Search

Assess (the situation) From the start of 2021, as the UK entered another COVID19 lockdown, we noticed a stark increase in the numbers of patients presenting with, or developing, Delirium Tremens (DTs). While historically, it had been rare to see DTs within our organisation, it became a frequent occurrence and concerns were raised about staff safety and adverse outcomes for patients. Diagnose (identify the problem) We (Alcohol Care Team) identified a knowledge gap in the recognition, treatment and nursing management of acute alcohol withdrawal amongst ward staff which was contributing to the onwards progression of DTs in patients. Plan Using our Trust guidelines for alcohol withdrawal and team expertise, we developed a nursing care plan for patients experiencing acute alcohol withdrawal, outlining optimal care and highlighting key elements of the Trust policy. Implement (deliver the plan) We used the care plan as a framework to guide informal teaching to staff on the Gastro/Hepatology wards. Furthermore, we made ourselves increasingly available when patients were in DTs and prioritised supporting staff in the hands on/active management of patients in DTs (akin to a low dose, high frequency approach, Jhpiego 2016)1 in order to maintain safety, optimise patient care and demonstrate clinical leadership. Evaluate (did the plan work? Where are we now?) The care plan has been well received by staff. It is due to be submitted through our internal governance structure in order for it to be used as a clinical tool in practice. (Figure Presented).

West Nile neuroinvasive disease (WNND) is a rare and severe manifestation of West Nile virus (WNV) infection that occurs in less than 1% of infected persons. It should be considered in patients who present with fever, neurological symptoms, and a history of recent outdoor activity where mosquitoes were active. This article highlights a case of a 55-year-old man whose history and symptoms of WNND were confounded with an alternate diagnosis, acute alcohol withdrawal. An overview of WNV infections, and important historical clues and objective findings characteristic of neuroinvasive disease, is discussed to increase readers' knowledge of WNV and awareness of when to consider WNND in the diagnostic differential.

Background Proton magnetic resonance spectroscopy (1 H-MRS) studies have demonstrated abnormal levels of a variety of neurometabolites in inpatients/outpatients with alcohol use disorder (AUD) following acute alcohol withdrawal relative to healthy controls. In contrast, few studies have compared neurometabolite levels between less severe, treatment-naive AUD individuals and light drinkers (LD) or related them to recent alcohol consumption. The present study compared neurometabolite levels between treatment-naive AUD and LD individuals. Methods Twenty treatment-naive individuals with AUD and 20 demographically matched LD completed an 1 H-MRS scan, approximately 2.5 days following their last reported drink. 1 H-MRS data were acquired in dorsal anterior cingulate (dACC) using a 2-dimensional J-resolved point-resolved spectroscopy sequence. dACC neurometabolite levels, with a focus on glutamate, glutamine, and GABA, were compared between AUD and LD participants. The associations between metabolite levels and recent drinking were explored. Results AUD participants had significantly lower concentrations of GABA (Cohen's d = 0.79, p = 0.017) and glutamine (Cohen's d = 1.12, p = 0.005), but not glutamate (Cohen's d = 0.05, p = 0.893), relative to LD. As previously reported, AUD participants' glutamate and N-acetylaspartate concentrations were inversely associated with their number of heavy drinking days. In contrast, neither number of drinking (mean p = 0.56) nor heavy drinking (mean p = 0.47) days were associated with metabolite concentrations in LD. Conclusions The present study demonstrated significantly lower levels of prefrontal γ-aminobutyric acid and glutamine in treatment-naive individuals with AUD relative to LD. Whether these findings reflect the neurotoxic consequence and/or neuroadaptive response of alcohol consumption versus a predrinking trait, and therefore a more durable neurochemical disturbance, awaits elucidation from longitudinal studies.

Background: Alcohol dependence is a common social problem which may be associated with other risk factors and co-morbidities. Abrupt cessation of alcohol intake may provoke an acute alcohol withdrawal phase with varying degrees of signs and symptoms. In conventional medical system, specific pharmacological interventions are used for management of Acute Alcohol Withdrawal (AAW). There exists a need to explore safe and holistic treatment of AAW. The present work reports the results of a prospective, observational, exploratory, multicentre trial (2008-2011) to assess the role of Homoeopathy in AAW. Materials and Methods: Individualised Homoeopathy was given to 112 patients reporting with AAW. The clinical assessment was done for 05 days using Clinical Institute Withdrawal Assessment Scale of Alcohol-Revised (CIWA-Ar). Post-withdrawal phase, quality of life of patients was assessed at end of 01 st , 03 rd and 06 th month using World Health Organisation quality of life (WHOQOL)- BREF. Results and Analysis: There was a significant decrease in CIWA-Ar mean scores and increase in quality of life score (P < 0.001). The most common remedies used were Arsenicum album, Lycopodium clavatum, Belladonna, Nux vomica and Pulsatilla. Conclusion: The results of current observational pilot study suggest the promising use of Homoeopathy in the management of acute alcohol withdrawal. Further studies with large sample size and rigorous design are warranted.

Patients suffering from mental disorders are often not treated on an equal basis with patients suffering from organic diseases. In Germany, for example, alcohol-dependent patients will be detoxifi ed on a clinical ward to ensure that they survive acute alcohol withdrawal; however, medical insurances often do not cover treatment costs for a therapy for the addictive behavior that underlies the acute alcohol problem. While patients suffering from diabetes mellitus can also display personally harmful choices and, for example, consume sugar although they know that this is detrimental for their health, medical insurances pay for the acute hyperglycemic shock treatment as well as for dietary and medical treatment of the underlying disorder, diabetes mellitus. Not so in alcoholism, where emergency treatment for delirium tremens (a form of severe alcohol withdrawal) will be covered but not psychosocial and medical treatment for the addiction itself. Problems of stigmatization and discrimination obviously play a role in this context. However, nicotine addiction is an example that clearly shows that the disease status of mental disorders itself is controversial—Is nicotine

Background: Previous data in both rat and mouse genetic models suggest that there is a genetic relationship between acute alcohol withdrawal responses and innate alcohol drinking behavior. The purpose of the present study was to examine whether acute alcohol withdrawal responses, as measured by acoustic startle and prepulse inhibition (PPI) of acoustic startle, may be genetically related to innate differences in alcohol preference in 2 mouse lines selectively bred for high (HAP1 and HAP2) or low (LAP1 and LAP2) alcohol preference. Line differences in startle responses at baseline, prior to alcohol or saline treatment, were also measured. Methods: Alcohol-naive, male and female HAP1 (n = 35) and LAP1 (n = 32) and HAP2 (n = 43) and LAP2 (n = 40) mice were tested under baseline conditions and during withdrawal from a single injection of 4.0 g/kg alcohol or equal volume of saline at 4, 8, and 12 hours post-injection. Results: On most trial types, baseline startle responses and PPI were greater in both HAP lines than in both LAP lines, and startle responses were greater in males than in females. During acute alcohol withdrawal, both male LAP lines, and LAP1 females, showed reduced startle responses at the 4-hour time point during acute alcohol withdrawal. In contrast, both HAP1 males and females showed a trend toward enhanced startle at 4 hours in withdrawal. No clear differences in PPI during withdrawal were evident. Conclusions: These findings indicate good evidence for a genetic relationship between greater baseline acoustic startle responses and PPI and high alcohol preference. Modest support for a genetic correlation between low alcohol preference and reduced startle responses at 4 hours in withdrawal was found in male mice. The suppression in acoustic startle during acute alcohol withdrawal in male LAP lines but not in male HAP lines suggests that a genetic propensity toward low alcohol preference may be related to greater sensitivity to alcohol as measured by acoustic startle responses during acute alcohol withdrawal.

Negative affect promotes dysregulated alcohol consumption in non-dependent and alcohol-dependent animals, and cues associated with negative affective states induce withdrawal-like symptoms in rats. This study was designed to test the hypotheses that: (1) the kappa-opioid receptor (KOR) system mediates phenotypes related to alcohol withdrawal and withdrawal-like negative affective states and (2) cues associated with negative affective states would result in dysregulated alcohol consumption when subsequently presented alone. To accomplish these goals, intracerebroventricular infusion of the KOR antagonist nor-binaltorphimine (nor-BNI) was assessed for the ability to attenuate the increase in 22-kHz ultrasonic vocalizations (USVs) associated with alcohol withdrawal and KOR activation in adult male wistar rats. Furthermore, cues associated with a KOR agonist-induced negative affective state were assessed for the ability to dysregulate alcohol consumption and the efficacy of intracerebroventricular KOR antagonism to reduce such dysregulation was evaluated. KOR antagonism blocked the increased number of 22-kHz USVs observed during acute alcohol withdrawal and a KOR agonist (U50,488) resulted in a nor-BNI reversible increase in 22-kHz USVs (mimicking an alcohol-dependent state). Additionally, cues associated with negative affective states resulted in escalated alcohol self-administration, an effect that was nor-BNI sensitive. Taken together, this study implicates negative affective states induced by both alcohol withdrawal and conditioned stimuli as being produced, in part, by activity of the DYN/KOR system.

Background Mice selectively bred for high or low withdrawal to acute alcohol differ on a number of traits, including consumption of alcohol, conditioned place preference for alcohol, and sensitivity to alcohol-induced locomotor activity. One trait that has not been examined in these mice is behavioral inhibition. Methods High and low alcohol withdrawal mice (second replicate: high and low acute alcohol withdrawal [HAW-2/LAW-2]) were trained and tested in a Go/No-go task. Mice were administered 0.0, 0.5, 1.0, and 1.5 g/kg ethanol (EtOH) on 3 occasions according to an incomplete Latin Square. A separate cohort of C57BL/6J (B6) and DBA/2J (D2) mice (the progenitor strains for HAW-2/LAW-2 mice) underwent the same protocol, using the same EtOH doses. Results HAW-2 and LAW-2 mice did not differ in behavioral inhibition at baseline, although LAW-2 mice did have higher overall levels of responding in the task. EtOH did not alter behavioral inhibition in these mice. However, it did decrease responses to the Go cue, and this effect was greater in HAW-2 mice than in LAW-2 mice. D2 mice had lower behavioral inhibition than B6 mice at baseline, and EtOH slightly decreased behavioral inhibition in both strains. Conclusions The findings with D2 and B6 mice generally fit with the existing literature. However, the lack of a difference in behavioral inhibition between HAW-2 and LAW-2 mice was unexpected, as well as the absence of any effect of these doses of EtOH on behavioral inhibition in these mice. Nonetheless, the findings do suggest that selectively breeding for high or low withdrawal to acute alcohol can lead to differences in operant behavior in the Go/No-go task.

Hong SB, Kim HJ, Huh JW, et al.: A cluster of lung injury associated with home humidifier use: clinical, radiological and pathological description of a new syndrome. Thorax 2014; 69: 694–702.

[Extract] Impacts of alcohol consumption on health and wellbeing in remote Indigenous communities are well documented. In response, governments have applied supply and demand reduction programs, including the "Meeting Challenges, Making Choices" program, which has lowered the rate of serious injury. Although a pattern of heavy, episodic drinking has been documented, the nature of physical dependence in relation to acute alcohol withdrawal syndrome is uncertain. We report the results of sudden, temporary removal of alcohol in a small Indigenous community.

Aims: The brain volume of chronic drinkers is known to partially recover with abstinence from alcohol. To investigate the relative contribution of grey and white brain matter to this process, magnetic resonance imaging and brain tissue segmentation was used to study brain tissue in acute alcohol withdrawal and abstinence in seven alcohol-dependent men. Methods: The patients were studied on three occasions; within 48 h after the last drink and approximately one month and two and a half months later. Total brain tissue class volumes (grey matter (GM) and white matter (WM) and cerebrospinal fluid (CSF)) were measured. Eleven healthy volunteers were scanned twice to serve as a control group. The alcohol-dependent patients were investigated with regard to drinking variables, neuropsychological performance and blood biochemistry. Results: In the alcohol-dependent patients, intracranial volume and total GM volume did not change between scan occasions, except in a single patient who demonstrated a GM increase of 4.8% (4.2% relative volume) between scans 2 and 3. For all patients, the increase in total WM volume ranged between 1.9 and 22.4% (absolute volumes) and 2.1 and 21.2% (relative volumes). Between scans 2 and 3, the increase in total WM volume ranged between 0.3 and 13.2% (absolute volumes), and between 1.5 and 14.0% (relative volumes). One patient resumed drinking and was investigated a second time during acute withdrawal. In this patient, the measured decrease of 8.1 and 8.5% of absolute and relative WM volumes corresponded to the size of the volume increase between scans 1 and 2. CSF, GM and WM volumes in the healthy subjects were constant over time. Conclusions: The results demonstrate that changes in brain volume during short-term abstinence in chronic alcohol-dependent patients are confined to the WM. The time limit of WM volume restitution is variable and continues longer than 3 weeks after withdrawal.

Early in my medical career, I was caring for a middle aged man with a disabling chronic disease that had left him bedbound. While he could barely open his mouth to eat, he could open it enough to drink, as evidenced by his multiple admissions with acute alcohol withdrawal. On this occasion, he had been admitted with an exacerbation of his underlying illness, accompanied by alcohol withdrawal and aspiration pneumonia. This time he did not seem his usual self. He had lost a lot of weight and had the …

Introduction Acute alcohol withdrawal (AAW) is an increasingly frequent cause for hospital admission in the UK. NICE guidance (2010) recommends the use of a symptom triggered regimen (STR) rather than a fixed-dose regimen of benzodiazepines for the management of AAW. The aim of this study is to observe the effects of the introduction of a STR protocol as part of the introduction of a specialist Alcohol Liaison Team (ALT) in a large teaching hospital trust. Methods Data were collected prospectively on all patients admitted for management of AAW during two 3-month periods; before and after the introduction of a symptom triggered regimen. The Clinical institute for Withdrawal Assessment for alcohol scale (CIWA-Ar) was used to assess AAW objectively. The introduction of the STR was overseen by an ALT consisting of a specialist nurse and a consultant at both hospital sites in the trust. Results In the initial period, 102 patients were managed using a fixed-dose regime. Median length of stay (LoS) was 4.0 days (IQR 2–6 days). Median total chlordiazepoxide dose was 260 mg (IQR 120–490 mg). After introduction of STR, 119 patients were included. Median length of stay was 3.0 days (IQR 1.5-5.0 days). Median total chlordiazepoxide dose was 200 mg (IQR 55–450 mg). Age, gender and comorbidities in the before and after groups were comparable. The reduction in length of stay and total chlordiazepoxide dosage following introduction of the STR protocol were statistically significant (p Conclusion Introduction of a STR protocol for management of acute alcohol withdrawal was associated with a reduction in the length of stay and total benzodiazepine dose required. A specialist ALT facilitated the introduction of the STR at two hospital sites in a large teaching hospital trust. The reduction in length of stay alone could contribute to potential cost savings to the trust of around £280 000 per annum. This justifies the presence of an alcohol liaison team in the trust and supports the recommendations of the NICE guidelines. Competing interests None declared.

알코올금단섬망 또는 진전섬망(delirium tremens)은 알코 올의존증의 심각한 후유증이다. 과거에는 진전섬망은 높은 사망률을 보였으나, 알코올금단의 치료 초기부터 benzodiazepine을 투약하면서 진전섬망에 의한 사망률이 감소하였다. 진전섬망을 미리 예측하여 이를 예방하기 위해서 진전섬 망과 연관된 위험인자를 찾으려는 임상연구가 지속되고 있 으며, 다양한 결과를 보이고 있다. 한 연구는 일일 음주량 그 리고 금단 삽화의 횟수가 진전섬망의 위험인자라고 보고하 였다. 종합병원 입원환자를 대상으로 한 조사에서는 관상 동맥질환, 감염, 외상, 또는 수술 등의 급성 신체질환이 진전 섬망의 발생과 관련이 있었다. 16개월 동안 334명의 알코 올의존 환자를 대상으로 진전섬망의 위험인자를 조사하고 회귀분석을 한 연구에서 진전섬망의 유발과 관련된 위험인 자는 병발된 염증성질환, 심박수의 증가, 알코올금단 증후, 알코올금단 경련의 과거력 및 진전섬망의 과거력 등이라고 하였다. 이 보고에서는 해독 중에 있는 환자에서 이 위험인 자를 전혀 보이지 않은 경우는 진전섬망이 나타나지 않았다 고 한다. 또한 이 연구에서는 음주 기간 및 음주량은 진전섬 망의 위험과 연관을 보이지 않았다. 1987년부터 2003년까지 스페인에서 시행한 코호트 연구에서는 알코올금단 경련의 과거력, 수축기 혈압의 증가, 그리고 체온의 증가 등이 진전 섬망과 연관을 보였으나 회귀분석에서는 이들 인자가 진전 섬망을 예측하는 정도는 높지 않다고 하였다. 또한 이 연구 에서는 환자에서 동반된 급성기 내과질환이 진전섬망의 발 생에는 영향을 보이지 않는다고 하였다. 앞선 연구들은 진전섬망과 관련 있는 인자에 대해서 일일 ORIGINAL ARTICLE

A double-blind, randomized trial is described which was designed to compare the clinical effect of 600 mg daily of carbamazepine (Tegretol®) and of tiapride (Sereprile®) in hospitalized patients with pre-delirium tremens. Physicians' assessment of patients' progress was made following 2, 4 and 7 days of treatment. Of the sixty patients admitted to the study, five dropped out for various reasons, leaving fifty-five patients who completed the study. Both drugs were effective in the treatment of alcohol withdrawal symptoms; no significant difference was found between the two treatments with respect to total symptoms' score and visual analogue scale assessment. Carbamazepine gave faster relief of symptoms and demonstrated a preferential action on symptoms like fear and hallucinations. No case of delirium tremens was observed in those patients who completed the trial.

The acute alcohol withdrawal syndrome is a disease of many different symptoms. Although the metabolism of ethanol is well-known, no specific treatment of the withdrawal syndrome has been developed. When assessing the therapeutic efficacy of drugs in this syndrome one of the main symptoms to be followed is sleep disturbances, because inability to sleep often maintains the drinking cycle. Besides different target symptoms, the visual analogue scale and the ability to work are useful parameters. The assessment of the efficacy relies mainly on subjective parameters and comparisons with placebo are needed.

An open study was carried out in 21 chronic alcoholics with severe withdrawal symptoms and incipient delirium tremens to evaluate the efficacy of adjuvant treatment with intramuscular lorazepam (5mg). All symptoms subsided within 2 hours after a single injection and remained under control with oral lorazepam (mean daily dose 7 mg). No adverse reactions attributable to lorazepam were observed.

Background Alcohol consumption can have adverse social, legal, occupational, psychological, and medical consequences. The prevalence of alcohol-use disorders is high in Emergency Departments. The novel establishment of a Quick Diagnostic Unit (QDU) in an ED setting has allowed expeditious and focused, medically supervised acute alcohol withdrawal. The purpose of the study was to describe the alcohol-use disorder clientele and treatment in this new setting.