Acute lead poisoning: a diagnostic challenge in the emergency department

Acute abdominal pain is a common presentation to the emergency department (ED). Ruling out life-threatening causes and giving pain relief are the most important tasks in ED. We describe a 32-year-old man who presented to ED with abdominal pain and vomiting which was unrelieved by usual doses of analgesic. Extensive investigations revealed no significant abnormalities. On further probing, he admitted taking traditional medications for infertility. The toxicological panel revealed a high blood lead level, leading to a diagnosis of acute lead toxicity. Chelation therapy with D-penicillamine was initiated and the patient's abdominal pain resolved within 4 days.

Baclofen for alcohol withdrawal

BACKGROUND

Baclofen shows potential for rapidly reducing symptoms of severe alcohol withdrawal syndrome (AWS) in people with alcoholism. Treatment with baclofen is easy to manage and rarely produces euphoria or other pleasant effects, or craving for the drug. This is an updated version of the original Cochrane Review published in 2015, Issue 4.

OBJECTIVES

To assess the efficacy and safety of baclofen for people with AWS.

SEARCH METHODS

We updated our searches of the following databases to March 2017: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, PubMed, Embase, and CINAHL. We also searched registers of ongoing trials. We handsearched the references quoted in the identified trials, and sought information from researchers, pharmaceutical companies, and relevant trial authors about unpublished or uncompleted trials. We placed no restrictions on language.

SELECTION CRITERIA

We included all randomised controlled clinical trials (RCTs) evaluating baclofen versus placebo or any other treatment for people with AWS. We excluded uncontrolled, non-randomised, or quasi-randomised trials. We included both parallel group and cross-over studies.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included three RCTs with 141 randomised participants. We did not perform meta-analyses due to the different control interventions. For the comparison of baclofen and placebo (1 study, 31 participants), there was no significant difference in Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) scores (very low quality evidence). For the comparison of baclofen and diazepam (1 study, 37 participants), there was no significant difference in CIWA-Ar scores (very low quality evidence), adverse events (risk difference (RD) 0.00, 95% confidence interval (CI) -0.10 to 0.10; very low quality evidence), dropouts (RD 0.00, 95% CI -0.10 to 0.10; very low quality evidence), and dropouts due to adverse events (RD 0.00, 95% CI -0.10 to 0.10; very low quality evidence). For the comparison of baclofen and chlordiazepoxide (1 study, 60 participants), there was no significant difference in CIWA-Ar scores (mean difference (MD) 1.00, 95% CI 0.70 to 1.30; very low quality evidence), global improvement (MD 0.10, 95% CI -0.03 to 0.23; very low quality evidence), adverse events (RD 2.50, 95% CI 0.88 to 7.10; very low quality of evidence), dropouts (RD 0.00, 95% CI -0.06 to 0.06; very low quality evidence), and dropouts due to adverse events (RD 0.00, 95% CI -0.06 to 0.06; very low quality evidence).

AUTHORS' CONCLUSIONS

No conclusions can be drawn about the efficacy and safety of baclofen for the management of alcohol withdrawal because we found insufficient and very low quality evidence.

[Benzodiazepines should still be first-line treatment for alcohol withdrawal]

In this review, we summarize the evidence for benzodiazepines and barbiturates as alcohol withdrawal treatment and outline a treatment guideline. A number of randomized controlled trials (RCTs) indicate that benzodiazepine treatment decreases alcohol withdrawal seizures and is safe. For barbiturates, only a few RCTs have been undertaken, and barbiturates were not found to be superior to benzodiazepines. Consequently, we suggest that benzodiazepines should still be first-line treatment for alcohol withdrawal.

Phenobarbital compared to benzodiazepines in alcohol withdrawal treatment: A register-based cohort study of subsequent benzodiazepine use, alcohol recidivism and mortality

BACKGROUND

Long-acting benzodiazepines such as chlordiazepoxide are recommended as first-line treatment for alcohol withdrawal. These drugs are known for their abuse liability and might increase alcohol consumption among problem drinkers. Phenobarbital could be an alternative treatment option, possibly with the drawback of a more pronounced acute toxicity. We evaluated if phenobarbital compared to chlordiazepoxide decreased the risk of subsequent use of benzodiazepines, alcohol recidivism and mortality.

METHODS

The study was a register-based cohort study of patients admitted for alcohol withdrawal 1998-2013 and treated with either phenobarbital or chlordiazepoxide. Patients were followed for one year. We calculated hazard ratios (HR) for benzodiazepine use, alcohol recidivism and mortality associated with alcohol withdrawal treatment, while adjusting for confounders.

RESULTS

A total of 1063 patients treated with chlordiazepoxide and 1365 patients treated with phenobarbital were included. After one year, the outcome rates per 100 person-years in the phenobarbital versus the chlordiazepoxide cohort were 9.20 vs. 5.13 for use of benzodiazepine, 37.9 vs. 37.9 for alcohol recidivism and 29 vs. 59 for mortality. Comparing phenobarbital to chlordiazepoxide treated, the HR of subsequent use of benzodiazepines was 1.56 (95%CI 1.05-2.30). Similarly, the HR for alcohol recidivism was 0.99 (95%CI 0.84-1.16). Lastly, the HR for 30-days and 1 year mortality was 0.25 (95%CI 0.08-0.78) and 0.51 (95%CI 0.31-0.86).

CONCLUSION

There was no decreased risk of subsequent benzodiazepine use or alcohol recidivism in patients treated with phenobarbital compared to chlordiazepoxide. Phenobarbital treatment was associated with decreased mortality, which might be confounded by somatic comorbidity among patients receiving chlordiazepoxide.

A randomized, open-label, standard controlled, parallel group study of efficacy and safety of baclofen, and chlordiazepoxide in uncomplicated alcohol withdrawal syndrome

Background

Alcohol withdrawal syndrome (AWS) is a distressing condition, generally controlled by benzodiazepines (BZD's). Baclofen, a gamma-aminobutyric acid-B (GABA_B) agonist, has also shown promising results in controlling AWS. As there are few studies comparing the efficacy and tolerability of chlordiazepoxide with baclofen, the present study was taken up. The objective of this study was to compare efficacy and tolerability of baclofen with chlordiazepoxide in uncomplicated AWS.

Methods

Sixty subjects with uncomplicated AWS were randomized into two groups of 30 each, to receive baclofen (30 mg) or chlordiazepoxide (75 mg) in decremented fixed dose regime for 9 days. Clinical efficacy was assessed by Clinical Institute Withdrawal Assessment for Alcohol-Revised Scale (CIWA-Ar) and tolerability by the nature and severity of adverse events. Lorazepam was used as rescue medication. Secondary efficacy parameters were Clinical Global Impression scores, symptom-free days, and subject satisfaction as assessed by visual analog scale. This study was registered with Clinical Trial Registry-India (CTRI/2013/04/003588), also subsequently registered with WHO's ICTRP clinical trial portal.

Results

Both baclofen and chlordiazepoxide showed a consistent reduction in the total CIWA-Ar scores. However, chlordiazepoxide showed a faster and a more effective control of anxiety and agitation requiring lesser lorazepam supplementation, and also showed a better subject satisfaction compared to baclofen. Both the drugs showed good tolerability with mild self-limiting adverse events.

Conclusion

The present study demonstrates that baclofen is not as good as chlordiazepoxide in the treatment of uncomplicated AWS. However, baclofen might be considered as an alternative.

Cost-effectiveness analysis of baclofen and chlordiazepoxide in uncomplicated alcohol-withdrawal syndrome

OBJECTIVES

Benzodiazepines (BZDs) are the first-line drugs in alcohol-withdrawal syndrome (AWS). Baclofen, a gamma-aminobutyric acidB (GABAB) agonist, controls withdrawal symptoms without causing significant adverse effects. The objective of this study was to compare the cost-effectiveness of baclofen and chlordiazepoxide in the management of uncomplicated AWS.

MATERIALS AND METHODS

This was a randomized, open label, standard controlled, parallel group study of cost-effectiveness analysis (CEA) of baclofen and chlordiazepoxide in 60 participants with uncomplicated AWS. Clinical efficacy was measured by the Clinical Institute Withdrawal Assessment for alcohol (CIWA-Ar) scores. Lorazepam was used as supplement medication if withdrawal symptoms could not be controlled effectively by the study drugs alone. Both direct and indirect medical costs were considered and the CEA was analyzed in both patient's perspective and third-party perspective.

RESULTS

The average cost-effectiveness ratio (ACER) in patient's perspective of baclofen and chlordiazepoxide was Rs. 5,308.61 and Rs. 2,951.95 per symptom-free day, respectively. The ACER in third-party perspective of baclofen and chlordiazepoxide was Rs. 895.01 and Rs. 476.29 per symptom-free day, respectively. Participants on chlordiazepoxide had more number of symptom-free days when compared with the baclofen group on analysis by Mann-Whitney test (U = 253.50, P = 0.03).

CONCLUSION

Both study drugs provided relief of withdrawal symptoms. Chlordiazepoxide was more cost-effective than baclofen. Baclofen was relatively less effective and more expensive than chlordiazepoxide.

A 'symptom-triggered' approach to alcohol withdrawal management

In acute hospital settings, alcohol withdrawal often causes significant management problems and complicates a wide variety of concurrent conditions, placing a huge burden on the NHS. A significant number of critical incidents around patients who were undergoing detoxification in a general hospital setting led to the need for a project to implement and evaluate an evidence-based approach to the management of alcohol detoxification-a project that included a pre-intervention case note audit, the implementation of an evidence-based symptom-triggered detoxification protocol, and a post-intervention case note audit. This change in practice resulted in an average reduction of almost 60% in length of hospital stay and a 66% reduction in the amount of chlordiazepoxide used in detoxification, as well as highlighting that 10% of the sample group did not display any signs of withdrawal and did not require any medication. Even with these reductions, no patient post-intervention developed any severe signs of withdrawal phenomena, such as seizures or delirium tremens. The savings to the trust (The Pennine Acute Hospital Trust) are obvious,but the development of a consistent, quality service will lead to fewer long-term negative effects for patients that can be caused by detoxification. This work is a project evaluation of a locally implemented strategy, which, it was hypothesised,would improve care by providing an individualised treatment plan for the management of alcohol withdrawal symptoms.

Unplanned alcohol withdrawal: a survey of consecutive admissions to an acute medical unit in 2010 and 2011

BACKGROUND

Alcohol-related presentations to hospital have been increasing in the UK in recent years, including the occurrence of acute withdrawal. This study sought to better characterize the clinical features, patterns of treatment and outcomes in this patient group.

METHODS

Patients admitted to the Acute Medical Unit of York Hospital due to acute alcohol withdrawal are normally treated according to a protocol that involves both fixed-dose and symptom-triggered drug administration. Admissions between 2010 and 2011 inclusive were studied.

RESULTS

There were 211 admission episodes solely due to acute alcohol withdrawal, involving 127 patients (97 men, 76.4%) with median age of 45 years (interquartile range: 39-52 years). There was a high prevalence of depression (34%), alcoholic liver disease (22%) and drug misuse (12%). Total dose of chlordiazepoxide varied between 0 and 610 mg and tapered rapidly after the first day of admission. Vitamin supplements were administered to >90% of patients, including parenteral and oral in 74%, parenteral alone in 9% and oral alone in 9%. A specialist alcohol nurse reviewed patients while in hospital in 40% of cases. Approximately one-third of patients had multiple admissions for alcohol withdrawal during the study period.

CONCLUSION

A high prevalence of physical and mental health disorders was observed. The local policy permitted high initial chlordiazepoxide doses and prompt downward titration, with a broad range of doses between individuals. Approximately 10% required no specific therapy, and there may be opportunities for developing alternative pathways for delivery of care in an ambulatory setting for these patients.

[Burning sensation in oral cavity--burning mouth syndrome in everyday medical practice]

Burning mouth syndrome (BMS) refers to chronic orofacial pain, unaccompanied by mucosal lesions or other evident clinical signs. It is observed principally in middle-aged patients and postmenopausal women. BMS is characterized by an intense burning or stinging sensation, typically on the tongue or in other areas of the oral mucosa. It can be accompanied by other sensory disorders such as dry mouth or taste alterations. Probably of multifactorial origin, and often idiopathic, with a still unknown etiopathogenesis in which local, systemic and psychological factors are implicated. Currently there is no consensus on the diagnosis and classification of BMS. This study reviews the literature on this syndrome, with special reference to the etiological factors that may be involved and the clinical aspects they present. The diagnostic criteria that should be followed and the therapeutic management are discussed with reference to the most recent studies.

Pharmacological modulation of stress-induced behavioral changes in the light/dark exploration test in male C57BL/6J mice

Psychological stress is a major risk factor for mood and anxiety disorders. However, the phenotypic manifestation of stress effects varies across individuals, likely due, in part, to genetic variation. Modeling the behavioral and neural consequences of stress across genetically diverse inbred mouse strains is a valuable approach to studying gene × stress interactions. Recent work has shown that C57BL/6J mice exposed to ten daily sessions of restraint stress exhibited increased exploration of the aversive light compartment in the light/dark exploration (LDE) test. Here we sought to clarify the nature of this stress-induced phenotype by testing the ability of treatment with various clinically efficacious drugs of different therapeutic classes to rescue it. Ten days of restraint increased light compartment exploration, reduced body weight and sensitized the corticosterone response to swim stress. Subchronic administration (during stress and LDE testing) of fluoxetine, and to a lesser extent, lithium chloride, rescued stress-induced LDE behavior. Chronic fluoxetine treatment prior to (plus during stress and testing) failed to block the LDE stress effect. Acute administration of antipsychotic haloperidol, anti-ADHD medication methylphenidate or anxiolytic drug chlordiazepoxide, prior to LDE testing, was also unable to normalize the LDE stress effect. Collectively, these data demonstrate a treatment-selective prophylactic rescue of a restraint stress-induced behavioral abnormality in the C57BL/6J inbred strain. Further work with this novel model could help elucidate genetic and neural mechanisms mediating stress-induced changes in mouse 'emotion-relevant' behaviors and, ultimately, further understanding of the pathophysiology of stress-related neuropsychiatric disorders. This article is part of a Special Issue entitled 'Anxiety and Depression'.

Hydroxyzine for generalised anxiety disorder

BACKGROUND

Generalised anxiety disorder (GAD) is a common chronic long-term psychiatric disorder, particularly frequent in primary care. There are several treatment options available, both non-pharmacological (i.e. cognitive behavioral therapy) and pharmacological. Among the pharmacological interventions, antidepressants, buspirone and benzodiazepines (BDZs) have been studied in GAD. Hydroxyzine is an anti-histamine medication which has been used in the treatment of anxiety.

OBJECTIVES

1. To determine the efficacy of hydroxyzine in comparison with placebo or any other active agent in alleviating the acute symptoms of GAD. 2. To review acceptability of treatment with hydroxyzine in comparison with placebo or any other active agent. 3. To investigate the adverse effects of hydroxyzine in comparison with other active agents.

SEARCH STRATEGY

The Cochrane Depression, Anxiety and Neurosis Group's controlled trial registers (CCDANCTR-Studies and CCDANCTR-References) were searched on 1 March 2010. The author team ran complementary searches on MEDLINE, CINAHL and PsycINFO and checked reference lists of included studies, previous systematic reviews and major textbooks of anxiety disorders. Personal communication with pharmaceutical companies and experts in the field was also undertaken.

SELECTION CRITERIA

Randomised controlled trials allocating patients with GAD to hydroxyzine versus placebo and/or any other anxiolytic agent.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy (such as the number of patients who responded to treatment or remitted), acceptability (the number of patients who failed to complete the study) and tolerability (side effect profile).

MAIN RESULTS

The search yielded 39 studies. We included five studies in the review with a total of 884 participants. We excluded 31 studies and designated three as awaiting assessment. The data from the included studies provide some evidence that hydroxyzine is more effective than placebo for GAD (odds ratio (OR) 0.30, 95% CI 0.15 to 0.58) and that it is also acceptable/tolerable (OR 1.00, 95% CI 0.63 to 1.58) (OR 1.49, 95% CI 0.92 to 2.40). Compared to other anxiolytic agents (benzodiazepines and buspirone), hydroxyzine was equivalent in terms of efficacy, acceptability and tolerability (hydroxyzine vs chloridiazepoxide: OR 0.75, 95% CI 0.35 to 1.62; hydroxyzine vs buspirone efficacy OR 0.76, 95% CI 0.40 to 1.42). In terms of side effects, hydroxyzine was associated with a higher rate of sleepiness/drowsiness than the active comparators (OR 1.74, 95% CI 0.86 to 3.53). There was, however, a high risk of bias in the included studies.

AUTHORS' CONCLUSIONS

The included studies did not report on all the outcomes that were pre-specified in the protocol for this review. Even though more effective than placebo, due to the high risk of bias of the included studies, the small number of studies and the overall small sample size, it is not possible to recommend hydroxyzine as a reliable first-line treatment in GAD.

Buspirone, chlordiazepoxide and diazepam effects in a zebrafish model of anxiety

Zebrafish are becoming more widely used to study neurobehavioral pharmacology. We have developed a method to assess novel environment diving behavior of zebrafish as a model of stress response and anxiolytic drug effects. In a novel tank, zebrafish dwell in the bottom of the tank initially and then increase their swimming exploration to higher levels over time. We previously found that nicotine, which has anxiolytic effects in rodents and humans, significantly lessens the novel tank diving response in zebrafish. The specificity of the diving effect was validated with a novel vs. non-novel test tank. The novel tank diving response of zebrafish was tested when given three anxiolytic drugs from two different chemical and pharmacological classes: buspirone, chlordiazepoxide and diazepam. When the test tank was novel the diving response was clearly seen whereas it was significantly reduced when the test tank was not novel. Buspirone, a serotonergic (5HT(1A) receptor agonist) anxiolytic drug with some D(2) dopaminergic effect, had a pronounced anxiolytic-like effect in the zebrafish diving model at doses that did not have sedative effects. In contrast, chlordiazepoxide, a benzodiazepine anxiolytic drug, which is an effective agonist at GABA-A receptors, did not produce signs of anxiolysis in zebrafish over a broad dose range up to those that caused sedation. Diazepam another benzodiazepine anxiolytic drug did produce an anxiolytic effect at doses that did not cause sedation. The zebrafish novel tank diving task can be useful in discriminating anxiolytic drugs of several classes (serotonergic, benzodiazepines and nicotinic).

Differential genetic regulation of motor activity and anxiety-related behaviors in mice using an automated home cage task

Traditional behavioral tests, such as the open field test, measure an animal's responsiveness to a novel environment. However, it is generally difficult to assess whether the behavioral response obtained from these tests relates to the expression level of motor activity and/or to avoidance of anxiogenic areas. Here, an automated home cage environment for mice was designed to obtain independent measures of motor activity levels and of sheltered feeding preference during three consecutive days. Chronic treatment with the anxiolytic drug chlordiazepoxide (5 and 10 mg/kg/day) in C57BL/6J mice reduced sheltered feeding preference without altering motor activity levels. Furthermore, two distinct chromosome substitution strains, derived from C57BL/6J (host strain) and A/J (donor strain) inbred strains, expressed either increased sheltering preference in females (chromosome 15) or reduced motor activity levels in females and males (chromosome 1) when compared to C57BL/6J. Longitudinal behavioral monitoring revealed that these phenotypic differences maintained after adaptation to the home cage. Thus, by using new automated behavioral phenotyping approaches, behavior can be dissociated into distinct behavioral domains (e.g., anxiety-related and motor activity domains) with different underlying genetic origin and pharmacological responsiveness.

Benzodiazepines: some aspects of their clinical pharmacology

Benzodiazepine derivatives are the most commonly prescribed anti-anxiety agents in clinical practice. Six benzodiazepine anxiolytics are now available in the United States. Additional drugs are used in other parts of the world, and many others are in various stages of clinical testing. All these benzodiazepine derivatives have similar neuropharmacological properties--they reduce anxiety, produce sedation and sleep, have anticonvulsant effects, and can produce muscle relaxation. Faced with this bewildering array of drugs from the same class which are very similar in intrinsic effects upon the brain, the clinician may well ask how best to make a rational choice among the available derivatives. Despite neuropharmacological similarities, there are differences among benzodiazepines in patterns of absorption, distribution, and elimination by the human body. These pharmacokinetic differences may in turn lead to apparent differences in clinical action. This review summarizes pertinent pharmacokinetic characteristics of benzodiazepine anti-anxiety agents.

The liberal state and the rogue agency: FDA's regulation of drugs for mood disorders, 1950s-1970s

The theory of the liberal state does not generally contemplate the possibility that regulatory agencies will turn into "rogues," regulating against the interests of their clients and, indeed, the public interest. In the years between circa 1955 and 1975 this seems to have happened to one of the prime regulatory agencies of the US federal government: the Food and Drug Administration (FDA). Intent upon transforming itself from a traditional "cop" agency to a regulatory giant, the FDA campaigned systematically to bring down some safe and effective drugs. This article concentrates on hearings in the area of psychopharmacology regarding several antianxiety drugs, namely meprobamate (Miltown), chlordiazepoxide (Librium) and diazepam (Valium). In addition, from 1967 to 1973 this regulatory vengefulness occurred on a broad scale in the Drug Efficacy Study Implementation (DESI), an administrative exercise that removed from the market almost half of the psychopharmacopoeia. The article explores possible bureaucratic motives for these actions.

Anxiolytic effects of lavender oil inhalation on open-field behaviour in rats

To establish a valid animal model of the effects of olfactory stimuli on anxiety, a series of experiments was conducted using rats in an open-field test. Throughout, effects of lavender oil were compared with the effects of chlordiazepoxide (CDP), as a reference anxiolytic with well-known effects on open-field behaviour. Rats were exposed to lavender oil (0.1-1.0 ml) for 30 min (Experiment 1) or 1h (Experiment 2) prior to open-field test and in the open field or injected with CDP (10 mg/kg i.p.). CDP had predicted effects on behaviour, and the higher doses of lavender oil had some effects on behaviour similar to those of CDP. In Experiment 3, various combinations of pre-exposure times and amounts of lavender oil were used. With sufficient exposure time and quantity of lavender the same effects were obtained as in Experiment 2. Experiment 4 demonstrated that these behavioural effects of lavender could be obtained following pre-exposure, even if no oil was present in the open-field test. In Experiments 2-4, lavender oil increased immobility. Together, these experiments suggest that lavender oil does have anxiolytic effects in the open field, but that a sedative effect can also occur at the highest doses.

Correlated species differences in the effects of cannabinoid ligands on anxiety and on GABAergic and glutamatergic synaptic transmission

Cannabinoid ligands show therapeutic potential in a variety of disorders including anxiety. However, the anxiety-related effects of cannabinoids remain controversial as agonists show opposite effects in mice and rats. Here we compared the effects of the cannabinoid agonist WIN-55,212 and the CB1 antagonist AM-251 in CD1 mice and Wistar rats. Special attention was paid to antagonist–agonist interactions, which had not yet been studied in rats. In mice, WIN-55,212 decreased whereas AM-251 increased anxiety. The antagonist abolished the effects of the agonist. In contrast, WIN-55,212 increased anxiety in rats. Surprisingly, the antagonist potentiated this effect. Cannabinoids affect both GABAergic and glutamatergic functions, which play opposite roles in anxiety. We hypothesized that discrepant findings resulted from species differences in the relative responsiveness of the two transmitter systems to cannabinoids. We investigated this hypothesis by studying the effects of WIN-55,212 on evoked hippocampal inhibitory and excitatory postsynaptic currents (IPSCs and EPSCs). IPSCs were one order of magnitude more sensitive to WIN-55,212 in mice than in rats. In mice, IPSCs were more sensitive than EPSCs to WIN-55,212. This is the first study showing that the relative cannabinoid sensitivity of GABA and glutamate neurotransmission is species-dependent. Based on behavioural and electrophysiological findings, we hypothesize that WIN-55,212 reduced anxiety in mice by affecting GABA neurotransmission whereas it increased anxiety in rats via glutamatergic mechanisms. In rats, AM-251 potentiated this anxiogenic effect by inhibiting the anxiolytic GABAergic mechanism. We suggest that the anxiety-related effects of cannabinoids depend on the relative cannabinoid responsiveness of GABAergic and glutamatergic neurotransmission.

Exposure to predator odor stress increases efflux of frontal cortex acetylcholine and monoamines in mice: comparisons with immobilization stress and reversal by chlordiazepoxide

Psychogenic stress may be associated with the development of mood disorders and schizophrenia. The frontal cortex (FC) regulates stress responses, and its dysfunction contributes to certain neuropsychiatric disorders. We tested the effects of exposure to predator odor stress (POS), a psychogenic stressor, on the concurrent efflux of four major neurotransmitters within the FC in mice in comparison to immobilization stress (IMS), a physical/systemic stressor. POS and IMS significantly increased efflux of acetylcholine (ACh), serotonin (5-HT) and dopamine (DA), but not norephinephrine, within the FC. POS produced a somewhat longer-lasting efflux of 5-HT, as compared to IMS. The effects of POS and IMS on ACh, 5-HT and DA were blocked by chlordiazepoxide. Overall, we demonstrate a novel method to measure the effects of distinctly different stress modalities on FC neurotransmission and suggest that FC responsivity to stressors may be an important marker for evaluating anxiolytic drugs.

An audit of symptom triggered chlordiazepoxide treatment of alcohol withdrawal on a medical admissions unit

Patients suffering from alcohol withdrawal were found on initial audit to be discharged before the resolution of their symptoms. A regimen using symptom triggered chlordiazepoxide was introduced and found, on re-audit and anecdotally, to be an improvement. The duration of symptoms was reduced significantly, the length of stay was reduced (although not statistically significant because of limited power), and most patients who had experience of both regimens found the symptom triggered regimen more effective.

Anxiogenic effect of sleep deprivation in the elevated plus-maze test in mice

RATIONALE

Several clinical studies demonstrate that the absence of periods of sleep is closely related to occurrence of anxiety symptoms. However, the basis of these interactions is poorly understood. Studies performed with animal models of sleep deprivation and anxiety would be helpful in the understanding of the mechanisms underlying this relationship, but some animal studies have not corroborated clinical data, reporting anxiolytic effects of sleep deprivation.

OBJECTIVES

The aim of the present study was to verify the effects of different protocols of sleep deprivation in mice tested in the elevated plus-maze and to assess the effect of chlordiazepoxide and clonidine.

METHODS

Three-month-old male mice were sleep-deprived for 24 or 72 h using the methods of single or multiple platforms in water tanks. Mice kept in their home cages were used as controls. Plus-maze behavior was observed immediately after the deprivation period.

RESULTS

Mice that were sleep-deprived for 72 h spent a lower percent time in the open arms of the apparatus than control animals. This sleep deprivation-induced anxiety-like behavior was unaffected by treatment with chlordiazepoxide (5.0 and 7.5 mg/kg IP), but reversed by an administration of 5 or 10 microg/kg IP clonidine.

CONCLUSION

The results indicate that under specific methodological conditions sleep deprivation causes an increase in anxiety-like behavior in mice exposed to the elevated plus-maze.

Altered response to benzodiazepine anxiolytics in mice lacking GABA B(1) receptors

Recently, we demonstrated that mice lacking the GABA(B(1)) subunit were more anxious than wild-type animals in several behavioural paradigms, most notably in the light-dark test. In an attempt to assess the effects of classical benzodiazepine anxiolytics on anxiety-like behaviour observed in these mice, animals were administered either chlordiazepoxide (10 mg/kg, p.o.) or diazepam (7.5 mg/kg, p.o.) prior to testing in the light-dark box. Surprisingly, in contrast with the wild-type mice, neither benzodiazepines decreased anxiety-like behaviour in GABA(B(1))(-/-) mice. These data suggest that targeted deletion of GABA(B(1)) subunit alters GABA(A) receptor function in vivo.

Anxiolytic properties of Piper methysticum extract samples and fractions in the chick social-separation-stress procedure

Piper methysticum extract (Kava kava) possesses anxiolytic properties. However, it is unknown whether these effects are best predicted by total kavalactone content or by one or more of its primary kavalactone constituents. Using the chick social separation-stress procedure as an anxiolytic bioassay, P. methysticum samples containing 12.8-100.0% total kavalactones (Exp. 1) and fractions containing 1-6 kavalactones of varying concentrations (0.1-67.5%; Exps. 2-3) were screened for activity and compared against a 5.0 mg/kg dose of chlordiazepoxide (CDP; Exp. 3). Eight-day-old chicks received IP injections of either vehicle or test compounds 30 min before being placed in the presence of two conspecifics or in isolation for a 3 min observation period. Dependent measures were ventral recumbency latency (sedation), distress vocalizations, and a measure of stress-induced analgesia (in Exps. 1 and 2 only). P. methysticum extract samples attenuated distress vocalizations in a concentration-dependent manner. The P. methysticum fraction that contained the highest concentration of dihydrokavain attenuated distress vocalizations in a manner equivalent to that of CDP. The extract samples and fractions that possessed anxiolytic properties did not possess the sedative properties found in CDP. Collectively, these findings suggest that dihydrokavain may be necessary and sufficient in mediating the anxiolytic properties of P. methysticum extract.

Corticosterone response in the chick separation-stress paradigm

Corticosterone response to separation stress and its sensitivity to the anxiolytic, chlordiazepoxide (CDP), were examined in 7-day-old domestic fowl (Gallus gallus). Saline or CDP (8.0 mg/kg) was injected intramuscularly 30 min before tests. Chicks were placed in isolation either with or without mirrors for a 15-min observation period, in which distress vocalizations were recorded. After testing, chicks were euthanized and blood was collected for the corticosterone assay. Chicks tested in the No-Mirror condition displayed an increase in vocalizations that was attenuated by CDP. Similarly, corticosterone levels were highest in chicks tested in the No-Mirror condition; however, CDP only modestly attenuated corticosterone levels. The present findings demonstrate that corticosterone levels parallel the behavioral marker of distress vocalizations in this paradigm, but this biological marker may be less sensitive than the behavioral marker to benzodiazepine anxiolytic manipulations.

Divalproex sodium (Depakote) for alcohol withdrawal and relapse prevention

This pilot study evaluates the safety and efficacy of divalproex sodium (Depakote) for alcohol withdrawal and relapse prevention. Sixteen patients in moderate alcohol withdrawal were randomized to receive a standard benzodiazepine detoxification, depakote detoxification, or depakote detox plus maintenance. Symptom reduction occurred more rapidly and consistently in the depakote treated patients than in the benzodiazepine control group, and at six-week follow up a greater percentage of patients in the depakote maintenance group were completely abstinent than either detox-only group. There were no significant differences in sociodemographic or drinking data amongst the three cohort samples at baseline. Our findings suggest that the anticonvulsant divalproex sodium (Depakote) may be a safe and efficacious alternative to benzodiazepines for the treatment of alcohol withdrawal. It may be an advantageous alternative for outpatient detoxification, as it has no abuse potential, pharmacologic synergy with alcohol, or substantial cognitive or psychomotor side effects.

Lack of interaction between the behavioral effects of ketamine and benzodiazepines in mice

The effect of co-administration of ketamine at the sub-effective dose with diazepam, chlordiazepoxide and clonazepam on their antinociceptive and protective efficacy against pentetrazole-induced seizures were studied in mice. Ketamine alone produces dose-dependent antinociception manifested as reduction in the number of writhing episodes evoked by acetic acid. In the writhing test, the antinociceptive effects of the threshold doses of diazepam, chlordiazepoxide or clonazepam were not changed by ketamine, whereas that of morphine was intensified by ketamine. In the hot plate test, slight antinociceptive effects of the threshold dose of diazepam, but not that of chlordiazepoxide (except the results at 120 min of observation), were significantly intensified by ketamine vs ketamine alone. Ketamine alone was able to protect mice, in the dose-related manner, against pentetrazole-induced seizures. The anticonvulsant effects of the threshold doses of diazepam, chlordiazepoxide and clonazepam were not changed by ketamine. These findings indicate that co-administration of ketamine (at the sub-effective dose) with diazepam, chlordiazepoxide and clonazepam (at non-effective doses) resulted in an intensification of neither antinociceptive nor protective effect against pentetrazole-induced seizures in mice. These data seem to indicate the lack of interaction between ketamine and benzodiazepines with respect to their antinociceptive and anticonvulsant efficacy.

The light-enhanced startle paradigm as a putative animal model for anxiety: effects of chlordiazepoxide, flesinoxan and fluvoxamine

RATIONALE

Recently, a new putative animal model of anxiety, "light-enhanced startle" was introduced. By placing a rat in a brightly lit environment, which is a naturally aversive stimulus to rats, the amplitude of the startle response to a startle-eliciting noise burst is increased.

OBJECTIVES

The present study aimed to determine the predictive validity of the light-enhanced startle as a putative model for anxiety.

METHODS

The effects of the GABA(A)-benzodiazepine receptor agonist chlordiazepoxide (CDP), the 5-HT1A receptor agonist flesinoxan and the specific 5-HT reuptake inhibitor fluvoxamine on light-enhanced startle were studied.

RESULTS

Both CDP and flesinoxan decreased startle potentiation, whereas fluvoxamine was devoid of any effects on potentiation. Effects on baseline startle amplitude were only seen after CDP administration.

CONCLUSIONS

The present experiment provides evidence for the predictive validity of the light-enhanced startle as an animal model for anxiety. Due to the use of an unconditioned anxiogenic stimulus, the light-enhanced startle offers several benefits over animal models that depend on conditioning. Drug effects can be ascribed more directly to effects on anxiety, as opposed to memory retrieval and, as shown in this study, non-specific drug effects can easily be detected without the interference of contextual fear.

A double-blind randomized placebo-controlled trial of lofexidine in alcohol withdrawal: lofexidine is not a useful adjunct to chlordiazepoxide

Lofexidine is an alpha-adrenoceptor agonist which has proved useful in opiate withdrawal and which, through its attenuation of noradrenergic activity, might be a valuable adjunct in the management of alcohol withdrawal. The objective of this study was to compare the clinical effectiveness and patient retention with adjunctive lofexidine versus placebo in the treatment of alcohol withdrawal under chlordiazepoxide cover. This was done in a prospective double-blind randomized placebo-controlled trial with 72 alcohol-dependent adults referred and admitted for in-patient alcohol detoxification. The adjunctive lofexidine group experienced significantly more severe withdrawal symptoms, greater hypotensive problems, more adverse effects, and no better rates of retention in treatment. Lofexidine provides no discernible benefit as an adjunctive medication (to chlordiazepoxide) in alcohol detoxification and, on the basis of our study, appears to be contra-indicated.

Anxiolytic effects of kava extract and kavalactones in the chick social separation-stress paradigm

RATIONALE

Piper methysticum extract (kava kava) possesses numerous therapeutic properties, but it is unknown which of its principle constituents (kavalactones) subserve such effects.

OBJECTIVES

This experiment sought to characterize the putative anxiolytic properties of P. methysticum extract and its six principle kavalactones in the chick social separation-stress paradigm.

METHODS

Eight-day-old chicks received intraperitoneal injections of either vehicle, chlordiazepoxide (5.0 mg/ml per kg), P. methysticum extract (containing 30% kavalactones), kavain, dihydrokavain, methysticin, dihydromethysticin, yangonin, or desmethoxyyangonin (30 mg/ml per kg for kava compounds) 30 min prior to being tested in the presence of two conspecifics or in isolation for a 3-min observation period. Latency to adopt a ventral recumbent posture to index sedation, number of vocalizations to index separation distress, and a composite pain score (in response to 50 microliters 0.10% formalin injection into the plantar surface of the foot) to index stress-induced analgesia served as dependent measures.

RESULTS

Both chlordiazepoxide and P. methysticum extract attenuated separation-induced distress vocalizations and stress-induced analgesia. Dihydrokavain attenuated separation-induced distress vocalizations.

CONCLUSIONS

These findings suggest that the anxiolytic effects of P. methysticum extract may be mediated, in part, by dihydrokavain.

Anticonvulsant effect of water extract of Scutellariae radix in mice

Since a previous study indicated that the water extract of Scutellariae radix (SR) had high affinity for the benzodiazepine (BDZ) binding site of GABA(A) receptors, the present study examined whether SR water extract has an anticonvulsant effect in vivo and an enhancing effect on gamma-amino-n-butyric acid (GABA)-stimulated uptake of 36Cl(-) in cortex preparation in vitro in mice. The results showed that SR water extract had little effect on pentylenetetrazol (PTZ, 85 mg/kg, s.c.)-induced clonic seizures but significantly inhibited maximal electroshock-induced tonic seizures with an ED(50) of 3.6 g/kg. The BDZ agonist chlordiazepoxide (10 mg/kg, i.p.) had anticonvulsant activity on both types of seizures. In 36Cl(-) uptake assay, SR water extract (1-500 microg/ml) had no significant effect on 25 microM GABA-stimulated 36Cl(-) uptake, whereas chlordiazepoxide (10 microM) increased the 36Cl(-) uptake to 125% of control. Therefore, the present results showed for the first time that SR water extract had anticonvulsant activity against maximal electroshock-induced tonic seizures, and suggested that this anticonvulsant effect might be not via the activation of the BDZ binding site of GABA(A) receptors, but probably via the prevention of seizure spread.

Effects of two acute stressors on the anxiolytic efficacy of chlordiazepoxide

RATIONALE

Limited published data show that drug efficacy can be influenced by stressors. Thus, drug testing in stressed animals may unravel important variables determining drug effects.

OBJECTIVES

The experiments tested the anxiolytic efficacy of the benzodiazepine chlordiazepoxide under conditions of acute stress.

METHODS

Previously group-housed rats were injected with 0, 3, and 10 mg/kg chlordiazepoxide, thereafter being exposed to two types of stress: novelty (transfer to an individual cage) and social defeat. Controls were group-housed animals. Anxiety was assessed on the plus maze.

RESULTS

Speed of locomotion was increased by chlordiazepoxide in both stressed groups but not in controls. Chlordiazepoxide exerted a marked reduction in anxiety in controls and defeated rats but not in novelty exposed animals. The effects of novelty exposure were considerably weaker when drug testing was performed 24 h later.

CONCLUSIONS

Stress exposure had an impact on the behavioral effects of chlordiazepoxide. Changes in locomotor activity induced by the drug appear to depend on the presence of a stressor, while anxiolytic efficacy appears to depend on the type of the stressor. Since it has been shown that drug efficacy changes in a variety of behavioral situations and drug classes, it is suggested that experimental background is an important variable in determining behavioral effects of drugs.

The neurosteroid pregnanolone prevents the anxiogenic-like effect of inescapable shock in the rat

RATIONALE AND OBJECTIVES

The ability of progesterone (P4) and its neurosteroid metabolite, 3alpha-OH-5beta-pregnan-20-one (pregnanolone) in protecting against the anxiogenic-like effect of inescapable shock (IS) in male rats was examined, as these steroids exert anxiolytic, anticonvulsant, and ataxic effects similar to the benzodiazepines (BZ), drugs shown to prevent IS-induced anxiogenesis.

METHODS

Adult male rats were injected with pregnanolone (8 mg/kg, SC), P4 (4 mg/rat) or its appropriate vehicle before exposure to IS. Twenty-four hours later, animals were injected with the steroid or its vehicle and then tested in the elevated plus-maze. In a control experiment, animals were injected with chlordiazepoxide (CDP, 15 mg/kg, IP) or vehicle before IS, and tested in the plus-maze 24 h later.

RESULTS

Whereas CDP or pregnanolone before IS resulted in the loss of the anxiogenic-like response seen 24 h after IS, P4 before IS did not protect against the anxiogenic-like effect of IS. The acute anxiolytic-like effect of pregnanolone and P4 was lost in animals that were injected with vehicle before the IS, but was observed in animals that were injected with the steroids before IS. Moreover, P4 injection in non-shocked animals was associated with an anxiogenic-like response observed 24 h after steroid administration.

CONCLUSION

The protection against the effect of IS afforded by a GABAergic neurosteroid is comparable to that observed with BZs, and thus provides further evidence of an allosteric relationship between the neurosteroid and BZ binding site on the GABA(A) receptor complex.

Outpatient detoxification of the addicted or alcoholic patient

Outpatient detoxification of patients with alcohol or other drug addiction is being increasingly undertaken. This type of management is appropriate for patients in stage I or stage II of withdrawal who have no significant comorbid conditions and have a support person willing to monitor their progress. Adequate dosages of appropriate substitute medications are important for successful detoxification. In addition, comorbid psychiatric, personality and medical disorders must be managed, and social and environmental concerns need to be addressed. By providing supportive, nonjudgmental, yet assertive care, the family physician can facilitate the best possible chance for a patient's successful recovery.

Inappropriate prescribing for elderly outpatients

The frequency of potentially inappropriate prescribing for elderly outpatients and factors predicting inappropriate prescribing for these patients were studied. A panel of experts in geriatric medicine and geriatric pharmacology developed a list of 20 drugs generally considered to be inappropriate for elderly patients. Data on outpatient visits by patients aged 65 years or older were extracted from the 1994 National Hospital Ambulatory Medical Care Survey and analyzed with respect to the 20 potentially inappropriate medications. Potentially inappropriate medications were prescribed at 4.45% of elderly outpatient visits involving medications. An estimated 319,302 (95% confidence interval, 256,269 to 382,334) visits involved potentially inappropriate medications. The most frequently prescribed potentially inappropriate medications were diazepam, propoxyphene, dipyridamole, amitriptyline, and chlordiazepoxide; these drugs accounted for 85% of the outpatient visits involving potentially inappropriate medications. Patients were more likely to be prescribed potentially inappropriate medications if they had been referred; had a number of medications prescribed; had a prescription for an antianxiety agent, a sedative, an antidepressant, an analgesic, a platelet inhibitor, or an antispasmodic agent; or had a medication prescribed by a provider from a nonmetropolitan area. Ambulatory care providers prescribed at least one potentially inappropriate medication at 4.45% of visits by elderly patients at which a medication was prescribed; patient characteristics, provider characteristics, and drug-use profiles can be used to predict inappropriate prescribing.

[Influence of stress and stress-protecting factors on rat tolerance to cold and efficiency of rat adaptation to cold]

The adaptive characteristics of the body, including the specific features of increased cold resistance upon repeated exposures to cold, are determined not only by the properties of thermogenic structures themselves, but largely depend on the contribution of the central mechanisms which control the processes of habituation and mobilization of functions. The experiments revealed an increase in cold resistance in rats after preexposure to cold. Immobilization stress prior to training cold significantly decreased rapid cold resistance in the animals, but increased the training effect of the first cooling. On the contrary, chlordiazepoxide increased cold resistance during the first cooling. Testing of the untreated animal showed no effect of training. No adaptive changes in cold resistance occurred in rats with impaired amygdaloid complex. Analyzing adrenal catecholamines revealed a significant elevation of dopamine concentrations in the rats exposed to cold. Hypothalamic catecholamines did not change with cold and serotonin in intact rats and 5-hydroxyindoleacetic acid in amygdalectomized rats substantially increased.

Role of the basolateral nucleus of the amygdala in the formation of a phobia

Specific phobia is an anxiety disorder that does not respond to benzodiazepines. The elevated plus-maze test of anxiety is sensitive to benzodiazepines on trial 1, but during the first 5-min trial the nature of the anxiety generated changes to a specific fear of heights, and, as a result, on trial 2 the rats no longer respond to benzodiazepines. However, rats that received reversible bilateral lesions of the basolateral amygdala (by lidocaine injection) immediately after trial 1 responded with an anxiolytic response to chlordiazepoxide when tested 48 h later on trial 2. Those that received vehicle injections after trial 1 showed the usual lack of response to chlordiazepoxide on trial 2. Thus, the basolateral amygdala plays a crucial role in the consolidation of information that leads to the formation of a specific phobia and subsequent insensitivity to benzodiazepines.

The role of subtypes of the opioid receptor in the anxiolytic action of chlordiazepoxide

Previous studies have shown that the opiate antagonist naloxone blocks the anxiolytic-like effects of benzodiazepines in several models of anxiety, including the elevated plus-maze. Although naloxone preferentially binds to the mu opioid receptor, its selectivity is rather low. The opioid receptor subtype important for anxiolytic-like actions of benzodiazepines in the plus-maze remains, therefore, unknown. In the present experiments, the ability of antagonists selective for subtypes of the opioid receptor to block the anxiolytic-like effects of chlordiazepoxide in the elevated plus-maze was evaluated in Swiss mice. Chlordiazepoxide, 5 mg/kg, increased the proportion as well as the number of open arms entries without modifying closed arms entries. Lower doses of the benzodiazepine were ineffective. The mu receptor antagonist beta-funaltrexamine, 10 and 20 mg/kg, the delta antagonist naltrindole, 10 mg/kg, and the kappa antagonist nor-binaltorphimine, 2.5 and 5 mg/kg, were then combined with chlordiazepoxide, 5 mg/kg. beta-funaltrexamine, 10 mg/kg, reduced the effects of the benzodiazepine while the dose of 20 mg/kg completely blocked the effects. Nor-binaltorphimine was ineffective at a dose of 2.5 mg/kg, but completely inhibited the actions of chlordiazepoxide when the dose was 5 mg/kg. Naltrindole was ineffective. None of the antagonists affected plus-maze behavior when administered alone. It was concluded that the mu and kappa receptors are important for the anxiolytic-like actions of chlordiazepoxide in the elevated plus maze.

Individualized treatment for outpatients withdrawing from alcohol

BACKGROUND

This prospective study addressed the applicability of symptom-triggered detoxification to the outpatient setting.

METHOD

We studied 108 alcohol-dependent patients consecutively enrolled in an outpatient detoxification program between January 17, 1995, and October 17, 1995. The diagnosis was confirmed by verifying, through chart review, that patients met DSM-IV criteria for alcohol dependence. Patients were prescribed chlordiazepoxide according to a symptom-triggered detoxification protocol that utilized a standardized withdrawal scale. We compiled outcome data by reviewing the chart and the computerized medical record. Outcome was operationally defined to include completion of outpatient detoxification as well as outcome measures that were used in earlier studies of symptom-triggered detoxification in the hospital setting.

RESULTS

Chlordiazepoxide was administered to only 41 patients (38%), yet 92 (85%) of the 108 enrolled successfully completed outpatient detoxification without medical complications. The patients who took chlordiazepoxide received a mean+/-SD total of 167.2+/-123.5 mg administered over 2.7+/-1.4 days. Mean gamma-glutamyltransferase levels were higher for the group of patients who subsequently received chlordiazepoxide (132.8+/-312.1 IU/L compared with 56+/-80.3 IU/L; Wilcoxon rank sum test, t=2600.5, p < .01).

CONCLUSION

This study is the first to support the feasibility of symptom-triggered detoxification from alcohol in an outpatient setting. Our completion rate compared favorably with completion rates from previous studies of outpatient detoxification from alcohol using fixed-dose schedules. The percentage of patients receiving chlordiazepoxide and mean total amount of chlordiazepoxide administered in our study were also comparable to results from previous studies of symptom-triggered detoxification with hospitalized patients.

Anxiety- and activity-related effects of diazepam and chlordiazepoxide in the rat light/dark and dark/light tests

We have investigated, through factor analysis, anxiety- and activity-related variables in rats placed in the light/dark box. Thus, vehicle-, diazepam (DZ)-, and chlordiazepoxide (CDP)-treated rats were submitted 30 min later to 5-min light/dark or dark/light tests (initial placements in light or dark, respectively). Following this test, the animals were tested for 5 min in an automated activity monitor. Doses of DZ (0.75-3.0 mg/kg) and CDP (2.5-10.0 mg/kg) were based on preliminary evidence for 1.5 mg/kg of DZ and 5 mg/kg of CDP being anxiolytic in the elevated plus-maze. In the light/dark test, DZ increased the number of visits to and duration in the light compartment, and locomotor activity in the dark compartment; moreover, DZ decreased the latency to enter the light compartment. These effects were, however, significant for the highest dose only. Although CDP yielded similar behavioural effects, only the highest dose had a significant effect, namely, on latency to enter the light side. Conversely, none of the other variables were benzodiazepine-sensitive. Locomotion in the activity cages was decreased by DZ and CDP, an effect significant for the highest doses of benzodiazepines (dark/light test condition only). In both tests, factor analyses revealed an anxiety-related factor (to which all variables related to the visits in the light and part of the locomotion in the dark contributed), and an activity-related factor (upon which the latency to enter the dark and part of the locomotion in the dark loaded) in the light/dark test only. It is suggested that although the light/dark and dark/light tests capture an approach/avoidance dimension, DZ and CDP are more effective in the former test. Compared to the light/dark test, however, the plus-maze may be more sensitive to the anxiolytic effects of DZ and CDP.

Anxiety and the irritable bowel syndrome: psychiatric, medical, or both?

The association between the irritable bowel syndrome (IBS) and psychiatric disorders is well-known to most clinicians, but the nature of the relationship is far from clear. There is an increased prevalence of psychiatric illness in IBS patients and an increase in IBS in psychiatric patients. Whether this association exists outside of treatment-seeking populations (i.e., in IBS sufferers who do not seek treatment) has not been well investigated. This paper will selectively review the existing literature regarding the association of IBS and psychiatric illness in both patient and nonpatient samples. A model of the brain-gut interaction will be presented, as will practical implications of this model for treatment of individuals with IBS.

[The effect of nifedipine and chlordiazepoxide on alcohol withdrawal syndrome]

The aim this study was to evaluate the efficacy and tolerability of DHP calcium channel antagonist-nifedipine in human AWS in comparison to conventional treatment with chlordiazepoxide. Fifty nine hospitalized alcoholics of both sexes with diagnosis of AWS according to DSM-III-R criteria were treated for 2 weeks in monotherapy with nifedipine (Cordafen-Polfa)-60 mg/d. or with chlordiazepoxide (Elenium-Polfa)-150 mg/d. Evaluation of AWS symptoms was performed at baseline and after 3, 7, 14 days using Sandowal-Wang scale. Our original scales (37 items) were designed for measuring the depth of dependence (WGU) and the velocity of dependence syndrome appearance (WWO). The results show that both groups were similar regarding WGU and WWO before treatment. Both drugs caused an improvement of AWS symptoms after 3 and 7 days lasting till the end of hospitalization. Nifedipine was well tolerated and no side effects were observed or reported. The group and multidimensional analyses were performed using original computer program. The patients were divided into 3 subgroups. Comparison of mean values of improvement index between both drugs in those subgroups of patients according to WGU criteria, revealed that nifedipine was more effective on the 3-rd and 7-th day in 3 groups and 2 groups resp. According to WWO criteria the improvement index was significantly higher on the 3-rd and 7-th day in two groups whereas in one group chlordiazepoxide and nifedipine action was equal. The proposed method of group and multidimensional analysis enable us to compare the effectiveness of different kinds of AWS treatment. It is an useful aid of choosing the best drug treatment for a new patient.

Benzodiazepines as antidepressants: does GABA play a role in depression?

Benzodiazepines, the most widely prescribed psychotropic drugs, are often used in patients with depressive disorders, either alone or in combination with standard antidepressants. This review evaluates the efficacy of benzodiazepines (alprazolam, diazepam, chlordiazepoxide) as established in acute-phase, randomized controlled trials (RCTs) in major depressive disorder. Metaanalyses using intent-to-treat, as well as adequate treatment exposure samples, revealed an overall efficacy of 47-63% and a drug-placebo difference of 0-27% for all benzodiazepines. Alprazolam, the best studied of the benzodiazepines, had a 27.1% (sd = 6.1%) greater response than placebo, which is comparable to standard antidepressants. Alprazolam, in particular, may be a useful treatment option for patients in whom standard antidepressant medications are contraindicated, poorly tolerated, or possibly ineffective. Alprazolam may have a more rapid onset of action for some patients. Benzodiazepines do not primarily affect biogenic amine uptake or metabolism, although they do augment gamma-amino butyric acid (GABA) activity. The antidepressant efficacy of benzodiazepines, which are GABAA receptor agonists, is consistent with the GABA theory of depression.

Alcohol withdrawal: a nationwide survey of inpatient treatment practices

OBJECTIVE

To describe current practices employed in the inpatient treatment for alcohol withdrawal.

DESIGN

Survey.

SETTING

Inpatient alcoholism treatment programs in the United States.

PARTICIPANTS

Medical directors of 176 (69%) of 257 eligible programs randomly selected from a national listing.

RESULTS

The medical directors estimated that of all inpatients treated for alcohol withdrawal at the programs, 68% received one of the following medications. Benzodiazepines, including the long-acting chlordiazepoxide (33%) and diazepam (16%), and less frequently the short-acting oxazepam (7%) and lorazepam (4%), were the most commonly used agents. Barbiturates (11%), phenytoin (10%), clonidine (7%), beta-blockers (3%), carbamazepine (1%), and antipsychotics (1%) were less frequently given. Drug was most often given on a fixed dosing schedule with additional medication "as needed" (52% of the programs). Only 31% of the programs routinely used a standardized withdrawal severity scale to monitor patients. Mean duration of sedative treatment was three days; inpatient treatment, four days. Use of fixed-schedule regimens was associated with longer sedative treatment (mean four vs three days, p < 0.01). Northeast census region location and psychiatrist program director were significantly associated with longer sedative and inpatient treatment duration.

CONCLUSIONS

The most commonly reported regimen for alcohol withdrawal included three days of long-acting benzodiazepines on a fixed schedule with additional medication "as needed." Standardized monitoring of the severity of withdrawal was not common practice. The directors reported using a variety of other regimens, some not known to prevent the major complications of withdrawal. Although geographic location and director specialty were significantly associated with treatment duration, much of the variation in treatment for alcohol withdrawal remains unexplained.

The relation of gastroesophageal reflux disease and its treatment to adenocarcinomas of the esophagus and gastric cardia

OBJECTIVE

To examine the relationship of gastrointestinal disorders and their treatment to the risk of adenocarcinomas of the esophagus and gastric cardia (AEC).

DESIGN

A medical record-based case-control study, with data collected on a standardized form by a trained abstractor, blind to the case-control status.

SETTING

A large prepaid health plan.

SUBJECTS

Case patients were plan members newly diagnosed with histologically confirmed AEC from 1986 to 1992. For each of the 196 eligible case patients, one control was selected who matched for membership at time of diagnosis, sex, year of birth, and duration of membership.

MAIN OUTCOME MEASURES

Association between AEC and history of gastroesophageal conditions and their treatment. Conditional logistic regression procedures were used for calculation of odds ratios (ORs) and corresponding 95% confidence intervals (Cls), with adjustment for race, smoking status, and body mass index. Medications were grouped into H2 antagonists (cimetidine, ranitidine, famotidine, and nizatidine) and anticholinergics (propantheline bromide, dicyclomine hydrochloride, Donnatal [combination of atropine sulfate, hyoscyamine sulfate, phenobarbital, and scopolamine hydrobromide], and Librax [combination of chlordiazepoxide hydrochloride and clidinium bromide]).

RESULTS

Significant twofold or greater risks of AEC were associated with a history of esophageal reflux, hiatal hernia, esophagitis/esophageal ulcer, and difficulty swallowing. The ORs increased with increasing number of these conditions. Although a fourfold risk was linked to four or more prescriptions for H2 antagonists, the risk was reduced to 1.5 (95% Cl, 0.4 to 5.4) after adjusting for the predisposing conditions. Further analysis revealed that the excess risk was restricted to persons with a history of gastroesophageal reflux and related conditions. No association was observed for overall use of anticholinergics. However, after adjustment for predisposing conditions, ORs decreased with increasing number of prescriptions for anticholinergics (P for trend = .08)

CONCLUSIONS

This study provides reassuring findings that use of H2 antagonists and anticholinergics does not increase AEC risk. It also quantifies the elevated risk of AEC associated with gastroesophageal reflux disease. Further research into reflux disease and the production of premalignant epithelial changes may help elucidate carcinogenic mechanisms and measures aimed at early detection and prevention of AEC.

Trends in the management of alcohol withdrawal syndrome

Alcohol use among head and neck cancer patients is common. Alcohol withdrawal (especially delirium tremens) poses significant potential morbidity to postsurgical patients. Treatment with newer benzodiazepines (BZDs) such as lorazepam and midazolam has become more widespread, and mortality rates from severe alcohol withdrawal have decreased in recent years. The authors retrospectively studied 102 patients with a diagnosis of alcohol withdrawal, including 20 patients undergoing surgery for cancer of the head and neck. There were 81 men and 21 women, with a mean (+/- standard deviation [SD]) age of 52.3 (+/- 16.1) years. Many of these patients (46%) were treated with more than one BZD or other neuroleptic, while 49% received single agent therapy of either chlordiazepoxide (26%) or lorazepam (23%). Delirium tremens occurred in 12% of all patients undergoing withdrawal and in 10% of head and neck cancer patients, with a mortality rate of 9% and 0%, respectively. Single agent use was successful in greater than 95% when either lorazepam or chlordiazepoxide was used. Instances of combination treatment where older BZDs were used yielded a 69% success rate. The higher complication rate and lower treatment success with combination treatment was multifactorial. Optimal management of the alcohol withdrawal syndrome requires an understanding of its pathophysiology and the principles of its prevention along with a familiarity of BZD pharmacokinetic drug profiles. The authors present a treatment plan which is cost-effective, keeps morbidity low, and should allow a continued decreasing trend in mortality rates from delirium tremens.