by 16% after a 4-hour period of conservative treatment consisting of mechanical respiration and the administration of intravenous fluids, vasopressors and inotropics. Subsequent hemodialysis rapidly reduced her blood ethanol concentrations to less threatening levels, with prompt restoration of her consciousness. Hemodialysis may be life-saving and should be considered in patients with severe ethanol intoxication.

The association of alcohol consumption with patient survival after organophosphate poisoning: a multicenter retrospective study

Organophosphate (OP) intoxication remains a serious worldwide health concern, and many patients with acute OP intoxication have also consumed alcohol. Therefore, we evaluated the association of blood alcohol concentration (BAC) with mortality among patients with OP intoxication. We retrospectively reviewed records from 135 patients who were admitted to an emergency department (ED) for OP intoxication between January 2000 and December 2012. Factors that were associated with patient survival were identified via receiver operating characteristic curve, multiple logistic regression, and Kaplan-Meier survival analyses. Among 135 patients with acute OP poisoning, 112 patients survived (overall mortality rate: 17 %). The non-survivors also exhibited a significantly higher BAC, compared to the survivors [non-survivors: 192 mg/dL, interquartile range (IQR) 97-263 mg/dL vs. survivors: 80 mg/dL, IQR 0-166.75 mg/dL; p < 0.001]. A BAC cut-off value of 173 mg/dL provided an area under the curve of 0.744 [95 % confidence interval (CI) 0.661-0.815], a sensitivity of 65.2 %, and a specificity of 81.2 %. A BAC of >173 mg/dL was associated with a significantly increased risk of 6-month mortality in the multiple logistic regression model (odds ratio 4.92, 95 % CI 1.45-16.67, p = 0.001). The Cox proportional hazard model revealed that a BAC of >173 mg/dL provided a hazard ratio of 3.07 (95 % CI 1.19-7.96, p = 0.021). A BAC of >173 mg/dL is a risk factor for mortality among patients with OP intoxication.

A clinical perspective of sepsis-associated delirium

The term sepsis-associated encephalopathy (SAE) has been applied to animal models, postmortem studies in patients, and severe cases of sepsis. SAE is considered to include all types of brain dysfunction, including delirium, coma, seizure, and focal neurological signs. Clinical data for sepsis-associated delirium (SAD) have been accumulating since the establishment of definitions of coma or delirium and the introduction of validated screening tools. Some preliminary studies have examined the etiology of SAD. Neuroinflammation, abnormal cerebral perfusion, and neurotransmitter imbalances are the main mechanisms underlying the development of SAD. However, there are still no specific diagnostic blood, electrophysiological, or imaging tests or treatments specific for SAD. The duration of delirium in intensive care patients is associated with long-term functional disability and cognitive impairment, although this syndrome usually reverses after the successful treatment of sepsis. Once the respiratory and hemodynamic states are stabilized, patients with severe sepsis or septic shock should receive rehabilitation as soon as possible because early initiation of rehabilitation can reduce the duration of delirium. We expect to see further pathophysiological data and the development of novel treatments for SAD now that reliable and consistent definitions of SAD have been established.

Aggression and increased glutamate in the mPFC during withdrawal from intermittent alcohol in outbred mice

RATIONALE

Disrupted social behavior, including occasional aggressive outbursts, is characteristic of withdrawal from long-term alcohol (EtOH) use. Heavy EtOH use and exaggerated responses during withdrawal may be treated using glutamatergic N-methyl-D-aspartate receptor (NMDAR) antagonists.

OBJECTIVES

The current experiments explore aggression and medial prefrontal cortex (mPFC) glutamate as consequences of withdrawal from intermittent access to EtOH and changes in aggression and mPFC glutamate caused by NMDAR antagonists memantine and ketamine.

METHODS

Swiss male mice underwent withdrawal following 1-8 weeks of intermittent access to 20 % EtOH. Aggressive and nonaggressive behaviors with a conspecific were measured 6-8 h into EtOH withdrawal after memantine or ketamine (0-30 mg/kg, i.p.) administration. In separate mice, extracellular mPFC glutamate after memantine was measured during withdrawal using in vivo microdialysis.

RESULTS

At 6-8 h withdrawal from EtOH, mice exhibited more convulsions and aggression and decreased social contact compared to age-matched water controls. Memantine, but not ketamine, increased withdrawal aggression at the 5-mg/kg dose in mice with a history of 8 weeks of EtOH but not 1 or 4 weeks of EtOH or in water drinkers. Tonic mPFC glutamate was higher during withdrawal after 8 weeks of EtOH compared to 1 week of EtOH or 8 weeks of water. Five milligrams per kilogram of memantine increased glutamate in 8-week EtOH mice, but also in 1-week EtOH and water drinkers.

CONCLUSIONS

These studies reveal aggressive behavior as a novel symptom of EtOH withdrawal in outbred mice and confirm a role of NMDARs during withdrawal aggression and for disrupted social behavior.

The assessment of an in-vitro model for evaluating the role of PARP in ethanol-mediated hepatotoxicity

This investigation aims to assess whether the hepatocellular carcinoma cell line, HepG2, is an appropriate model to assess the role of poly (ADP-ribose) polymerase (PARP) during acute ethanol toxicosis. HepG2 cells were dosed with graded concentrations of ethanol, ranging from 100 mM to 800 mM, for 6 hours to assess PARP activity induction, while another parallel experiment examined cellular damage via medium aspartate aminotransferase activity and cellular viability via MTT reduction. Aspartate aminotransferase activity was significantly elevated at 600 mM ethanol (FOLD; P < 0.01), with further increases at the 800 mM dose (1.43 fold; P < 0.001), compared to controls. Cellular viability was not significantly decreased compared to controls among all dose groups. PARP activity measured in total cell lysates showed a significant decreasing trend with respect to ethanol dose, reaching statistical significance at the 100 mM dose group (P < 0.05). Paradoxically, exposure to 50 μM etoposide (Positive apoptosis-inducing control) did not demonstrate significant PARP activity ablation. When analyzing PARP activity observation temporally, a significant correlation (R(2) =0.5314) was observed between activity and assay sequence. Overall, a clear HepG2 insensitivity to ethanol was observed.

A case of self‐harm by alcohol intoxication resulted in unintended in‐hospital death

Key Clinical Message

In-hospital hanging during a confusional state from alcohol intoxication is rare. To treat cases of acute alcohol intoxication, careful observation will be needed to avoid accidental psychological reactions.

An unexpected clinical course in a 29-day-old infant with ethanol exposure

Ethanol exposure can affect all pediatric age groups but occurs most commonly in ambulatory children and adolescents. Infants are less likely to ingest ethanol because they have limited ability to explore their environments. However, ethanol exposures in infants can occur. We report the case of a 29-day-old (3.5 kg) baby girl who presented with a blood alcohol level of 301 mg/dL after ingesting formula that had been prepared with gin. To our knowledge, she is the youngest reported child with such an elevated ethanol level in the medical literature. Despite her markedly elevated blood alcohol level, she had an unexpectedly mild clinical course, exhibiting subtle neurologic symptoms but no hypothermia, hypoglycemia, or cardiorespiratory impairment. This case demonstrates that the ethanol-exposed infant may lack typical or clear symptoms of acute intoxication. Therefore, the clinician must have a low threshold for pursuing blood alcohol testing in infants and young children with altered mental status. A prompt diagnosis of ethanol exposure is important for ensuring the health and safety of the child.

Alcohol: intoxication and poisoning - diagnosis and treatment

Alcohol intoxication refers to a clinically harmful condition induced by recent ingestion of alcohol, when alcohol and its metabolites accumulate in the blood stream faster than it can be metabolized by the liver. The major adverse effects of alcohol that gain clinical attention are the neurologic, gastrointestinal, and cardiovascular problems, which are usually related to blood alcohol concentration; however, the extent of acute alcohol intoxication also depends on several factors. Individuals who seek medical treatment for acute alcohol intoxication likely have additional medical problems related to chronic alcohol consumption or alcohol dependence. For this reason, additional investigations to identify potential problems needing particular attention should be considered, depending on the clinical features of the patient.

Toxicokinetics/Toxicodynamics of γ-hydroxybutyrate-ethanol intoxication: evaluation of potential treatment strategies

γ-Hydroxybutyrate (GHB), a common drug of abuse, is often coingested with ethanol. Increasing renal clearance via monocarboxylate transporter (MCT) inhibition represents a potential therapeutic strategy in GHB overdose, as does inhibition of GABAB receptors. In this study, we investigate toxicokinetic/toxicodynamic interactions between GHB-ethanol and efficacy of treatment options for GHB-ethanol intoxication in rats. Sedation was assessed using the endpoint of return-to-righting reflex. Respiration was assessed using plethysmography. Coadministration of 2.0 g/kg ethanol i.v. with 600 mg/kg GHB i.v. increased sleep time compared with GHB alone. Administration of ethanol to steady-state concentrations of 0.1-0.2% and 0.3-0.4% (w/v) did not affect toxicokinetics of 600 mg/kg GHB i.v., or respiratory rate, but did result in significantly lower peak tidal volumes compared with GHB alone. Oral administration of 2.5 g/kg ethanol had no significant effect on toxicokinetics of 1500 mg/kg orally administered GHB. Pretreatment with specific receptor inhibitors indicated no effect of GABAA receptor inhibition on sleep time or respiratory depression in GHB-ethanol intoxication. GABAB receptor inhibition partially prevented sedation and completely prevented respiratory depression. Ethanol increased fatality when administered at 0.1-0.2% (4 of 10) and 0.3-0.4% (9 of 10) versus 1500 mg/kg GHB i.v. alone (0 of 10). Treatment with the MCT inhibitor, l-lactate, significantly decreased sleep time after GHB-ethanol and decreased fatality at 0.1-0.2% (0 of 10) and 0.3-0.4% ethanol (5 of 10). Treatment with a GABAB receptor antagonist completely prevented fatality at 0.3-0.4% (0 of 10). These data indicate that ethanol potentiates the sedative and respiratory depressant effects of GHB, increasing the risk of fatality. MCT and GABAB receptor inhibition represent potentially effective treatments in GHB-ethanol intoxication.

A rational approach to the treatment of alcohol withdrawal in the ED

Approximately 7% of the US population abuses or is dependent on alcohol. Patients with alcohol disorders often seek medical attention in Emergency Departments (EDs) for complications directly related to alcohol use or due to other medical issues associated with alcohol use. Because of increasing lengths of stay in EDs, alcohol-dependent patients are at high risk of developing alcohol withdrawal syndrome (AWS) during their ED visit. This article reviews the physiology of alcohol withdrawal as well as the symptoms of this potentially deadly illness for the practicing emergency physician (EP). We provide evidence-based guidelines for the appropriate ED treatment of moderate to severe AWS, including pharmacologic interventions, adjunctive therapies, and disposition of these patients.

Beneficial and harmful effects of alcohol exposure on Caenorhabditis elegans worms

Alcoholic beverages are consumed widely throughout the world. While the harmful effects of alcoholism are well recognized, the beneficial effects of moderate alcohol consumption to human health remain debatable. In this study, we investigated the effects of long-term ethanol exposure on nematode Caenorhabditis elegans worms. At high concentrations (≥ 4%), ethanol significantly impaired mobility, reduced fertility, and shortened lifespan. Interestingly, at low concentrations (1-2%), it extended lifespan, accompanied with a slower decline of mobility during aging, although it slightly impaired development, fertility, and chemotaxis. The lifespan-prolonging effects of ethanol at the low concentrations were seen in normal worms exposed to ethanol from egg, young larva, and young adult stages but were not observed in age-1 and sir-2.1 mutant worms. Our study demonstrated hormetic effects of ethanol and further established C. elegans as a suitable animal model to study ethanol related problems.

Alcohol-related seizures

The term alcohol-related seizures (ARS) is used to refer to all seizures in the aggregate associated with alcohol use, including the subset of alcohol withdrawal seizures (AWS). From 20% to 40% of patients with seizure who present to an emergency department have seizures related to alcohol abuse. However, it is critical to avoid prematurely labeling a seizure as being caused by alcohol withdrawal before performing a careful diagnostic evaluation. Benzodiazepines alone are sufficient to prevent AWS. The alcoholic patient with a documented history of ARS, who experiences a single seizure or a short burst of seizures should be treated with lorazepam, 2 mg intravenously.

Pharmacotherapy of alcohol and drug problems

Substantial progress has been made in the pharmacotherapy of withdrawal syndromes and organic complications of alcohol and drug abuse. Diazepam loading (alcohol withdrawal), phenobarbital loading (barbituate withdrawal) and diazepam tapering (benzodiazepine discontinuation) have considerably simplified treatment of withdrawal syndromes and have enhanced efficacy. Propylthiouracil shows considerable promise in the out-patient treatment of alcoholic liver disease. New medications, particularly those modifying serotonergic function, have efficacy in decreasing alcohol consumption and show considerable therapeutic potential. Human pharmacology and pharmacotherapy should be a central part of training programmes in the field in order that further advances can be made.

Genetic and early environmental contributions to alcohol's aversive and physiological effects

Genetic and early environmental factors interact to influence ethanol's motivational effects. To explore these issues, a reciprocal cross-fostering paradigm was applied to Fischer and Lewis rats. The adult female offspring received vehicle or the kappa opioid antagonist nor-BNI (1 mg/kg) followed by assessments of conditioned taste aversion (CTA), blood alcohol concentrations (BACs) and hypothermia induced by 1.25 g/kg intraperitoneal ethanol. CTA acquisition in the in-fostered Fischer and Lewis animals did not differ; however, the Fischer maternal environment produced stronger acquisition in the cross-fostered Lewis rats versus their in-fostered counterparts. CTAs in the Fischer rats were not affected by cross-fostering. In extinction, the in-fostered Lewis animals displayed stronger aversions than the Fischer groups on two trials (of 12) whereas the cross-fostered Lewis differed from the Fischer groups on nine trials. Despite these CTA effects, Lewis rats exhibited higher BACs and stronger hypothermic responses than Fischer with no cross-fostering effects in either strain. No phenotypes were affected by nor-BNI. These data extend previous findings dissociating the aversive and peripheral physiological effects of ethanol in female Fischer and Lewis rats, and highlight the importance of genetic and early environmental factors in shaping subsequent responses to alcohol's motivational effects in adulthood.

Single-session prolonged alcohol-retention sclerotherapy for large hepatic cysts

OBJECTIVE

Our purpose was to evaluate the safety and therapeutic efficacy of single-session prolonged alcohol sclerotherapy in treating large hepatic cysts. A therapeutic comparison between 4-hour and 2-hour retention techniques was also studied.

MATERIALS AND METHODS

Twenty-seven patients with 31 hepatic cysts were enrolled in this study. Seventeen patients (18 cysts) were treated by alcohol retention for 4 hours (group 1) and 10 patients (13 cysts) for 2 hours (group 2). The mean diameter of the hepatic cysts was 12.4 cm (range, 8-23 cm) with a comparable size range in each group. The sclerosing agent used was 95% alcohol, and the maximum amount was limited to 200 mL. Patients changed position and vital signs were monitored every 10-15 minutes. The blood alcohol concentrations were checked hourly for 5 consecutive hours in the initial nine patients. The nonparametric Mann-Whitney U test was used to compare the difference in characteristics and treatment results of the subjects between these two groups. The level of statistical significance was set at a p value of less than 0.05.

RESULTS

All but one patient in group 2 tolerated the entire course of sclerotherapy. The mean aspirated volume and mean injected alcohol volume of the hepatic cysts were 730 mL and 138.3 mL, respectively, in group 1 patients, and 931 mL and 139 mL, respectively, in group 2 patients. The mean maximum blood alcohol concentration was 128.2 mg/dL (range, 60-199 mg/dL) at 3-4 hours after alcohol instillation. The mean posttherapy residual cystic diameter was 2.5 cm (range, 0-6 cm), with an average volume reduction rate of 98.3% and 97.7%, respectively, for patients in group 1 and group 2 after a mean follow-up period of 29.6 months (9-59 months). No statistical differences of the mean reduction rate between the two groups were noted.

CONCLUSION

Long retention of the alcohol in a single-injection technique is safe and effective. Two-hour alcohol retention has a comparable efficacy to that of 4-hour retention.

Biphasic changes in cardiac excitation-contraction coupling early in chronic alcohol exposure

Although the negative inotropic effects of both acute and chronic ethanol (EtOH) exposure are well known, little is known concerning the acute-to-chronic transition of such effects. In this study, our objective was to address this question by detailing the effects that acute EtOH exposure induces on cellular excitation-contraction (EC) coupling and, subsequently, comparing whether and how such changes translate to the early chronic EtOH condition in a rat model known to develop alcohol-induced cardiomyopathy. Acute EtOH exposure, as formerly reported, indeed induced dose-dependent negative inotropic changes in cellular EC coupling, manifest as reductions in cell shortening, Ca2+ transient amplitude, Ca2+ decay rate, and sarcoplasmic reticulum Ca2+ content of isolated rat ventricular cardiac myocytes. Supplementary to this, we found Ca2+ spark character not to be significantly affected by acute EtOH exposure. In contrast, the results obtained from cardiac myocytes isolated from rats fed a diet containing ∼9% (vol/vol) EtOH for 1 mo revealed changes in these parameters reflecting positive inotropy, whereas at 3 mo, these parameters again reflected negative inotropy similar but not identical to that induced by acute EtOH exposure. No significant changes were evident at either 1- or 3-mo chronic EtOH administration in echocardiographic parameters known to be perturbed in alcoholic cardiomyopathy (ACM), thus indicating that we were examining an asymptomatic stage in chronic EtOH administration consistent with an acute-to-chronic transition phase. Continued study of such transition-phase events should provide important insight into which molecular-cellular components of EC coupling play pivotal roles in EtOH-induced disease processes, such as ACM.

Pulmonary Artery Pressure Changes during Ethanol Embolization Procedures to Treat Vascular Malformations: Can Cardiovascular Collapse be Predicted?

PURPOSE

Ethanol has been used for embolization of vascular malformations. Cardiovascular collapse, although rare, has been reported, occurring immediately to a few hours after ethanol embolization. The pathophysiology has been theoretically attributed to direct toxicity to the cardiac conduction system or pulmonary artery (PA) vasospasm leading to cardiovascular collapse. Because of cardiovascular collapse in one patient at the authors' institution, it was standard of care at the time of this study to monitor the pulmonary artery pressures during ethanol embolization. This study was conducted to clarify the effect of ethanol on the PA pressure during these procedures.

METHODS

Data from 92 ethanol embolization procedures performed on 56 patients with vascular malformations between May 2001 and May 2003 are reported. PA and noninvasive cuff systemic pressures were recorded before and after each injection and also before and after the entire procedure. Upper limit for volume of ethanol used during these procedures was drawn at 1 mL/kg. Simple and multiple linear regression analyses were done to study factors affecting changes in PA and systemic blood pressure.

RESULTS

For each injection, ethanol volume averaged 3.1 mL per injection. The systolic systemic and PA systolic pressures increased by 2.3 and 1.0 mm Hg, respectively. Amount of ethanol injected and systemic blood pressure changes were predictive of change in PA blood pressure. During the entire procedure, systemic systolic blood pressure increased by an average of 11.6 mm Hg, and PA systolic blood pressure by 5 mm Hg. Change in systemic blood pressure was a strong predictor of, and volume of ethanol was a weak predictor of, change in PA blood pressure.

CONCLUSION

The mild rise in PA blood pressure in the patients during ethanol embolization correlated strongly with minor elevation in systemic blood pressure throughout the procedure, which the authors believe is related to pain from the ethanol injection causing sympathetic stimulation, even when patients are under general anesthesia. The minimal rise in PA blood pressure during these procedures does not elucidate the cause of the rare complication of cardiovascular collapse during ethanol embolization.

Clinical predictors for delirium tremens in alcohol dependence

BACKGROUND AND AIMS

This study was aimed to find clinical predictors for developing delirium tremens (DT) in alcohol dependence.

METHODS

This cohort study was retrospectively carried out among patients who were diagnosed as having alcohol dependence between January 2001 and July 2004. Fifteen parameters were compared between patients who developed DT and ones who did not. We identified clinical predictors for DT by using multivariate analysis.

RESULTS

A total of one hundred and seventy-eight consecutive admission cases from 147 patients were analyzed. The mean age was 47.8 years, and 95.5% were male. Delirium tremens developed in 59 cases (33%) during hospitalization. On multiple logistic regression analysis, a previous history of DT (odds ratio (OR) 3.990; 95% CI 1.631, 9.759) and high pulse rate above 100 b.p.m. (OR 4.158; 95% CI 2.032, 8.511) were significant predictors for developing DT. When combined, DT developed in just 20.4% of cases without any predictors; however, if one predictor was present, DT developed in 45.6%, and if two predictors were present, DT developed in all cases (100%).

CONCLUSIONS

A simple assessment using the past history of DT and the pulse rate, which may be easily evaluated in clinical settings, can allow physicians to readily identify the patients who are at a high risk of developing DT during an alcohol dependence period and reserve more intensive therapies for the selected cases.

Sensitivity and tolerance to autonomic effects of ethanol in adolescent and adult rats during repeated vapor inhalation sessions

BACKGROUND

It is during adolescence that most drinkers initiate ethanol intake, with some of this use being excessive. One possible contributor to the increased ethanol consumption often seen during adolescence in humans and in various animal models is age differences in ethanol sensitivity and tolerance. The present study examined the impact of age on ethanol-related alterations in the autonomic nervous system.

METHODS

Sensitivity to the initial ethanol challenge and chronic tolerance as well as acute and protracted withdrawal-like phenomena were assessed in male adolescent and adult Sprague-Dawley rats, using implanted telemetry probes with ethanol delivered via vapor inhalation.

RESULTS

Both ages showed similar ethanol-induced tachycardia and activity suppression; however, adolescents were found to be more sensitive than adults to the hypothermic effect of ethanol, data opposite other results from our laboratory and elsewhere using intragastric intubations or intraperitoneal administrations of ethanol. Although little tolerance to ethanol's tachycardic or activity suppressant effects was seen after repeated ethanol inhalation sessions, chronic tolerance to ethanol's hypothermic effect developed faster in adults than in adolescents. A withdrawal-like syndrome, characterized by bradycardia and hypoactivity, typically emerged during the dark phase of the diurnal cycle after ethanol vapor exposure sessions. These effects were observed in animals of both ages, with the bradycardic effect more pronounced in adolescents.

CONCLUSIONS

In contrast to results indicating that adolescents may be less sensitive than adults to ethanol's hypothermic effect when ethanol is administered via bolus injection/intubation, adolescents appear more sensitive and develop tolerance to ethanol's hypothermic effects more slowly than adults when ethanol is administered at a more moderate rate via vapor inhalation.

Proposal of a comprehensive clinical typology of alcohol withdrawal--a cluster analysis approach

AIMS

To characterize the various courses of alcohol withdrawal.

METHODS

The Alcohol Withdrawal Scale (AWS) was applied to 217 alcohol-dependent patients every 4 h till the symptoms of withdrawal had passed (until each of four consecutive scores were <3). Patients were medicated by a standardized treatment scheme according to AWS-scores. Hierarchical cluster analysis and discriminant analysis were applied.

RESULTS

We found five clusters representing increasing severity of alcohol withdrawal. Each cluster is characterized by a combination of the two maximum subscores (vegetative and psychopathological subscore) and three additional psychopathological symptoms (anxiety, disorientation, and hallucination). In 18.4% of the patients, relevant symptoms were not observed (cluster 1), 18.9% developed mild or moderate vegetative symptoms only (cluster 2), and 40.6% additional anxiety (cluster 3). In cluster 4 (11.1%) the most frequent psychopathological symptoms were disorientation and anxiety but no hallucinations, which could be observed only in cluster 5 (11.1%). Discriminant analysis using the maximum subscores at the first day of treatment as independent variables correctly predicted 89.9% of the five clusters.

CONCLUSIONS

Our findings support a model of alcohol withdrawal clustering along the two dimensions of vegetative and psychopathological severity. Furthermore, the AWS may be useful to predict the course of alcohol withdrawal already at the first day of treatment.

Alcoholism and neuro-immune-endocrine interactions: physiochemical aspects

The role of alcohol consumption and alcoholism as an addiction in regulating the chemistry of the brain and its physiology has gained a backlog of interest over the past few decades. Besides the notion that alcohol acts as a brain depressant, the molecular mechanisms and neuronal interactions are not well understood. Emerging evidence implicates alcohol as a neurochemical messenger that influences a cross talk amongst the nervous, immune, and endocrine systems. Specifically, alcohol acts as a crucial regulator of the hypothalamic-pituitary-adrenal (HPA) axis, thereby modulating the release of hormones, particularly adrenocorticotropic hormone (ACTH) and corticosterone (CORT). It is the aim of this review, therefore, to investigate current concepts on how alcohol, particularly ethanol, and alcoholism affect neuro-immune-endocrine neurochemical interactions via the regulation of the HPA axis, taking into consideration bio-behavioral and physiochemical aspects.

Delirium Tremens

The varied clinical manifestations and management of 14 male patients with delirium tremens (DT) have been studied. Eight patients were initially hospitalised for diseases unrelated to ethanol abuse i.e. 2 each for gun shot wound, myocardial infarction and stroke, and one each for pneumonia and gastroenteritis. One patient was going through withdrawal because of prodrome of viral hepatitis before he was hospitalised for uncontrolled agitation and delirium. Two known cases of mild essential hypertension on dietary therapy reported for agitation, abnormal behaviour, a single episode of tonic clonic seizure and hypertensive encephalopathy as they could not/did not get alcohol for 3 days. Three patients presented denovo with DT without concomitant illness. The other features besides delirium and hallucinations were tremulousness in 10, tachycardia in 12, fever in 3, diaphoresis in 2 and tonic clonic seizures in 4 patients. The symptoms fluctuated markedly at short intervals and 2 patients did not have any features of sympathetic overactivity. Altered hepatic biochemical parameters and ketonuria with normal blood sugar were noted in 4 and one patients respectively. Other biochemical parameters including serum electrolytes were normal. CT scan brain done for 5 patients revealed subdural haematoma in one. Cerebro spinal fluid (CSF) and EEG findings were noncontributory. All made good recovery with heavy doses of intravenous vitamin B complex, glucose and oral benzodiazepine. Short course of haloperidol was used in 2 patients. Two patients developed pancreatitis during follow up. All patients made complete recovery, and 8 patients have been followed for 8 to 12 months without relapse. The reason for hospitalisation in such cases is often unrelated to alcohol abuse; hence a detailed history of alcoholism is mandatory to identify those at risk as well as for prompt treatment and decreasing the mortality.

Phase I trial and pharmacological study of a 3-hour paclitaxel infusion in children with refractory solid tumours: a SFOP study

The maximum tolerated dose of paclitaxel administered by 24-hour continuous infusion in children is known. Short infusion might offer equivalent antitumour efficacy and reduced haematological toxicity, without increasing the allergic risk. Our aims were to determine the maximum tolerated dose and the pharmacokinetics of paclitaxel in children when administered in 3-h infusion every 3 weeks. Patients older than 6 months, younger than 20 years with refractory malignant solid tumours were eligible when they satisfied standard haematological, renal, hepatic and cardiologic inclusion criteria with life expectancy exceeding 8 weeks. Paclitaxel was administered as a 3-hour infusion after premedication (dexamethasone, dexchlorpheniramine). Pharmacokinetic analysis and solvent assays (ethanol, cremophor) were performed during the first course. 20 courses were studied in 17 patients; 4 dosage levels were investigated (240 to 420 mg/m(2)). No dose-limiting haematological toxicity was observed. Severe acute neurological and allergic toxicity was encountered. One treatment-related death occurred just after the infusion at the highest dosage. Delayed peripheral neurotoxicity and moderate allergic reactions were also encountered. Pharmacokinetic analysis showed dose-dependent clearance of paclitaxel and elevated blood ethanol and Cremophor EL levels. Although no limiting haematological toxicity was reached, we do not recommend this paclitaxel schedule in children because of its acute neurological toxicity.

Substance abuse and withdrawal in the intensive care unit. Contemporary issues

Because 36% of intentional injury victims are drug dependent, the association between drug abuse and violence, especially in urban settings, is high. Withdrawal syndromes in ICU patients confuse their clinical management, may be extremely difficult to diagnose, are often lethal, need to be suspected, and should be prophylaxed against; therefore, all ICU patients should be considered to be at high risk for drug or alcohol dependence, should be tested for evidence of such drugs, and should be interviewed (together with their family members) for the presence of drug dependence traits. Appropriate patients should be referred for formal evaluation and treatment. Withdrawal syndromes must be promptly recognized, differentiated from traumatic or metabolic deterioration, and immediately treated. As patients are unique, so is their drug dependence. Individualized withdrawal therapy, not a "one method fits all" approach, works best. The mainstay of most withdrawal therapy is supportive care and benzodiazepine therapy. Also, considering the high rate of multiple intoxicants present in trauma patients, withdrawal can occur from multiple agents in a single patient, further compounding these difficulties. Withdrawal from unusual substances, such as GHB, or from therapeutic interventions (e.g., prolonged opioid or benzodiazepine administration) also must be considered.

Delirium in the intensive care unit: are we helping the patient?

The intensive care unit (ICU) represents a dynamic interaction between patient factors and interventional factors. The complexity of this situation can generate an impaired consciousness in the patients. The critical care provider is faced with deducing the etiology and treatment of delirium in the ICU. Many of the therapeutic agents that are used in the ICU may precipitate delirium. Patients may also experience delirium as part of their underlying medical conditions. Withdrawal syndromes, delirium tremens in particular, are known to cause delirium. By a combination of appropriate selection of medications and an awareness of delirium as a side effect, the patient in the ICU may be treated in a manner to minimize the clouding of consciousness. An understanding of the proposed pathophysiology of various types of delirium will allow appropriate clinical measures to be taken.

Alcohol problems in a general hospital

Alcohol is a ubiquitous drug which is responsible for a substantial amount of ill health and approximately 20% of patients in a general hospital will have alcohol-related problems, although only 4% will be admitted with alcohol-caused conditions. Eight per cent of patients, however, can be expected to have sufficient neuroadaptation to be at risk of withdrawal. This level of prevalence of alcoholism in general hospital patients requires that hospitals must become expert at providing good quality care for alcohol-related problems in all areas including obstetrics, but particularly in the management of intoxication, withdrawal and the various alcohol-related diseases. This paper provides some suggested benchmarks for acceptable standards of care for alcohol problems in the acute hospital.

Hemodialysis as a Treatment of Severe Ethanol Poisoning

A 64-year-old woman presented with coma and shock due to severe ethanol intoxication. Her initial, markedly elevated blood alcohol level of 136.5 mM fell only by 16% after a 4-hour period of conservative treatment consisting of mechanical respiration and the administration of intravenous fluids, vasopressors and inotropics. Subsequent hemodialysis rapidly reduced her blood ethanol concentrations to less threatening Ievels, with prompt restoration of her consciousness. Hemodialysis may be Iife-saving and should be considered in patients with severe ethanol intoxication.

Dexmedetomidine alleviates ethanol withdrawal symptoms in the rat

The effect of dexmedetomidine, a selective alpha 2-adrenoceptor agonist, on ethanol withdrawal symptoms was studied in chronically ethanol-fed rats. After a 4-day ethanol intoxication period the rats were given s.c. injections of dexmedetomidine (3, 10, or 30 micrograms/kg) or saline (control group) at 10, 16, 22, and 39 h after the last dose of ethanol. The severity of ethanol withdrawal symptoms (rigidity, tremor, irritability, hypoactivity) was rated up to 58 h, blind to the treatments. The results showed that dexmedetomidine at doses 10 and 30 micrograms/kg significantly diminished the severity of the ethanol withdrawal reaction as measured by the sum score of the three most specific withdrawal signs (rigidity, tremor, and irritability). Dexmedetomidine at 10 micrograms/kg was the most effective dose, especially in the latter half of the withdrawal period (23-58 h after last dose of ethanol). The results suggest that dexmedetomidine in the treatment of ethanol withdrawal symptoms should be further studied.

Sleep quality during alcohol withdrawal with bright light therapy

1. Alcohol withdrawal is a complex syndrome that ranges from anxiety, insomnia to delirium tremens. Common treatment is the application of sedative medication. Exposure to bright light in the daytime should advance the normal sleep/wake cycle and moreover it should improve the availability of man's adaptive behavior during alcohol withdrawal. 2. This pilot study describes bright light therapy (BL) during alcohol withdrawal in ten alcohol dependent patients (DSM-III-R: 291.80) without any sedative medication. BL (3000 Lux) was administered on day 3 of abstinence between 7.00-9.00 a.m. and 5.00-9.00 p.m. Total-sleep-polysomnography (recordings between 10.30 p.m.-6.00 a.m.) and self-rating scale were performed to compare intraindividual changes during three nights. After one adaptation night (immediately after alcohol withdrawal), one baseline night and one "BL-night" and one "post-BL night" were analysed. 3. At baseline, total sleep time and sleep efficiency were severely deteriorated, but tended to improve in the following nights after BL. Sleep onset latency showed a significant decline after BL. Stages 3 and 4 were reduced at baseline. Latencies to slow wave sleep were significantly shortened after BL. REM increased in the nights after BL. Subjective sleep quality improved after BL. Although the present results, bright light having a possible stabilizing effect on sleep maintenance and sleep architecture during acute alcohol withdrawal, the authors could only derive hypotheses for further ongoing controlled investigations using placebo light, to receive final verification.

Recognition and treatment of ethanol abuse in trauma patients

OBJECTIVE

To evaluate physicians' recognition of possible ethanol-related complications in trauma patients, and to compare benzodiazepine requirements in patients with positive and negative blood-ethanol concentrations.

DESIGN

Retrospective investigation.

SETTING

University medical center (level I trauma center).

PATIENTS

One hundred thirty-one trauma patients more than 18 years of age who were admitted for at least 24 hours.

OUTCOME MEASURES

(1) Physicians' recognition of ethanol (EtOH) as a potential factor complicating patient recovery in trauma patients admitted with positive blood-EtOH concentrations. (2) The amount of benzodiazepines administered to trauma patients with positive EtOH-blood concentrations compared to trauma patients with no detectable EtOH in their blood.

RESULTS

The presence of EtOH in the blood or the potential for EtOH withdrawal was mentioned in the progress notes of approximately one fourth of the patients with positive blood-EtOH concentrations. Thiamine was administered in 8.2% of patients with EtOH-related injuries. Benzodiazepine requirements were significantly higher in patients with positive versus negative blood-EtOH concentrations.

CONCLUSIONS

Prompt recognition and charting of suspected ethanol abuse is recommended, in conjunction with prompt administration of thiamine. It should be anticipated that patients with positive blood-ethanol concentrations will require higher doses of benzodiazepines compared to trauma patients without ethanol-related injuries.

Acute alcohol intoxication among children and adolescents

Severe toxicity from ethanol, manifested as coma, occurs at lower blood alcohol concentrations in young teenagers than in adults. Coma, vomiting and hypothermia are the commonest symptoms in young teenagers intoxicated by alcohol. The biochemical disturbances in children 11-16 years of age with alcohol intoxication resemble those of adults. Mild acidosis of a respiratory and metabolic origin and mild hypokalaemia are common findings in young teenagers. Young teenagers eliminate ethanol at the same rate as adults, whereas preschool age children are reported to eliminate ethanol twice as fast. The effect of ethanol on the state of consciousness is directly proportional to the blood alcohol concentration. Among small children the risk of hypoglycaemia is increased. Data on family history, social status, drinking habits, and children's motives for getting drunk are also of clinical importance. Fluid replacement with glucose-containing fluids and follow up are generally the only treatments needed for complete recovery. When children and adolescents are healthy, well-nourished and have not fasted, no severe complications are expected.

Double-blind study of alprazolam, diazepam, clonidine, and placebo in the alcohol withdrawal syndrome: preliminary findings

Both a reduction in the inhibitory effects of GABA (disinhibition) and activation of the sympathetic nervous system are manifested during the alcohol withdrawal syndrome. This study was designed to explore the relative efficacy of medications that differentially affects these two biological systems: the benzodiazepines, which attenuate GABAergic disinhibition, and the alpha 2-adrenergic receptor agonists, which decrease sympathetic activation. The benzodiazepine diazepam (n = 6), the alpha 2-receptor agonist clonidine (n = 7), the benzodiazepine alprazolam (this is also purported to have alpha 2-receptor agonist properties) (n = 6), and placebo (n = 6) were evaluated in their effectiveness in decreasing signs and symptoms of alcohol withdrawal. Drug-free, alcohol-dependent patients were administered 1 of the 4 medications in a double-blind design until symptoms of withdrawal, as measured by the Clinical Instrument Withdrawal Assessment for Alcohol-Revised, were successfully treated. Alprazolam was significantly more efficacious than both clonidine and placebo in decreasing withdrawal symptoms. Diazepam was more effective than clonidine and placebo on some measures of withdrawal. Clonidine decreased systolic blood pressure significantly more than the other two active drugs and placebo, but was no more effective than placebo in decreasing other symptoms of withdrawal. Alprazolam did not significantly decrease blood pressure compared with diazepam or placebo. Despite the small sample size, these preliminary findings suggest that the efficacy of alprazolam in the treatment of alcohol withdrawal is related to its effect at the benzodiazepine receptor and not its alpha 2-receptor agonist properties.

Intravenous pyridoxine in acute ethanol intoxication

Intravenous pyridoxine was evaluated as an agent for the reversal of ethanol-induced central nervous depression in a randomised double blind controlled study of 108 patients presenting with a clinical diagnosis of acute ethanol intoxication to two accident and emergency departments. Level of consciousness, measured by a modified Glasgow coma scale, showed no significant change after a single 1 g dose of intravenous pyridoxine when compared to controls given saline. The mean fall in blood alcohol concentration after one hour was 33 mg dl-1 (7.2 mmol l-1) in both groups suggesting that pyridoxine has no antidotal action and no short term effect on the rate of metabolism of ethanol.

Treatment of alcohol withdrawal syndrome

Treatment of the alcohol withdrawal syndrome is the first step towards the rehabilitation of alcohol-dependent patients. The objectives of treatment are relief of symptoms, prevention of complications and a smooth transition into a long-term rehabilitation programme. Recently, progress has been made in the clinical management of the alcohol withdrawal syndrome through standardization of the assessment using the CIWA-A scale and frequent monitoring of clinical findings, recognition of the efficacy of non-pharmacological interventions (i.e. standardized supportive care) and simplification of pharmacotherapy by optimizing the use of long-acting benzodiadepines via a loading dose technique. Benzodiazepines, because of their cross-tolerance with ethanol, wide margin of safety and low potential for physical dependence and tolerance, are very effective and are the drugs of choice for the treatment of the alcohol withdrawal syndrome.