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Kádár BK, Gajdics J, Pribék IK, Andó B, Lázár BA. Characterization of alcohol-related seizures in withdrawal syndrome. Epilepsia Open 2024; 9:679-688. [PMID: 38279829 PMCID: PMC10984295 DOI: 10.1002/epi4.12906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 12/14/2023] [Accepted: 01/15/2024] [Indexed: 01/29/2024] Open
Abstract
OBJECTIVE Alcohol-related seizures (ARS) are one of the most important consequences of alcohol withdrawal syndrome (AWS). However, demographic and clinical characteristics, and furthermore, the relationship of ARS with delirium tremens (DT), have not yet been evaluated in detail. Therefore, the aim of the present study was to reveal the correlates of ARS and examine the interaction of ARS with the occurrence of DT and with the severity of AWS. METHODS In the retrospective study (Study 1) 2851 medical charts of inpatient admissions characterized by AWS and DT were listed. Demographic and clinical variables of ARS were assessed. In the follow-up study (Study 2), patients admitted with AWS without (N = 28) and with (N = 18) ARS were enrolled. Study 1 was performed between 2008 and 2023, and Study 2 was performed in 2019 in Hungary. To determine the severity of AWS, the Clinical Institute Withdrawal Assessment Scale for Alcohol, Revised (CIWA-Ar) was used. ARS is a provoked, occasional seizure; therefore, patients with epilepsy syndrome were excluded from the two studies. Statistical analyses were performed by the means of chi-square tests, multinomial logistic regressions, mixed ANOVA, and derivation. RESULTS The occurrence of DT, the history of ARS, and somatic co-morbidities were found to be risk factors for the appearance of ARS. ARS was proved to be a risk factor for the development of DT. In the follow-up study, there was no difference in the decrease of CIWA-Ar scores between the groups. SIGNIFICANCE Our present findings support the likelihood of kindling, which is one of the most important mechanisms underlying the development of ARS, but do not directly prove its presence. Additionally, our results revealed that the severity of AWS is not influenced by the presence of ARS. PLAIN LANGUAGE SUMMARY Provoked, occasional seizures during AWS are defined as ARS. In the present study, predictors and interactions of these seizures with DT-the most severe form of withdrawal-and with the severity of withdrawal were examined in retrospective and follow-up studies. The present study shows that a history of withdrawal seizures, the occurrence of DT, and somatic comorbidities are predictors of the development of seizures. Furthermore, our findings suggest that the presence of seizures does not influence the severity of withdrawal.
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Affiliation(s)
- Bettina Kata Kádár
- Addiction Research Group, Department of Psychiatry, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Janka Gajdics
- Addiction Research Group, Department of Psychiatry, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Ildikó Katalin Pribék
- Addiction Research Group, Department of Psychiatry, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Bálint Andó
- Addiction Research Group, Department of Psychiatry, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Bence András Lázár
- Addiction Research Group, Department of Psychiatry, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
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Unlu H, Macaron MM, Ayraler Taner H, Kaba D, Akin Sari B, Schneekloth TD, Leggio L, Abulseoud OA. Sex difference in alcohol withdrawal syndrome: a scoping review of clinical studies. Front Psychiatry 2023; 14:1266424. [PMID: 37810604 PMCID: PMC10556532 DOI: 10.3389/fpsyt.2023.1266424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background We conducted a review of all studies comparing clinical aspects of alcohol withdrawal syndrome (AWS) between men and women. Methods Five databases (PubMed, Cochrane, EMBASE, Scopus and Clinical Trials) were searched for clinical studies using the keywords "alcohol withdrawal syndrome" or "delirium tremens" limited to "sex" or "gender" or "sex difference" or "gender difference." The search was conducted on May 19, 2023. Two reviewers selected studies including both male and female patients with AWS, and they compared males and females in type of AWS symptoms, clinical course, complications, and treatment outcome. Results Thirty-five observational studies were included with a total of 318,730 participants of which 75,346 had AWS. In twenty of the studies, the number of patients presenting with or developing AWS was separated by sex, resulting in a total of 8,159 (12.5%) female patients and a total of 56,928 (87.5%) male patients. Despite inconsistent results, males were more likely than females to develop complicated AWS [delirium tremens (DT) and AW seizures, collective DT in Males vs. females: 1,792 (85.4%) vs. 307 (14.6%), and collective seizures in males vs. females: 294 (78%) vs. 82 (22%)]. The rates of ICU admissions and hospital length of stay did not show sex differences. Although variable across studies, compared to females, males received benzodiazepine treatment at higher frequency and dose. One study reported that the time from first hospitalization for AWS to death was approximately 1.5 years shorter for males and males had higher mortality rate [19.5% (197/1,016)] compared to females [16% (26/163)]. Conclusion Despite the significant heterogeneity of the studies selected and the lack of a focus on investigating potential sex differences, this review of clinical studies on AWS suggests that men and women exhibit different AWS manifestations. Large-scale studies focusing specifically on investigating sex difference in AWS are needed.
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Affiliation(s)
- Hayrunnisa Unlu
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, Phoenix, AZ, United States
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | | | - Hande Ayraler Taner
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | - Duygu Kaba
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | - Burcu Akin Sari
- Department of Child and Adolescent Psychiatry, Baskent University School of Medicine Hospital, Ankara, Turkey
| | - Terry D. Schneekloth
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Lorenzo Leggio
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, Translational Addiction Medicine Branch, National Institute on Drug Abuse, and National Institute on Alcohol Abuse and Alcoholism, Baltimore, MD, United States
| | - Osama A. Abulseoud
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, Phoenix, AZ, United States
- Department of Neuroscience, Graduate School of Biomedical Sciences, Mayo Clinic College of Medicine, Phoenix, AZ, United States
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Day E, Daly C. Clinical management of the alcohol withdrawal syndrome. Addiction 2022; 117:804-814. [PMID: 34288186 DOI: 10.1111/add.15647] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/06/2021] [Indexed: 02/06/2023]
Abstract
Up to half of individuals with a history of long-term, heavy alcohol consumption will experience the alcohol withdrawal syndrome (AWS) when consumption is significantly decreased or stopped. In its most severe form, AWS can be life-threatening. Medically assisted withdrawal (MAW) often forms the first part of a treatment pathway. This clinical review discusses key elements of the clinical management of MAW, necessary adjustments for pregnancy and older adults, likely outcome of an episode of MAW, factors that might prevent completion of the MAW process and ways of overcoming barriers to ongoing treatment of alcohol use disorder. The review also discusses the use of benzodiazepines in MAW. Although there is clear evidence for their use, benzodiazepines have been associated with abuse liability, blunting of cognition, interactions with depressant drugs, craving, delirium, dementia and disrupted sleep patterns. Because glutamatergic activation and glutamate receptor upregulation contribute to alcohol withdrawal, anti-glutamatergic strategies for MAW and other potential treatment innovations are also considered.
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Affiliation(s)
- Ed Day
- Addiction Psychiatry, Institute for Mental Health, School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK
| | - Chris Daly
- Addiction Psychiatry, Greater Manchester Mental Health FT, Chapman Barker Unit, Prestwich Hospital, Manchester, UK
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Burkhardt G, Adorjan K, Kambeitz J, Kambeitz-Ilankovic L, Falkai P, Eyer F, Koller G, Pogarell O, Koutsouleris N, Dwyer DB. A machine learning approach to risk assessment for alcohol withdrawal syndrome. Eur Neuropsychopharmacol 2020; 35:61-70. [PMID: 32418843 DOI: 10.1016/j.euroneuro.2020.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 03/04/2020] [Accepted: 03/27/2020] [Indexed: 02/01/2023]
Abstract
At present, risk assessment for alcohol withdrawal syndrome relies on clinical judgment. Our aim was to develop accurate machine learning tools to predict alcohol withdrawal outcomes at the individual subject level using information easily attainable at patients' admission. An observational machine learning analysis using nested cross-validation and out-of-sample validation was applied to alcohol-dependent patients at two major detoxification wards (LMU, n = 389; TU, n = 805). 121 retrospectively derived clinical, blood-derived, and sociodemographic measures were used to predict 1) moderate to severe withdrawal defined by the alcohol withdrawal scale, 2) delirium tremens, and 3) withdrawal seizures. Mild and more severe withdrawal cases could be separated with significant, although highly variable accuracy in both samples (LMU, balanced accuracy [BAC] = 69.4%; TU, BAC = 55.9%). Poor outcome predictions were associated with higher cumulative clomethiazole doses during the withdrawal course. Delirium tremens was predicted in the TU cohort with BAC of 75%. No significant model predicting withdrawal seizures could be found. Our models were unique to each treatment site and thus did not generalize. For both treatment sites and withdrawal outcome different variable sets informed our models' decisions. Besides previously described variables (most notably, thrombocytopenia), we identified new predictors (history of blood pressure abnormalities, urine screening for benzodiazepines and educational attainment). In conclusion, machine learning approaches may facilitate generalizable, individualized predictions for alcohol withdrawal severity. Since predictive patterns highly vary for different outcomes of withdrawal severity and across treatment sites, prediction tools should not be recommended for clinical practice unless adequately validated in specific cohorts.
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Affiliation(s)
- Gerrit Burkhardt
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany.
| | - Kristina Adorjan
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany; Institute of Psychiatric Phenomics and Genomics (IPPG), University Hospital, LMU Munich, Munich, Germany
| | - Joseph Kambeitz
- Department of Psychiatry and Psychotherapy, University of Cologne, Germany
| | - Lana Kambeitz-Ilankovic
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany
| | - Florian Eyer
- Department of Clinical Toxicology, TUM School of Medicine, Technical University of Munich, Germany
| | - Gabi Koller
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany
| | - Oliver Pogarell
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany
| | - Nikolaos Koutsouleris
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany
| | - Dominic B Dwyer
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich Nussbaumstr. 7, 80336 Munich, Germany
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Derivation and validation of a multivariable model, the alcohol withdrawal triage tool (AWTT), for predicting severe alcohol withdrawal syndrome. Drug Alcohol Depend 2020; 209:107943. [PMID: 32172129 DOI: 10.1016/j.drugalcdep.2020.107943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Alcohol withdrawal and its consequences are a common concern for the large numbers of patients who present to emergency departments (EDs) with alcohol use disorders. While the majority of patients who go on to develop alcohol withdrawal experience only mild symptoms, a small proportion will experience seizures or delirium tremens. The aim of this study was to develop a tool to predict the need for hospital admission in patients at risk for alcohol withdrawal using only objective criteria that are typically available during the course of an ED visit. METHODS We conducted a retrospective study at an academic medical center. Our primary outcome was severe alcohol withdrawal syndrome (SAWS), which we defined as a composite of delirium tremens, seizure, or use of high benzodiazepine doses. All candidate predictors were abstracted from the electronic health record. A logistic regression model was constructed using the derivation dataset to create the alcohol withdrawal triage tool (AWTT). RESULTS Of the 2038 study patients, 408 20.0 %) developed SAWS. We identified eight independent predictors of SAWS. Each of the predictors in the regression model was assigned one point. Summing the points for each predictor generated the AWTT score. An AWTT score of 3 or greater was defined as high risk based on sensitivity of 90 % and specificity of 47 % for predicting SAWS. CONCLUSIONS We were able to identify a set of objective, timely, independent predictors of SAWS. The predictors were used to create a novel clinical prediction rule, the AWTT.
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Heilbroner SP, Xanthopoulos EP, Buono D, Huang Y, Carrier D, Shah A, Kim J, Corradetti M, Wright JD, Neugut AI, Hershman DL, Cheng SK. Impact of estrogen monotherapy on survival in women with stage III-IV non-small cell lung cancer. Lung Cancer 2018; 129:8-15. [PMID: 30797496 DOI: 10.1016/j.lungcan.2018.12.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 11/13/2018] [Accepted: 12/23/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Women with lung cancer have better survival than men. The reasons are unknown, but estrogen is hypothesized to improve survival. Our objective was to examine the association between estrogen monotherapy and cancer-specific and overall survival in elderly women with non-small cell lung cancer (NSCLC). MATERIALS AND METHODS We used the SEER-Medicare database to identify women ≥65 years old who were diagnosed with stage III or IV NSCLC. Estrogen monotherapy (EM) was defined as at least one estrogen claim without any progesterone claims 6 months prior to diagnosis. To assess cancer-specific survival and overall survival, we used Kaplan-Meier and multivariate Cox modeling with propensity score adjustments. As an exploratory analysis, we also examined the effect of combined estrogen and progesterone hormonal therapy on survival using Cox modeling. RESULTS We identified 6958 women in our initial cohort: 283 used EM (4%) and 6675 (96%) did not. The median follow-up time was 46.5 months in the EM patients and 49.5 months in the non-EM patients. In a Kaplan-Meier analysis, median overall survival was 8.2 months in patients who receive EM and 6.2 months in those who did not (p = 0.004). In our 1:4 propensity-matched cohort, median follow-up was 46.5 in the EM group and 50.6 in the non-EM group; median overall survival was 8.0 months in the EM group and 6.4 months in the non-EM group (p = 0.02). In a multivariate Cox regression of the matched cohort, EM was significantly associated with overall survival (HR 0.84; 95% CI 0.73 - 0.97). All results were similar for cancer-specific survival. In our exploratory analysis, combined Estrogen-Progesterone did significantly impact overall survival (HR 0.84; 95% CI 0.71-0.99, p = 0.04) but did not appear to effect cancer-specific survival (HR 0.91; 95% CI 0.77-1.09, p = 0.30). CONCLUSION EM was associated with a significant improvement in cancer-specific survival and overall survival in women with late stage NSCLC.
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Affiliation(s)
- Samuel P Heilbroner
- Columbia University College of Physicians & Surgeons, 630 W 168th St, New York, NY, 10032, United States
| | - Eric P Xanthopoulos
- Department of Radiation Oncology, Columbia University Irving Medical Center, 622 W 168th St, New York, NY, 10032, United States
| | - Donna Buono
- Herbert Irving Comprehensive Cancer Center, 1130 St Nicholas Ave, New York, NY, 10032, United States
| | - Yongmei Huang
- Herbert Irving Comprehensive Cancer Center, 1130 St Nicholas Ave, New York, NY, 10032, United States
| | - Daniel Carrier
- Department of Radiation Oncology, Columbia University Irving Medical Center, 622 W 168th St, New York, NY, 10032, United States
| | - Anand Shah
- Food and Drug Administration, 10 Exchange Pl #804, Jersey City, NJ, 07302, United States
| | - Jerry Kim
- Columbia Business School, Uris Hall 719, 3022 Broadway, New York, NY, 10027, United States
| | - Michael Corradetti
- Duke Cancer Center, 3404 Wake Forest Rd, Raleigh, NC, 27609, United States
| | - Jason D Wright
- Department of Obstetrics and Gynecology, New York Presbyterian Hospital, 161 Fort Washington Avenue, 4th Floor, New York, NY, 10032, United States
| | - Alfred I Neugut
- Herbert Irving Comprehensive Cancer Center, 1130 St Nicholas Ave, New York, NY, 10032, United States
| | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center, 1130 St Nicholas Ave, New York, NY, 10032, United States
| | - Simon K Cheng
- Department of Radiation Oncology, Columbia University Irving Medical Center, 622 W 168th St, New York, NY, 10032, United States; Herbert Irving Comprehensive Cancer Center, 1130 St Nicholas Ave, New York, NY, 10032, United States.
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Maldonado JR. Novel Algorithms for the Prophylaxis and Management of Alcohol Withdrawal Syndromes–Beyond Benzodiazepines. Crit Care Clin 2017; 33:559-599. [DOI: 10.1016/j.ccc.2017.03.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Sarkar S, Choudhury S, Ezhumalai G, Konthoujam J. Risk factors for the development of delirium in alcohol dependence syndrome: Clinical and neurobiological implications. Indian J Psychiatry 2017; 59:300-305. [PMID: 29085088 PMCID: PMC5659079 DOI: 10.4103/psychiatry.indianjpsychiatry_67_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Alcohol withdrawal delirium (AWD) or delirium tremens (DT) is associated with severe complications and high mortality. Prospectively identifying patients with increased risk of developing DT would have important preventive and therapeutic implications. Thus, the present study aimed to identify clinical risk factors predicting the development of DT. MATERIALS AND METHODS The study was a cross-sectional quasi-experimental one with equivalent control group, conducted at a tertiary hospital from August 2014 to May 2015. Forty adult male inpatients, diagnosed with DT, were compared with forty age- and sex-matched inpatients in alcohol withdrawal state without delirium. Assessments were done using confusion assessment method, Clinical Institute Withdrawal Assessment of Alcohol Scale, and Mini-Mental Status Examination. For group comparisons, Pearson's Chi-square test and independent sample t-test were used; logistic regression was applied to identify predictors followed by receiver operating characteristic curve analysis. RESULTS Heavy drinking (P = 0.005; odds ratio [OR]: 1.17, confidence interval [CI]: 1.05-1.31), continuous pattern of drinking (P = 0.027; OR: 4.67, CI: 1.19-18.33), past history of delirium (P = 0.009; OR: 552.8, CI: 4.88-625.7), alcohol-induced psychosis (P = 0.002; OR: 74.6, CI: 4.68-1190), and presence of cognitive deficits (P = 0.044; OR: 12.5, CI: 1.07-147.3) emerged as strong predictors of AWD. CONCLUSION The risk factors found can be easily evaluated in a clinical setting for physicians to readily identify patients at risk for developing DT and plan intensive therapies for them. At a neurobiological level, patients with preexisting brain neurotransmitter disturbances are at greater risk for developing DT.
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Affiliation(s)
- Sukanto Sarkar
- Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - Sunayana Choudhury
- Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - Gem Ezhumalai
- Department of Allied Health Sciences, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - Janet Konthoujam
- Department of Psychiatry, Jawaharlal Nehru Institute of Medical Sciences, Imphal, India
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Abstract
Delirium tremens is recognized as a potentially fatal and debilitating complication of ethanol withdrawal. Research thus far has primarily focused on the prevention of delirium tremens.
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Affiliation(s)
- Ronald DeBellis
- Massachusetts College of Pharmacy and Health Sciences, School of Pharmacy-Worcester, 01608, USA.
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Shu JE, Lin A, Chang G. Alcohol Withdrawal Treatment in the Medically Hospitalized Patient: A Pilot Study Assessing Predictors for Medical or Psychiatric Complications. PSYCHOSOMATICS 2015; 56:547-55. [DOI: 10.1016/j.psym.2014.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 11/28/2014] [Accepted: 12/01/2014] [Indexed: 10/24/2022]
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Straube A, Klein M, Erbguth F, Maschke M, Klawe C, Sander D, Hilz MJ, Ziemssen T, Klucken J, Kohl Z, Winkler J, Bettendorf M, Staykov D, Berrouschot J, Dörfler A. Metabolische Störungen. NEUROINTENSIV 2015. [PMCID: PMC7175475 DOI: 10.1007/978-3-662-46500-4_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Im folgenden Kapitel werden die verschiedenen metabolischen Störungen betrachtet. Zunächst wird auf die allgemeinen und spezifischen neurologischen Komplikationen bei Organtransplantation eingegangen. Dann geht es um die metabolischen Enzephalopathien: Störungen der Gehirntätigkeit bei angeborenen und erworbenen Stoffwechselerkrankungen im engeren Sinn, Elektrolytstörungen, Hypovitaminosen, zerebrale Folgen einzelner Organdysfunktionen, zerebrale Hypoxien, Endotheliopathien und Mitochondropathien. Anschließend werden das Alkoholdelir und die Wernicke-Enzephalopathie erörtert. Bei zahlreichen akuten Erkrankungen von Gehirn, Rückenmark und peripherem Nervensystem treten typische Störungen vegetativer Systeme auf, deren Erkennung und Therapie insbesondere bei Intensivpatienten eine vitale Bedeutung haben kann: die autonomen Störungen. Bei der zentralen pontinen Myelinolyse kommt es zu einer akuten, vorwiegend fokal-symmetrischen Demyelinisierung im Hirnparenchym. Auch Basalganglienerkrankungen können intensivmedizinisch relevant werden. Und schließlich wird die akute Stressreaktion betrachtet, die aufgrund der vielfältigen metabolischen und endokrinen Veränderungen bei kritischen Erkrankungen entsteht. Gerade das RCVS als neuere Krankheitsentität und wichtige Differenzialdiagnose zur Vaskulitis des ZNS verdient einen eigenen Platz, in diesem Unterkapitel werden ebenfalls verwandte Syndrome wie die hypertensive Enzephalopathie und das PRES abgehandelt.
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Goodson CM, Clark BJ, Douglas IS. Predictors of Severe Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis. Alcohol Clin Exp Res 2014; 38:2664-77. [DOI: 10.1111/acer.12529] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 07/15/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Carrie M. Goodson
- University of Colorado School of Medicine; Denver Colorado
- Denver Health Medical Center, Department of Medicine; Denver Colorado
| | | | - Ivor S. Douglas
- University of Colorado School of Medicine; Denver Colorado
- Denver Health Medical Center, Department of Medicine; Denver Colorado
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Maldonado JR, Sher Y, Ashouri JF, Hills-Evans K, Swendsen H, Lolak S, Miller AC. The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol 2014; 48:375-90. [PMID: 24657098 DOI: 10.1016/j.alcohol.2014.01.004] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Revised: 01/22/2014] [Accepted: 01/23/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND To date, no screening tools for alcohol withdrawal syndromes (AWS) have been validated in the medically ill. Although several tools quantify the severity of AWS (e.g., Clinical Institute Withdrawal Assessment for Alcohol [CIWA]), none identify subjects at risk of AWS, thus missing the opportunity for timely prophylaxis. Moreover, there are no validated tools for the prediction of complicated (i.e., moderate to severe) AWS in the medically ill. OBJECTIVES Our goals were (1) to conduct a systematic review of the published literature on AWS to identify clinical factors associated with the development of AWS, (2) to use the identified factors to develop a tool for the prediction of alcohol withdrawal among patients at risk, and (3) to conduct a pilot study to assess the validity of the tool. METHODS For the creation of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), we conducted a systematic literature search using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for clinical factors associated with the development of AWS, using PubMed, PsychInfo, MEDLINE, and Cochrane Databases. Eligibility criteria included: (i) manuscripts dealing with human subjects, age 18 years or older, (ii) manuscripts directly addressing descriptions of AWS or its predisposing factors, including case reports, naturalistic case descriptions, and all types of clinical trials (e.g., randomized, single-blind, or open label studies), (iii) manuscripts describing characteristics of alcohol use disorder (AUD), and (iv) manuscripts dealing with animal data (which were considered only if they directly dealt with variables described in humans). Obtained data were used to develop the Prediction of Alcohol Withdrawal Severity Scale, in order to assist in the identification of patients at risk for complicated AWS. A pilot study was conducted to assess the new tool's psychometric qualities on patients admitted to a general inpatient medicine unit over a 2-week period, who agreed to participate in the study. Blind to PAWSS results, a separate group of researchers retrospectively examined the medical records for evidence of AWS. RESULTS The search produced 2802 articles describing factors potentially associated with increased risk for AWS, increased severity of withdrawal symptoms, and potential characteristics differentiating subjects with various forms of AWS. Of these, 446 articles met inclusion criteria and underwent further scrutiny, yielding a total of 233 unique articles describing factors predictive of AWS. A total of 10 items were identified as correlated with complicated AWS (i.e., withdrawal hallucinosis, withdrawal-related seizures, and delirium tremens) and used to construct the PAWSS. During the pilot study, a total of 68 subjects underwent evaluation with PAWSS. In this pilot sample the sensitivity, specificity, and positive and negative predictive values of PAWSS were 100%, using the threshold score of 4. DISCUSSION The results of the literature search identified 10 items which may be correlated with risk for complicated AWS. These items were assembled into a tool to assist in the identification of patients at risk: PAWSS. The results of this pilot study suggest that PAWSS may be useful in identifying risk of complicated AWS in medically ill, hospitalized individuals. PAWSS is the first validated tool for the prediction of severe AWS in the medically ill and its use may aid in the early identification of patients at risk for complicated AWS, allowing for prophylaxis against AWS before severe alcohol withdrawal syndromes develop.
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Affiliation(s)
- José R Maldonado
- Psychiatry, Internal Medicine, Surgery, & Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Yelizaveta Sher
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Judith F Ashouri
- Internal Medicine (Rheumatology), University of California, San Francisco, CA, USA
| | | | - Heavenly Swendsen
- Psychosomatic Medicine, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA
| | - Sermsak Lolak
- Psychiatry, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
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Stephens JR, Liles EA, Dancel R, Gilchrist M, Kirsch J, DeWalt DA. Who needs inpatient detox? Development and implementation of a hospitalist protocol for the evaluation of patients for alcohol detoxification. J Gen Intern Med 2014; 29:587-93. [PMID: 24395104 PMCID: PMC3965748 DOI: 10.1007/s11606-013-2751-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 09/04/2013] [Accepted: 12/09/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clinicians caring for patients seeking alcohol detoxification face many challenges, including lack of evidence-based guidelines for treatment and high recidivism rates. OBJECTIVES To develop a standardized protocol for determining which alcohol dependent patients seeking detoxification need inpatient versus outpatient treatment, and to study the protocol's implementation. DESIGN Review of best evidence by ad hoc task force and subsequent creation of standardized protocol. Prospective observational evaluation of initial protocol implementation. PARTICIPANTS Patients presenting for alcohol detoxification. INTERVENTION Development and implementation of a protocol for evaluation and treatment of patients requesting alcohol detoxification. MAIN MEASURES Number of admissions per month with primary alcohol related diagnosis (DRG), 30-day readmission rate, and length of stay, all measured before and after protocol implementation. RESULTS We identified one randomized clinical trial and three cohort studies to inform the choice of inpatient versus outpatient detoxification, along with one prior protocol in this population, and combined that data with clinical experience to create an institutional protocol. After implementation, the average number of alcohol related admissions was 15.9 per month, compared with 18.9 per month before implementation (p = 0.037). There was no difference in readmission rate or length of stay. CONCLUSIONS Creation and utilization of a protocol led to standardization of care for patients requesting detoxification from alcohol. Initial evaluation of protocol implementation showed a decrease in number of admissions.
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Affiliation(s)
- John R Stephens
- Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, 5034 Old Clinic Building, CB#7110, Chapel Hill, NC, 27599-7110, USA,
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Harshe D, Shetty A, Rai SK, Mate OS, Karira A, Ramakrishnan A, Cholera R, Kale S. Biochemical Predictors of Delirium Tremens in Patients in Alcohol Withdrawal. Alcohol Alcohol 2014; 49:227. [DOI: 10.1093/alcalc/agt137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Mainerova B, Prasko J, Latalova K, Axmann K, Cerna M, Horacek R, Bradacova R. Alcohol withdrawal delirium - diagnosis, course and treatment. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013; 159:44-52. [PMID: 24399242 DOI: 10.5507/bp.2013.089] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 11/21/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Delirium tremens represents the most severe complication of alcohol withdrawal syndrome and, in its complications, significantly increases the morbidity and mortality of patients. Alcohol withdrawal delirium is characterized by features of alcohol withdrawal itself (tremor, sweating, hypertension, tachycardia etc.) together with general delirious symptoms such as clouded consciousness, disorientation, disturbed circadian rhythms, thought processe and sensory disturbances, all of them fluctuating in time. The treatment combines a supportive and symptomatic approach. Benzodiazepines in supramaximal doses are usually used as drugs of choice but in some countries such as the Czech Republic or Germany, clomethiazole is frequently used as well. METHOD A computer search of the all the literature published between 1966 and December 2012 was accomplished on MEDLINE and Web of Science with the key words "delirium tremens", "alcohol withdrawal", "treatment" and "pharmacotherapy". There were no language or time limits applied. CONCLUSIONS When not early recognized and treated adequately, delirium tremens may result in death due to malignant arrhythmia, respiratory arrest, sepsis, severe electrolyte disturbance or prolonged seizures and subsequent trauma. Owing to these possible fatalities and other severe unexpected complications, delirium tremens should be managed at an ICU or wards ensuring vital signs monitoring. In symptomatic treatment, high doses of benzodiazepines, especially lorazepam, diazepam and oxazepam are considered the gold standard drugs. Supportive therapy is also of great importance.
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Affiliation(s)
- Barbora Mainerova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
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Ignjatovic-Ristic D, Rancic N, Novokmet S, Jankovic S, Stefanovic S. Risk factors for lethal outcome in patients with delirium tremens - psychiatrist's perspective: a nested case-control study. Ann Gen Psychiatry 2013; 12:39. [PMID: 24294907 PMCID: PMC4175103 DOI: 10.1186/1744-859x-12-39] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 11/18/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The aim was to identify potential risk factors for lethal outcome in patients with delirium tremens (DT) treated in the psychiatric setting. METHODS In a nested case-control study, a total of 190 medical records of patients with DT hospitalized at the Psychiatric Clinic in Serbia between 2002 and 2011 were reviewed and analyzed. The characteristics of patients who died (cases) were compared with those who survived (controls). For each case, two controls (matched for age, gender, and year of hospitalization) were randomly chosen. RESULTS Significant differences between cases and controls were found for serum potassium levels (p < 0.001), the number of hospitalizations (p < 0.001), and duration of hospitalization (p < 0.001). A significant association with lethal outcome was found for serum potassium levels even in the normal range (adjusted odds ratio 40.52; 95% CI 1.20, >1,000.00; p = 0.004). CONCLUSIONS Even though the number and duration of psychiatric hospitalizations were identified as factors determining survival after admission for DT, only serum potassium levels were found to be significant. Patients with an increase in potassium (or absence of hypokalemia) may require more intensive treatment. Monitoring of serum levels of potassium is important not only as an indicator for replacement but also as an indicator of maladaptation.
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Affiliation(s)
- Dragana Ignjatovic-Ristic
- Center for Clinical Pharmacology, Medical Faculty Military Medical Academy, University of Defence, Crnotravska 17, Belgrade 11000, Serbia.
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Thiercelin N, Andrianirina B, Plat A. Delirium tremens : étude rétrospective de 39 observations. Rev Med Interne 2013; 34:73-7. [DOI: 10.1016/j.revmed.2012.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 05/25/2012] [Accepted: 08/06/2012] [Indexed: 11/28/2022]
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de la Espriella Guerrero R, de la Hoz Bradford AM, Gómez-Restrepo C, Zárate AUH, Menéndez MC, Barré MC, Rentería AMC, Hernández DC. [Clinical Practice Guide for Early Detection, Diagnosis and Treatment of the Acute Intoxication Phase in Patients with Alcohol Abuse or Dependence: Part I: Screening, Early Detection and Risk Factors in Patients with Alcohol Abuse or Dependence]. REVISTA COLOMBIANA DE PSIQUIATRIA 2012; 41:787-804. [PMID: 26572266 DOI: 10.1016/s0034-7450(14)60047-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 11/06/2012] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Worldwide, alcohol is the second most-used psychotropic substance and the third risk factor for early death and disability. Its noxious use is a world public health problem given its personal, labor, family, economic and social impact. 70 % of people under risk of having alcohol problems go undetected in medical practice, a fact that underlines the need for specific screening measures allowing early detection leading to timely treatment. This article presents evidence gathered by alcohol abuse and dependence screening as well as by risk factor identification and screening. It also presents evidence concerning withdrawal symptoms, delirium tremens and Wernicke's encephalopathy in order to promote early detection and timely treatment. METHODOLOGY Systematic revision of the evidence available together with an evaluation of pertinent guidelines found in literature so as to decide whether to adopt or adapt the existing recommendation for each question or to develop de novo recommendations. For de novo recommendations as well as those adapted, it was carried out an evidence synthesis, together with evidence tables and formulation of recommendations based on the evidence. RESULTS Evidence was found and recommendations were made for the pertinent screening and search of risk factors, in order to perform a diagnosis and carry out a timely management of alcohol abuse, dependence and ensuing complications: withdrawal syndrome, delirium tremens and Wernicke's encephalopathy.
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Affiliation(s)
- Ricardo de la Espriella Guerrero
- Médico psiquiatra, terapeuta sistémico, magister Epidemiología Clínica, Pontificia Universidad Javeriana, director GAI, Bogotá, Colombia.
| | - Ana María de la Hoz Bradford
- Médica cirujana, magíster en Epidemiología Clínica, Pontificia Universidad Javeriana, coordinadora GAI, Bogotá, Colombia
| | - Carlos Gómez-Restrepo
- Médico psiquiatra, MSc Epidemiología Clínica, Psiquiatra de Enlace, Psicoanalista, profesor titular Departamento de Psiquiatría y Salud Mental, director Departamento de Psiquiatría y Salud Mental, director Departamento de Epidemiología Clínica y Bioestadística, Pontificia Universidad Javeriana, Director GAI Depresión, codirector CINETS, Bogotá, Colombia
| | - Alina Uribe-Holguín Zárate
- Medica cirujana, residente de Psiquiatría, Pontificia Universidad Javeriana, asistente de investigación, Bogotá, Colombia
| | - Miguel Cote Menéndez
- Médico psiquiatra, fellow en abuso de sustancias, MSc en psicología y terapia sistémica, psiquiatra de CAD Fundar Bogotá, profesor de psiquiatría de la Facultad de Medicina de la Universidad Nacional de Colombia, experto temático, Bogotá, Colombia
| | - Michelle Cortés Barré
- Médica cirujana, magíster en educación, candidata a MSc en Epidemiología Clínica, Pontificia Universidad Javeriana, asistente de investigación, Bogotá, Colombia
| | - Ana María Cano Rentería
- Médica psiquiatra, miembro activo del subcomité de adicciones de la ACP, coordinadora del área científica de la ESE Hospital Mental de Filandia, Quindío, docente de clínica psiquiátrica, programa de Medicina de la Facultad de Ciencias de la Salud, Universidad del Quindío, entrenadora del Programa Treatnet II Colombia de ONU-DC. Asociación Colombiana de Psiquiatría, experta temática, Filandia, Quindío, Colombia
| | - Delia Cristina Hernández
- Médica psiquiatra, Universidad del Valle, máster en Conductas Adictivas, Universidad de Valencia, docente de Farmacodependencia, Universidad Libre, directora general de Fundar Colombia (Cali), Asociación Colombiana de Psiquiatría, coordinadora del subcomité de adicciones de la ACP, experta temática, Cali, Colombia
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McPherson A, Benson G, Forrest EH. Appraisal of the Glasgow assessment and management of alcohol guideline: a comprehensive alcohol management protocol for use in general hospitals. QJM 2012; 105:649-56. [PMID: 22328545 DOI: 10.1093/qjmed/hcs020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Guidelines exist for the management of alcohol withdrawal syndrome (AWS) but few have been assessed as to their suitability for general hospitals. The Glasgow Assessment and Management guideline for alcohol has been specifically developed for use in this context. AIM To determine if this alcohol assessment guideline aids the management of AWS in general hospitals. DESIGN The four components of the Glasgow Assessment and Management of Alcohol guideline were evaluated. This included the use of the Fast Alcohol Screening Test (FAST) to identify at risk patients, a risk stratification strategy to indicate fixed dose or symptom-triggered benzodiazepine treatment, the Glasgow Modified Alcohol Withdrawal Scale (GMAWS) for symptom-triggered treatment and a clear recommendation for vitamin prophylaxis of Wernicke's encephalopathy. METHODS FAST scores were assessed along with the CAGE (cut down, annoyed, guilty and eye-opener) screening tool to ascertain if a single screening tool could identify hazardous and dependent drinking. The GMAWS and Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) were compared between two medical units. A staff survey of the two AWS tools was also carried out. RESULTS FAST was able to identify both probable hazardous and dependent drinking. The GMAWS was reliable and gauged both physical and cognitive aspects of AWS. Staff generally preferred the GMAWS-based treatment as opposed to CIWA-Ar management and welcomed the Guideline as a whole. CONCLUSION The Glasgow Guideline aids the management of patients with AWS in an acute hospital setting. It allows early identification of at risk patients and directs effective therapeutic intervention.
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Affiliation(s)
- A McPherson
- Acute Addiction Liaison Team, Glasgow Addiction Services, Legal House, 101 Gorbals Street, Glasgow, G5 9DW, UK.
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Clinical Factors Correlated to Delirium Tremens during Acute Alcohol Withdrawal of Inpatients with Alcohol Dependence. ACTA ACUST UNITED AC 2012. [DOI: 10.4306/jknpa.2012.51.4.164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Thiercelin N, Rabiah Lechevallier Z, Rusch E, Plat A. Facteurs de risque du delirium tremens : revue de la littérature. Rev Med Interne 2012; 33:18-22. [DOI: 10.1016/j.revmed.2011.08.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2011] [Revised: 06/13/2011] [Accepted: 08/06/2011] [Indexed: 01/09/2023]
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Lyon JE, Khan RA, Gessert CE, Larson PM, Renier CM. Treating alcohol withdrawal with oral baclofen: a randomized, double-blind, placebo-controlled trial. J Hosp Med 2011; 6:469-74. [PMID: 21990176 DOI: 10.1002/jhm.928] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Abrupt cessation of alcohol intake causes habituated drinkers to experience symptoms of alcohol withdrawal syndrome (AWS). OBJECTIVE To determine the effect of the gamma-aminobutyric acid (GABA)-B agonist baclofen on the course of acute symptomatic AWS. DESIGN Prospective, randomized, double-blind, placebo-controlled clinical study. SETTING Two tertiary-care hospitals in Duluth, Minnesota. PATIENTS Inpatient adults admitted for any reason (including AWS) judged to be at high risk for AWS. INTERVENTION Inpatients who developed symptoms of AWS received symptom-triggered benzodiazepine treatment using lorazepam by standard protocol, and were randomized to receive baclofen 10 mg or placebo, 3 times per day, orally. MEASUREMENTS AWS severity was assessed using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar); lorazepam dose was monitored. RESULTS Seventy-nine subjects were enrolled. The 44 subjects who developed symptoms of AWS were randomized to baclofen or placebo. Thirty-one subjects (18 baclofen, 13 placebo) completed 72 hours of assessments, either entirely as inpatients or with outpatient follow-up. The need for high doses of benzodiazepines (20 mg or more of lorazepam over 72 hours) to control AWS was less likely in the baclofen treatment group (1 of 18) than in the placebo-treated group (7 of 13) (P = 0.004). CONCLUSIONS We found that the use of baclofen was associated with a significant reduction in the use of high doses of benzodiazepine (lorazepam) in the management of symptomatic AWS. The use of low-dose baclofen in the management of AWS deserves further study, as reduced dependence on high-dose benzodiazepines in AWS management could improve patient safety.
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Affiliation(s)
- Jeffrey E Lyon
- Hospital Internal Medicine, Essentia Health, Duluth, Minnesota 55805-1983, USA
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Eyer F, Schuster T, Felgenhauer N, Pfab R, Strubel T, Saugel B, Zilker T. Risk Assessment of Moderate to Severe Alcohol Withdrawal--Predictors for Seizures and Delirium Tremens in the Course of Withdrawal. Alcohol Alcohol 2011; 46:427-33. [DOI: 10.1093/alcalc/agr053] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Huang MC, Chen CH, Liu HC, Chen CC, Ho CC, Leu SJ. Differential patterns of serum brain-derived neurotrophic factor levels in alcoholic patients with and without delirium tremens during acute withdrawal. Alcohol Clin Exp Res 2010; 35:126-31. [PMID: 21039634 DOI: 10.1111/j.1530-0277.2010.01329.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Brain-derived neurotrophic factor (BDNF) is associated with alcohol addiction and withdrawal-related neurotoxicity. Delirium tremens (DT) is the most serious complication of alcohol withdrawal syndrome (AWS). In this study, we explored the differences in serum BDNF levels, measured at baseline and 1 week after alcohol withdrawal among alcoholic patients with and without DT. METHODS Sixty-five inpatients, fulfilling the DSM-IV criteria of alcohol dependence and admitted for alcohol detoxification, as well as 39 healthy control subjects were enrolled. The alcoholic patients were divided by the appearance of DTs into the DT group (n = 25) and non-DT group (n = 40). We collected blood samples of the patient groups on the first and seventh days of alcohol withdrawal and measured serum BDNF levels by sandwich enzyme-linked immunosorbent assay. RESULTS Serum BDNF levels differed significantly among the three groups: (i) control group 14.8 ± 4.7 ng/ml; (ii) non-DT group 12.3 ± 3.3 ng/ml; (iii) DT group 6.2 ± 2.6 ng/ml (p < 0.001). One week after alcohol withdrawal, the BDNF levels increased significantly for both alcoholic groups. While non-DT group had comparable BDNF levels (13.4 ± 3.5 ng/ml) with controls, the DT group still exhibited lower levels (8.9 ± 4.4 ng/ml). CONCLUSIONS This study suggests chronic drinking leads to a reduction in BDNF levels, and patients with more deficient BDNF expression are vulnerable to the development of DTs. Additionally, BDNF levels elevated after prompt alcohol detoxification treatment. These findings indicate that BDNF could involve modifying the phenotypes of AWS as well as the pertinent neuroadaptive processes of alcohol dependence.
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Affiliation(s)
- Ming-Chyi Huang
- Graduate Institute of Medical Sciences, Taipei Medical University, Taiwan
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Abstract
STUDY DESIGN The incidence and risk factors of postoperative delirium were retrospectively examined in patients who had spine surgery for degenerative lumbar disease. OBJECTIVE The aim of this study is to examine the incidence, pre- and postoperative risk factors and clinical results of postoperative delirium after spine surgery. SUMMARY OF BACKGROUND DATA Postoperative delirium is of great concern in older patients. Patients with postoperative delirium tend to have delay in functional restoration and difficulty in postoperative care. But to author's knowledge this is the first report to postoperative delirium after spine surgery in South Korean population. METHODS Eighty-one patients over 70 years of age, who underwent spinal fusion for degenerative lumbar disease from November 2000 and March 2007 were selected. We analyzed the relation between postoperative delirium and such variables as operation time, intraoperative blood loss and transfusion, fusion level, comorbidity and laboratory data checked before surgery and at 1 day after surgery. RESULTS Postoperative delirium was found in 11 patients (13.6%). There were significant relationships between postoperative delirium and comorbidity such as cerebral vascular disease and gastric ulcer. Hemoglobin and hematocrit levels at 1 day after surgery and albumin level before surgery was significantly lower than in control group. Oswestry disability index was improved from 50.4% to 27.6% in delirium group and from 48.5% to 24.9% in control group. Hospitalization period was significantly longer in delirium group. CONCLUSION History of cerebral vascular disease, low hemoglobin and hematocrit levels at 1 day after surgery, and bad nutritional status were risk factors for delirium. As it is of great concern in older patients, careful observation is necessary for the management of patients with risk factors for delirium.
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Barrons R, Roberts N. The role of carbamazepine and oxcarbazepine in alcohol withdrawal syndrome. J Clin Pharm Ther 2010; 35:153-67. [PMID: 20456734 DOI: 10.1111/j.1365-2710.2009.01098.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The goal of this review is to evaluate the efficacy and safety of carbamazepine and oxcarbazepine in treatment of alcohol withdrawal syndrome (AWS) and determine the role in therapy of both agents. METHODS Relevant literature was identified through a search of MEDLINE (1966-June 2008), PubMed (1966-June 2008); Cochrane database was performed to identify English-language publications. Search terms included carbamazepine, oxcarbazepine, AWS, alcoholism, substance syndrome withdrawal. RESULTS In seven studies, including 612 patients, carbamazepine demonstrated significant reduction in alcohol withdrawal scores. However, in comparative trials with a benzodiazepine agent, carbamazepine's ability to prevent alcohol withdrawal seizures (OR = 0.93; 95% CI = 0.06-14.97, P = NS) and delirium tremens (DTs; OR = 1.25; 95% CI = 0.28-5.64, P = NS) was uncertain as a result of insufficient patient enrollment. In three trials, carbamazepine failed to reduce alcohol withdrawal symptoms possibly as a result of delayed administration, inadequate dosage or inadequate sample size. At daily doses of 800 mg either fixed or tapered over 5-9 days, carbamazepine was well tolerated, and safely administered when blood alcohol concentration dropped below 0.15%. The role of oxcarbazepine in AWS is undefined because of inconsistent findings in two trials. CONCLUSION Carbamazepine has demonstrated safety, tolerability and efficacy in treatment of moderate to severe symptoms of alcohol withdrawal in the inpatient setting. However, trials of carbamazepine provide inconclusive evidence for prevention of alcohol withdrawal seizures and DTs in comparison with benzodiazepines. Benzodiazepines remain the primary treatment of moderate to severe AWS.
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Affiliation(s)
- R Barrons
- Wingate University School of Pharmacy, Wingate, NC 28174, USA.
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Karpyak VM, Biernacka JM, Weg MWV, Stevens SR, Cunningham JM, Mrazek DA, Black JL. Interaction of SLC6A4 and DRD2 polymorphisms is associated with a history of delirium tremens. Addict Biol 2010; 15:23-34. [PMID: 20002020 DOI: 10.1111/j.1369-1600.2009.00183.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Several genetic polymorphisms have been reported to be associated with alcohol withdrawal seizures (AWS) and delirium tremens (DT). To replicate and further explore these findings, we investigated the effects of 12 previously reported candidate genetic variations in two groups of alcohol-dependent European Americans with a history of withdrawal, which differed according to the presence (n = 112) or absence (n = 92) of AWS and/or DT. Associations of AWS and/or DT with the genomic and clinical characteristics and gene-gene interaction effects were investigated using logistic regression models. None of the polymorphisms were significantly associated with AWS/DT after correction for multiple testing. However, we found a significant interaction effect of the SLC6A4 promoter polymorphism (5-HTTLPR) and DRD2 exon 8 single nucleotide polymorphism rs6276 on AWS and/or DT history (P = 0.009), which became more significant after adjustment for lifetime maximum number of drinks consumed per 24 hours (P < 0.001). Subsequent analysis revealed an even stronger association of the SLC6A4-DRD2 interaction with DT (P < 0.0001), which remained significant after Bonferroni correction. Results reveal decreased likelihood of DT in alcoholics that carry the DRD2 rs6276 G allele and SLC6A4 LL genotype. This study provides the first evidence to implicate the interaction between serotonin and dopamine neurotransmission in the etiology of DT. Replication is necessary to verify this potentially important finding.
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Affiliation(s)
- Victor M Karpyak
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Monte R, Rabuñal R, Casariego E, Bal M, Pértega S. Risk factors for delirium tremens in patients with alcohol withdrawal syndrome in a hospital setting. Eur J Intern Med 2009; 20:690-4. [PMID: 19818288 DOI: 10.1016/j.ejim.2009.07.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 07/06/2009] [Accepted: 07/18/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The clinical expressions of alcohol withdrawal syndrome (AWS) may vary and the factors determining these variations are not well-known. It would be useful to have a set of clinical tools capable of predicting which patients are likely to develop the more severe forms of the syndrome. AIM To analyse the clinical variables associated with the development of delirium tremens (DTs) in patients who were admitted to a general hospital with AWS. METHODS Cohort study of AWS patients admitted to the Xeral Hospital in Lugo, Spain, between 1987 and 2003. The characteristics of patients with the syndrome who did not develop delirium tremens were contrasted with those who did. Cases presenting with DTs at diagnosis were excluded. The different clinical, epidemiological and biochemical variables reflective of alcohol consumption habits, basal health status and presentation features of syndrome were all recorded. RESULTS Data from 156 episodes of AWS that coursed without DTs were compared with 147 cases that coursed with it. Three independent variables for development of DTs were identified in a multivariate logistic regression model: number of seizures [1 or 2: OR 2.2 (CI 95% 1.2-3.8), p=0.005; 3 or more: OR 2.6 (CI 95% 1.04-6.8), p=0.04]; systolic blood pressure >150 mm Hg [OR 1.9 (CI 95% 1.1-3.8), p=0.03] and axillary temperature >38 degrees C [OR 1.9 (CI 95% 1.05-3.5), p=0.01]. ROC analysis revealed an area under the curve of 0.679. CONCLUSION Three clinical findings (seizures, blood pressure and temperature) can aid in identifying patients with AWS who are likely to develop DTs. The model's predictive capacity is not high.
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Affiliation(s)
- R Monte
- Department of Internal Medicine, Xeral-Calde Hospital, Lugo, Spain.
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Berggren U, Fahlke C, Berglund KJ, Blennow K, Zetterberg H, Balldin J. Thrombocytopenia in Early Alcohol Withdrawal is Associated with Development of Delirium Tremens or Seizures. Alcohol Alcohol 2009; 44:382-6. [DOI: 10.1093/alcalc/agp012] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Delirium not induced by alcohol or other psychoactive substance and alcohol withdrawal delirium (or delirium tremens) are both cerebral syndromes with similar presentations and are associated with various adverse outcomes. Recently, interest in identifying genetic predisposing factors that influence the occurrence or the outcome of delirium has become a prominent point of delirium research. We systematically searched published articles concerning genetic associations and the occurrence and outcome of delirium. Of 33 identified articles, six investigated non-alcohol withdrawal delirium, and from those six, five evaluated an association with apolipoprotein E (APOE). One association of APOE genotype with the emergence of delirium and two associations of APOE genotype with the duration of delirium were reported. The remaining 27 identified articles investigated genetic associations with alcohol withdrawal delirium and were mainly related to dopamine. Two studies reported a significant association of alcohol withdrawal delirium with the dopamine transporter gene (SLC6A3) and the dopamine receptor 3 (DRD3). Results are inconclusive, and no hard evidence exists due primarily to insufficiently powered studies and other methodological issues. Prospective studies incorporating systematic and rigorous diagnostic criteria and involving long term follow up are needed to advance understanding of this field.
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Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis and treatment. Crit Care Clin 2008; 24:657-722, vii. [PMID: 18929939 DOI: 10.1016/j.ccc.2008.05.008] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. It is also the most common psychiatric syndrome found in the general hospital setting, its prevalence surpassing better known psychiatric disorders. This article reviews the published literature on delirium and addresses the epidemiology, known etiologic factors, presentation and characteristics of delirium, while emphasizing what is known about treatment strategies and prevention. Given increasing evidence that delirium is not always reversible and the many sequelae associated with its development, physicians must do everything possible to prevent its occurrence or shorten its duration, by recognizing its symptoms early, correcting underlying contributing causes, and using treatment strategies proven to help recover functional status.
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Affiliation(s)
- José R Maldonado
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Mennecier D, Thomas M, Arvers P, Corberand D, Sinayoko L, Bonnefoy S, Harnois F, Thiolet C. Factors predictive of complicated or severe alcohol withdrawal in alcohol dependent inpatients. ACTA ACUST UNITED AC 2008; 32:792-7. [DOI: 10.1016/j.gcb.2008.06.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2007] [Revised: 03/21/2008] [Accepted: 06/09/2008] [Indexed: 11/15/2022]
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Mihai A, Damsa C, Allen M, Baleydier B, Lazignac C, Heinz A. Viewing videotape of themselves while experiencing delirium tremens could reduce the relapse rate in alcohol-dependent patients. Addiction 2007; 102:226-31. [PMID: 17222276 DOI: 10.1111/j.1360-0443.2006.01667.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS The aim of this prospective randomized controlled study was to determine whether viewing videotape of themselves while experiencing delirium tremens (DT) reduces the relapse rate in alcohol-dependent patients. Our hypothesis about the efficacy of videotapes exposure to DT is consistent with a cognitive behavior model. DESIGN Sixty patients with DT and a minimum of 3 years of severe alcohol dependence [Diagnostic and Statistical Manual version IV (DSM-IV criteria] were included in this study. Patients were videotaped during the acute phase of DT and randomized into two groups: group A patients received individual exposure to their videotape and an explanation of the symptoms by a psychiatrist; and control group B patients, who were without videotape experience. Both groups received the same treatment during the acute and the maintenance phases, without aversive therapy or psychotherapy. The two groups did not differ significantly in number of drinks per day prior to admission, age, marital status, social environment, education, professional and financial status or family psychiatric history. SETTING An in-patient crisis unit for patients with alcohol dependence. MEASUREMENTS All patients were observed for 6 months during monthly visits. Outcomes included relapse, drinking days per week and number of drinks per drinking day. All patients and their families signed informed consent. FINDINGS The patients with videotape experience had a significantly lower relapse rate after the first month (0% versus 20%), 2 months (13.33% versus 46.67%) and 3 months (26.67% versus 53.33%). Patients with videotape experience had less severe relapses and consumed fewer units of alcohol than controls. CONCLUSIONS Videotape exposure in delirium tremens is an original therapeutic method which seems to be effective in reducing relapse risk in patients with alcohol dependence.
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Affiliation(s)
- Adriana Mihai
- Department of Psychiatry, University of Medicine and Pharmacy, Tg Mures, Romania
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Wetterling T, Weber B, Depfenhart M, Schneider B, Junghanns K. Development of a rating scale to predict the severity of alcohol withdrawal syndrome. Alcohol Alcohol 2006; 41:611-5. [PMID: 16980710 DOI: 10.1093/alcalc/agl068] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIM Various factors that may influence the severity of the alcohol withdrawal syndrome (AWS) have been identified. We tested the predictive value of these factors compiled in a newly developed scale, LARS (Luebeck alcohol withdrawal risk scale). METHOD A total of 100 individuals (81 males, 19 females, mean age: 47.6 +/- 9.9 years) consecutively transferred to inpatient detoxification were included in this prospective study. All fulfilled the ICD-10 criteria for alcohol dependence. The LARS was applied at the time of admission. The course of the AWS was assessed by AWS-scale at least every 4 h. The maximum AWS-score was taken as indicator of the severity of AWS. RESULTS The mean AWS-score(max) was 6.5 +/- 3.3. In all 20% of the patients developed a severe AWS (AWS-score(max) > or =10). The maximum score usually occurred within 36 h after the last drink. A short version, the LARS11, was developed by statistically grounded item reduction. The optimal cut-off of the LARS11 was calculated as 10. The positive predictive value for severe AWS was 76%, while the negative predictive value was 98.7%. The sensitivity and specificity were high (95 or 92.5%, respectively). CONCLUSION LARS11 assessed immediately before detoxification appears to provide a useful estimate of mild/moderate versus severe AWS, and is now ready to be validated in an independent sample.
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Affiliation(s)
- Tilman Wetterling
- Department of Psychiatry, Psychosomatics, Psychotherapy, JW Goethe University, Frankfurt, Germany.
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Lee JH, Jang MK, Lee JY, Kim SM, Kim KH, Park JY, Lee JH, Kim HY, Yoo JY. Clinical predictors for delirium tremens in alcohol dependence. J Gastroenterol Hepatol 2005; 20:1833-7. [PMID: 16336440 DOI: 10.1111/j.1440-1746.2005.03932.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Jun Ho Lee
- Department of Internal Medicine, Kangdong Sacred Heart Hospital of Hallym University Medical Center, Seoul, Korea
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Romelsjö A, Palmstierna T, Hansagi H, Leifman A. Length of outpatient addiction treatment and risk of rehospitalization. J Subst Abuse Treat 2005; 28:291-6. [PMID: 15857730 DOI: 10.1016/j.jsat.2004.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2003] [Revised: 06/21/2004] [Accepted: 12/01/2004] [Indexed: 11/23/2022]
Abstract
Several studies, mainly from the U.S. and usually with selected male samples, show that aftercare is positively related to lower risk of re-addiction or re-treatment. The present study extends this line of research in a report from public health health care addiction treatment services in Stockholm County. The study sample comprises all 196 men and 100 women alcohol-dependent patients from 10 districts hospitalized for at least 2 days during 1997-99 and who received outpatient care within 5 days. These patients were followed up until 2000, without attrition for renewed rehospitalization. Greater length of outpatient treatment was significantly related to reduced rehospitalization, but only in men. The intensity (average number of visits) of outpatient treatment was not significantly related to rehospitalization. The different effect of length of outpatient treatment between the genders may be due to differences in severity of alcohol dependence, social situation, psychiatric co-morbidity, and/or the extent to which treatment met patients' needs.
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Affiliation(s)
- Anders Romelsjö
- Centre for Social Research on Alcohol and Drugs (SoRAD), Stockholm University, 106 91 Stockholm, Sweden.
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Driessen M, Lange W, Junghanns K, Wetterling T. Proposal of a comprehensive clinical typology of alcohol withdrawal--a cluster analysis approach. Alcohol Alcohol 2005; 40:308-13. [PMID: 15897220 DOI: 10.1093/alcalc/agh167] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Martin Driessen
- Center of Psychiatry and Psychological Medicine, Gilead Hospital, Bethel, Bielefeld, Germany.
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Kraemer KL, Mayo‐Smith MF, Calkins DR. Independent clinical correlates of severe alcohol withdrawal. Subst Abus 2003. [DOI: 10.1080/08897070309511551] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Gorwood P, Limosin F, Batel P, Hamon M, Adès J, Boni C. The A9 allele of the dopamine transporter gene is associated with delirium tremens and alcohol-withdrawal seizure. Biol Psychiatry 2003; 53:85-92. [PMID: 12513948 DOI: 10.1016/s0006-3223(02)01440-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The dopamine transporter (DAT) plays a key role in homeostatic regulation of dopaminergic neurotransmission and could thus be involved in the variability of two severe alcohol-withdrawal symptoms, alcohol-withdrawal seizure (AWS) and delirium tremens (DT). Interestingly, an association was found between the DAT gene (9-copy repeat) and the risk for these symptoms in two previous case-control studies. METHODS We reanalyzed the role of the DAT gene in the lifetime risk for AWS and DT in 120 alcohol-dependent patients, taking into account potentially confounding factors. RESULTS Alcohol-dependent patients with the A(9) allele had experienced AWS or DT at least once (odds ratio [OR] = 2.52, p =.03). This association persisted when excluding patients with antisocial personality comorbidity (OR = 3.48, p =.02) or limiting the analysis to older patients (OR = 8.3, p =.0008). CONCLUSIONS This study provides convergent data in favor of a significant role of the DAT gene in the risk for some severe withdrawal symptoms. If further replicated in larger samples, the DAT genetic polymorphism could be one of the factors to be analyzed to further assess the risk of some severe alcohol-withdrawal symptoms.
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Affiliation(s)
- Philip Gorwood
- Service de Psychiatrie, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris [AP-HP], Colombes, France
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