A quantitative evaluation of alcohol withdrawal tremors

This paper evaluates the relation between Alcohol Withdrawal Syndrome tremors in the left and right hands of patients. By analyzing 122 recordings from 61 patients in emergency departments, we found a weak relationship between the left and right hand tremor frequencies (correlation coefficient of 0.63). We found a much stronger relationship between the expert physician tremor ratings (on CIWA-Ar 0-7 scale) of the two hands, with a correlation coefficient of 0.923. Next, using a smartphone to collect the tremor data and using a previously developed model for obtaining estimated tremor ratings, we also found a strong correlation (correlation coefficient of 0.852) between the estimates of each hand. Finally, we evaluated different methods of combining the data from the two hands for obtaining a single tremor rating estimate, and found that simply averaging the tremor ratings of the two hands results in the lowest tremor estimate error (an RMSE of 0.977). Looking at the frequency dependence of this error, we found that higher frequency tremors had a much lower estimation error (an RMSE of 1.102 for tremors with frequencies in the 3-6Hz range as compared to 0.625 for tremors with frequencies in the 7-10Hz range).

Diagnostic challenges in alcohol use disorder and alcoholic liver disease

Alcohol use disorders represent a heterogeneous spectrum of clinical manifestations that have been defined by the Diagnostic and Statistical Manual of Mental Disorders-5. Excessive alcohol intake can lead to damage of various organs, including the liver. Alcoholic liver disease includes different injuries ranging from steatosis to cirrhosis and implicates a diagnostic assessment of the liver disease and of its possible complications. There is growing interest in the possible different tools for assessing previous alcohol consumption and for establishing the severity of liver injury, especially by non-invasive methods.

[Neurological complications of chronic alcoholism: study of 42 observations in Guinea]

Neurologic disorders related to chronic alcoholism in traditional areas of Guinea are frequent, but reports about them are rare. We conducted the first study in Guinea on this subject and retrospectively collected 42 cases of neurologic manifestations related to alcoholism over a 7-year period. The standard findings of the literature were confirmed in our population: peak frequency after the age of 40 years (82.8%) and clear male overrepresentation (M/F sex ratio: 13/1). All the standard signs and symptoms are reported, with a clear predominance of alcoholic polyneuropathy and hepatic encephalopathy. The study of nutritional status by both body mass index (BMI) and the Detsky criteria showed that these patients were severely malnourished. The brain MRI was a crucial contribution for diagnosing the standard central nervous system complications of alcoholism: Gayet Wernicke encephalopathy, Marchiafava-Bignami disease, Korsakoff syndrome, central pontine myelinolysis, and cerebellar degeneration.

Time-frequency visualization of alcohol withdrawal tremors

In this paper, we propose a signal processing method of assessing the severity tremors caused by alcohol withdrawal (AW) syndrome. We have developed an iOS application to calculate the Clinical Institute Withdrawal Assessment (CIWA) score which captures iPod movements using the built-in accelerometer in order to reliably estimate the tremor severity component of the score. We report on the characteristics of AW tremor, the accuracy of electronic assessment of tremor compared to expert clinician assessment, and the potential for using signal processing assessment to differentiate factitious from real tremor in patients seen in the emergency department, as well as in nurses mimicking a tremor. Our preliminary results are based on 84 recordings from 61 subjects (49 patients, 12 nurses). In general we found a linear relationship between energy measured by the accelerometer (in the 4.4-10 Hz range) and the expert rating of tremor severity. Additionally, we demonstrate that 75% of the recordings from patients with actual AW syndrome had a mean peak frequency higher than 7 Hz whereas only 17% of the nurses' factitious tremors were above 7 Hz, suggesting that tremor above 7 Hz could be a potential discriminator of real versus factitious tremors.

[Features of psychopharmacotherapeutic correction of alcohol dependence in the elderly]

The article is devoted to the actual in modern medicine problem as the study of the prevalence of alcohol dependence and its psyhofarmacological correction in the elderly. It is shown that elderly and old age as a result of reduction of the reserve capacity of the organism for clinical pathology becomes addictive specific psychopathological features that affect the course of disease and maintenance of preventive treatment. On the basis of empirical evidence the authors prove that at the border severity of alcohol withdrawal syndrome the drug "Cytoflavin" has a fairly pronounced psyhofarmacological activity for older people with alcohol dependence.

[A woman without speech]

A 56-year-old woman with a history of alcohol abuse was found at home amidst empty wine bottles with somnolence and severe dysarthria. MRI of the brain revealed selective demyelination of the corpus callosum, consistent with Marchiafava-Bignami disease.

Induced theta oscillations as biomarkers for alcoholism

OBJECTIVE

Studies have suggested that non-phase-locked event-related oscillations (ERO) in target stimulus processing might provide biomarkers of alcoholism. This study investigates the discriminatory power of non-phase-locked oscillations in a group of long-term abstinent alcoholics (LTAAs) and non-alcoholic controls (NACs).

METHODS

EEGs were recorded from 48 LTAAs and 48 age and gender comparable NACs during rest with eyes open (EO) and during the performance of a three-condition visual target detection task. The data were analyzed to extract resting power, ERP amplitude and non-phase-locked ERO power measures. Data were analyzed using MANCOVA to determine the discriminatory power of induced theta ERO vs. resting theta power vs. P300 ERP measures in differentiating the LTAA and NAC groups.

RESULTS

Both groups showed significantly more theta power in the pre-stimulus reference period of the task vs. the resting EO condition. The resting theta power did not discriminate the groups, while the LTAAs showed significantly less pre-stimulus theta power vs. the NACs. The LTAAs showed a significantly larger theta event-related synchronization (ERS) to the target stimulus vs. the NACs, even after accounting for pre-stimulus theta power levels. ERS to non-target stimuli showed smaller induced oscillations vs. target stimuli with no group differences. Alcohol use variables, a family history of alcohol problems, and the duration of alcohol abstinence were not associated with any theta power measures.

CONCLUSIONS

While reference theta power in the task and induced theta oscillations to target stimuli both discriminate LTAAs and NACs, induced theta oscillations better discriminate the groups. Induced theta power measures are also more powerful and independent group discriminators than the P3b amplitude.

SIGNIFICANCE

Induced frontal theta oscillations promise to provide biomarkers of alcoholism that complement the well-established P300 ERP discriminators.

Lack of recognition and complexity of foetal alcohol neuroimpairments

AIMS

To obtain the recorded prevalence of foetal alcohol syndrome (FAS) and foetal alcohol spectrum disorders (FASD) in Norway, and evaluate the effect of a general information program to increase the recognition of FAS/FASD for health care and social workers.

METHODS

A questionnaire regarding prevalence of FAS/FASD was sent to all Norwegian paediatric and child psychiatry departments. In the region Hordaland county, an information program was carried out to educate health-care and social workers on symptoms and signs of FAS/FASD, and referral was encouraged for suspected cases. Referred children received a neuropaediatric evaluation, and the effect of the information program on recorded FAS/FASD was recorded.

RESULTS

Based on the national survey, a prevalence of 0.3 per 1000 was calculated. After the information program, the estimated prevalence in Hordaland County increased to 1.5 per 1000. In 5 years, 25 children were diagnosed with FAS and 22 with FASD. One-third of all children were mentally retarded. Microcephaly and neuroimpairments were more common among FAS children. Almost all children met the criteria of ADHD.

CONCLUSION

The rate of FAS/FASD may be greatly underestimated because of lack of knowledge. An information program aimed at health-care and social workers is effective.

Alcohol abuse in the critically ill patient

Alcohol abuse and dependence disorders are common in the 10% of hospitalised patients who need admission to the intensive care unit (ICU), but these disorders are often undiagnosed. The systemic effects from the excessive use of alcohol increase susceptibility to, or directly cause various important disorders in the critically ill. Early recognition of alcohol abuse and dependence is necessary and should prompt consideration of several alcohol-specific diagnoses that have important prognostic and therapeutic implications for these patients. We discuss the use of screening tests to improve the identification of alcohol abuse and dependence disorders, the epidemiology and pathogenesis of important alcohol-related disorders, differences in the presentation of several common alcohol-related diagnoses in the ICU, and important alcohol-specific therapies.

Subacute encephalopathy with seizures in alcoholics (SESA syndrome): report of an unusual case

Subacute encephalopathy with seizures in alcoholics (SESA syndrome) is a rare neurologic disorder complicating the chronic abuse of alcohol. This acute or subacute condition is characterized by transient neurologic deficits, seizures and severe lateralized abnormalities on the electroencephalogram (EEG). Our case demonstrates that in SESA syndrome, convulsive (generalized tonic-clonic) and nonconvulsive (complex partial) seizures may coexist.

Acute effects of 3,4-methylenedioxymethamphetamine (MDMA) on behavioral measures of impulsivity: alone and in combination with alcohol

The use of 3,4-methylenedioxymethamphetamine (MDMA) has frequently been associated with increased levels of impulsivity during abstinence. The effects of MDMA on measures of impulsivity, however, have not yet been studied during intoxication. The present study was designed to assess the acute effects of MDMA and alcohol, alone and in combination, on behavioral measures of impulsivity and risk-taking behavior. A total of 18 recreational users of MDMA entered a double-blind placebo-controlled six-way crossover study. The treatments consisted of MDMA 0, 75, and 100 mg with and without alcohol. Alcohol dosing was designed to achieve a peak blood alcohol concentration (BAC) of about 0.06 g/dl during laboratory testing. Laboratory tests of impulsivity were conducted between 1.5 and 2 h post-MDMA and included a stop-signal task, a go/no-go task, and the Iowa gambling task. MDMA decreased stop reaction time in the stop-signal task indicating increased impulse control. Alcohol increased the proportion of commission errors in the stop-signal task and the go/no-go task. Signal detection analyses of alcohol-induced commission errors indicated that this effect may reflect impairment of perceptual or attentive processing rather than an increase of motor impulsivity per se. Performance in the Iowa gambling task was not affected by MDMA and alcohol, but there was a nonsignificant tendency towards improvement following alcohol intake. None of the behavioral measures of impulsivity showed a MDMA x alcohol interaction effect. The lack of interaction indicated that the CNS stimulant effects of MDMA were never sufficient to overcome alcohol-induced impairment of impulse control or risk-taking behavior.

Magnetic resonance imaging findings in substance abuse: alcohol and alcoholism and syndromes associated with alcohol abuse

Alcohol abuse is common among the population and results in significant diseases that shorten life span. Ethanol may result in chronic brain changes such as atrophy but may also result in neurologic disease that may be acute or chronic and sometimes life threatening. Accompanying vitamin deficiencies may lead to Wernicke's encephalopathy and changes in serum osmosis may lead to several acute demyelinating disorders. In addition, pregnant women who consume alcohol place their babies at high risk for the fetal alcohol syndrome. In this article we review these disorders and emphasize their imaging features.

Clinical correlates of quantitative EEG alterations in alcoholic patients

OBJECTIVE

To evaluate the incidence and clinical correlations of abnormal QEEG features in alcoholic patients.

METHODS

Quantitative EEG (frequency analysis, absolute and relative powers of the four classical bands) was assessed in 191 male alcoholic patients admitted in our facility for detoxification process. All underwent psychiatric, medical and neurological examination prior to the EEG recording, in search for specific clinical or paraclinical findings. The presence or absence of relevant clinical features was codified as nominal dichotomic variables to be related to specific QEEG features.

RESULTS

Only 7 patients had normal QEEG. The most frequent alteration (81 cases) was decreased power in slow (delta and theta) bands with a concurrent increase in beta band, followed by decreased power only in slow bands (33), increase only in beta band (29), decrease in both slow and alpha bands without beta alterations (28), decrease only in alpha band (6) and others. Alterations in slow and beta bands were uncorrelated. However, a significant correlation was found between decreased power in slow bands and cortical atrophy as revealed by MRI (especially in patients with early onset of alcoholism), time elapsed from the beginning of alcoholic habits (but only in younger or early onset subjects) and in a lesser degree arterial hypertension, but neither with age nor any other clinical or psychiatric feature. On the other hand, increased power in beta band correlated mainly with the use of benzodiazepines, sensoperceptual alterations (hallucinations, illusions), clinical seizures and family history of alcoholism. The effects of those variables were strongly interrelated.

CONCLUSIONS

Decreased power in slow bands in alcoholic patients may be an indicator of brain atrophy or chronic brain damage, while increase in beta band is related to medication use, family history of alcoholism, hallucinations and seizures, suggesting a state of cortical hyperexcitability.

SIGNIFICANCE

This study show the relation of specific QEEG alterations to certain clinical features found in alcoholics, in a further attempt to elucidate the semiological value of those alterations in individual patients.

[Marchiafava-Bignami disease]

Marchiafava-Bignami disease (MBD) is a rare central nervous system disorder of an unknown etiology strongly associated with alcoholism. MBD primarily affects the corpus callosum leading to confusion, dysarthria, seizures and frequently to death. About 250 cases of different races and nationalities, mostly alcoholics have been reported. We report a single-case study of a 43-year-old woman with the history of severe alcohol abuse, who demonstrated typical picture of Marchiafava-Bignami disease (MBD) with fatal course. We reviewed the literature on cases of MBD.

[Neurologic sequelae of chronic alcoholism]

Chronic alcohol abuse causes several distinct diseases of the central and peripheral nervous system. Widely known are the alcohol withdrawal syndrome, alcohol-induced epileptic seizures, alcoholic polyneuropathy and myopathy, and Wernicke's encephalopathy. Beside these complications, less common syndromes have been identified, including Marchiafava-Bignami syndrome, subacute encephalopathy with seizure activity (SESA syndrome), and tobacco alcohol amblyopia. These syndromes can be diagnosed by their characteristic features in cranial MRI or in EEG. Moreover, certain disorders in which alcohol abuse is only indirectly involved in the pathogenesis are more frequent in alcoholics than in nonalcoholics. In daily practice, it is important to differentiate these disorders when encountering patients with chronic alcohol abuse.

Alcohol-induced paroxysmal nonkinesogenic dyskinesia after pallidal hypoxic insult

We describe the first case of paroxysmal nonkinesogenic dyskinesia secondary to pallidal ischaemia, which is uniquely and specifically triggered by alcohol.

[Brain MR imaging of chronic alcoholism]

Brain complications from chronic alcoholism (Wernicke encephalopathy, central pontine myelinolysis, Marchiafava-Bignami disease, Korsakoff's syndrome, hepatic encephalopathy, cerebellar atrophy, hemorrhagic and ischemic brain lesions) may be diagnosed by MR imaging.

Disruption of frontocerebellar circuitry and function in alcoholism

This article represents a symposium of the 2002 joint meeting of RSA and ISBRA held in San Francisco. Presentations were Neuropathology of alcohol-related cerebellar damage in humans, by Antony J. Harding; Neuropathological evidence of cerebellar damage in an animal model of alcoholism, by Roberta Pentney and Cynthia Dlugos; Understanding cortical-cerebellar circuits through neuroimaging study of chronic alcoholics, by Peter R. Martin and Mitchell H. Parks; and Functional reorganization of the brain in alcoholism: neuroimaging evidence, by John E. Desmond, S.H. Annabel Chen, Michelle R. Pryor, Eve De Rosa, Adolf Pfefferbaum, and Edith V. Sullivan.

A 47-year-old alcoholic man with progressive abnormal gait

Central pontine myelinolysis should be considered in the differential diagnosis of a patient with a history of alcoholism and malnutrition presenting with ataxia, regardless of serum sodium values. T2-weighted images are the most sensitive imaging technique, but changes may not be evident for weeks after the insult, and in addition, the insult may not be known. Supportive care is important to prevent complications, but no treatment has been found to be effective in treating the illness. Patient outcomes vary considerably and are difficult to predict.

[A case of Marchiafava-Bignami disease: serial changes with diffusion-weighted MR imaging]

We report a 34-year-old man who presented with alcohol-withdrawal delirium. In the early phase, diffusion-weighted MR imaging demonstrating a high intensity area in the corpus callosum, indicating Marchiafava-Bignami disease. T2-weighted MR imaging did not clearly show the lesion. He was treated and completely recovered in terms of clinical state and MRI findings. Although historically the most of Marchiafava-Bignami disease was not cured, it seems that the lesion is reversible by management in the early stage. We propose that diffusion-weighted MR imaging is useful for the early detection of Marchiafava-Bignami disease.

Coma induced by intoxication

Clinicians in the emergency department are often confronted with coma patients due to poisoning. A systematic general approach involving early consultation with a neurologist is of paramount importance. A high index of suspicion, a systematic first assessment already in the prehospital phase and early stabilisation of vital functions are the essential first steps. Specific antidotes like hypertonic glucose and thiamine are part of a "coma cocktail". The opiate antagonist naloxone should be used only when clinically indicated and in a titrated way. Flumazenil should only be used with caution and in restricted cases. Clinical neurological evaluation and technical investigations like CT-scan and laboratory tests should make part of a careful diagnostic plan. Toxicological tests deserve their place in the diagnostic work up of a coma patient with suspected poisoning. Knowledge of the possibilities of the toxicology lab and optimal communication with the clinical toxicologist is important for optimal patient care.

Arylsulfatase A levels in patients with chronic alcoholism

BACKGROUND

The goal of this study was to find the association between low arylsulfatase A (ASA) activity and psychiatric disorders in chronic alcoholic patients.

METHODS

The study was carried out in 30 chronic alcoholic patients (27 male, 3 female); age range was 25-65 years. There were 20 normal controls (18 males, 2 females), and age range was 24-67 years. ASA and routine aspartate aminotransferase (AST) and alanine aminotransferase (ALT) activity laboratory tests were measured in blood serum from all patients and control subjects.

RESULTS

Alcoholic patients with psychiatric disorders have ASA average values of 68.25 nmol/mL/4 h. This is less than averages found in the alcoholics without psychiatric disorders group (82.48 nmol/mL/4 h) and the control group (90.8 nmol/mL/4 h). There were no statistically significant differences among the three groups studied. Alcoholic subjects with elevated activity of AST and ALT (n = 10) have ASA activity average values of 134.82 nmol/mL/4 h), which is 48.8% higher than the control group (90.6 nmol/mL/4 h). These means show statistically significant differences (p <0.05).

CONCLUSIONS

Results indicate an association between low serum ASA activity and alcoholism. The appearance of psychiatric manifestations could be related to the low activity of this enzyme in chronic alcoholic patients. Alcoholic patients with elevated enzyme activity of AST and ALT in sera also have elevated sera arylsulfatase A (ASA) activity. We consider that these findings may be useful for evaluating the psychiatric state as a prognosis in chronic alcoholic patients, and should be a routine laboratory test in alcoholic patients.

[Subacute encephalopathy with epileptic seizures in an alcoholic patient]

We introduce a case of a 66 year-old male with chronic alcoholism who suffered from confusion, Wernicke-aphasia and epileptic seizures. Several EEG revealed periodic lateralized epileptiform discharges. The patient's case resembles the symptoms of a subacute encephalopathy with epileptic seizures which can occur in alcoholics.

Group and case study of the dysexecutive syndrome in alcoholism without amnesia

OBJECTIVES

To test the dysexecutive syndrome (DES) hypothesis of chronic alcoholism by the neuropsychological group and case study approaches.

METHODS

A comprehensive neuropsychological assessment, including the "behavioural assessment of dysexecutive syndrome", a battery of tests recently designed to be "ecologically valid", was administered to 17 patients with chronic alcoholism without amnesia to examine executive functions, intelligence, and memory. In terms of each neuropsychological measure, reciprocal analyses of group means and individual case profiles were conducted: for the first contrasting the alcoholic patients with 17 age matched healthy subjects; and for the second making intersubject and intrasubject comparison of the patients, according to percentile basis impairment indices obtained from the control subjects.

RESULTS

Despite relatively unimpaired memory and intelligence, the patients as a whole had the impairment of a wide range of executive domains, extending to "everyday" problem solving as well as more elementary aspects of executive functions, such as visuospatial performance, mental set shifting, and the inhibition of habitual behaviour. The profile analysis divided individual patients into four groups: the representative DES characterised by a clear dissociation between impaired executive functions and preserved intelligence and memory; the group of a modified dysexecutive pattern in which memory as well as executive functions were impaired with intelligence preserved; the group of general cognitive deterioration; and the group of unimpaired cognitive functioning. About two thirds of the patients were categorised into either the first or the second type of DES.

CONCLUSION

DES characterised by the even more pronounced impairment of executive functions than of intelligence and memory afflicts a considerable proportion of patients with chronic alcoholism. Due to its subtlety, this would be potentially left out, unless appropriate behavioural measures were administered. This condition may prevent patients with alcoholism from achieving full recovery and benefiting from rehabilitation.

[A case of alcoholic multiple nervous system degeneration]

Chronic ethyl alcohol abuse is associated with different types of neurological involvement. We report a 51-year-old woman with alcoholic encephalopathy, neuropathy and autonomic dysfunction. After the alcohol abuse of about thirty years, gait disturbance, dysphagia and dysarthria progressively worsened. We thought that the disease was caused by poor nutrition due to chronic alcohol abuse and vitamin B1, B12 deficiency. Her neurological symptoms and signs improved after discontinuation of alcohol and nutritional treatment.

Automatic 3-D segmentation of internal structures of the head in MR images using a combination of similarity and free-form transformations: Part II, validation on severely atrophied brains

Studies aimed at quantifying neuroanatomical differences between populations require the volume measurements of individual brain structures. If the study contains a large number of images, manual segmentation is not practical. This study tests the hypothesis that a fully automatic, atlas-based segmentation method can be used to quantify atrophy indexes derived from the brain and cerebellum volumes in normal subjects and chronic alcoholics. This is accomplished by registering an atlas volume with a subject volume, first using a global transformation, and then improving the registration using a local transformation. Segmented structures in the atlas volume are then mapped to the corresponding structures in the subject volume using the combined global and local transformations. This technique has been applied to seven normal and seven alcoholic subjects. Three magnetic resonance volumes were obtained for each subject and each volume was segmented automatically, using the atlas-based method. Accuracy was assessed by manually segmenting regions and measuring the similarity between corresponding regions obtained automatically. Repeatability was determined by comparing volume measurements of segmented structures from each acquisition of the same subject. Results demonstrate that the method is accurate, that the results are repeatable, and that it can provide a method for automatic quantification of brain atrophy, even when the degree of atrophy is large.

[Confusion syndrome in alcoholism. Faulty assessment can produce deleterious course]

Confusion is a frequent syndrome in alcoholism caused by a large number of neuropsychiatric and somatic disorders with severe alcohol intoxication, pathological intoxication, alcohol dementia and hepatic encephalopathy among them. Possible pathophysiologic mechanisms involved and therapeutic strategies are discussed.