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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.

Alcohol withdrawal syndrome is a common and life-threatening condition in patients suffering from alcohol use disorder. Treatment of this syndrome is challenging, especially in patients that are critically ill, either because of withdrawal symptoms or underlying conditions. For the treatment, several pharmacological agents exist, such as benzodiazepines, barbiturates, or dexmedetomidine. Nonetheless, as alcohol withdrawal syndromes can occur in every clinical setting, it is necessary to provide a guideline for clinicians confronted with this syndrome in varying clinical contexts.The authors provide a systematic review of the literature found in PubMed and Embase following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.For the treatment of alcohol withdrawal syndrome, medications targeting the GABA system are preferred. Benzodiazepines are regarded as the gold standard. However, as many adjunct therapeutic options exist, it is essential to find symptom-triggered approaches and treatment protocols for the variety of clinical contexts. Apart from that, it is necessary to compare protocols toward clinical variables rather than investigating medications that are in use for the treatment of alcohol withdrawal syndrome.

Purpose: To characterize physicians’ stated practices in the treatment of patients with severe acute alcohol withdrawal syndrome (sAAWS) and to use intravenous (IV) phenobarbital as an adjuvant treatment for sAAWS. Methods: A multidisciplinary, cross-sectional, self-administered survey at 2 large academic centers specializing in inner-city healthcare. Results: We analyzed 105 of 195 questionnaires (53.8% response rate). On average, clinicians managed 32 cases of AAWS over a 6-month period, of which 7 (21.9%) were severe. Haloperidol (Haldol; 40 [39%]), clonidine (Catapres; 31 [30%]), phenobarbital (Luminal, Tedral; 29 [27%]) and propofol (Diprivan; 29 [28%]) were the most commonly used adjuvant medications for sAAWS. Sixty-three (60%) of respondents did not use phenobarbital in practice. Of phenobarbital users, 23 (55%) respondents used it early in patients who were refractory to symptom-triggered benzodiazepine treatment. Others waited until patients experienced seizures (5 [10%]) or required intensive care unit admission (8 [18%]). Respondents who used phenobarbital preferred to use the IV versus oral form (66% vs 29%, P < .001). Most respondents, however, were unfamiliar with the pharmacokinetics, side effects, contraindications, and evidence supporting phenobarbital use for sAAWS. Although many respondents (64 [61%]) expressed discomfort using phenobarbital, 87 (83%) expressed comfort or neutrality with enrolling patients in a trial to evaluate IV phenobarbital in sAAWS. Conclusions: Considerable stated practice variation exists in how clinicians treat patients with sAAWS. Our findings support conduct of a pilot trial to evaluate IV phenobarbital as an adjuvant treatment to symptom-triggered benzodiazepines for sAAWS and have informed trial design.

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.

Alcohol and other drug abuse has become a national crisis with approximately 26% of general medical patients having alcohol-related problems. New nurses and social workers are often not prepared to care for patients with severe alcohol withdrawal symptoms because they lack experience in actual crisis situations. The purpose of this study was to prepare nursing and social work students to care for a patient undergoing an acute alcohol withdrawal process. Nine groups of 8-10 students participated in a 2.5-hour simulation event that included an alcohol withdrawal seizure, team meeting, and discharge of the patient. Students recognized the importance of all the professional roles and how each professional benefits patient care. Before the simulation, students thought they were prepared to care for patients experiencing alcohol withdrawal; however, the crisis of an alcohol seizure decreased the student's ability to perform skills and communicate effectively. These findings suggest that new nurses and social workers may not be prepared to care for the acute alcohol withdrawal patient.

Objectives Although sleep disturbances are prominent during alcohol withdrawal, less is known about the specific components of sleep that are disturbed prior to and during acute detoxification. This study aimed to determine whether specific sleep components are affected prior to and during acute detoxification and their relationship to psychological distress. Methods Twenty-nine participants were recruited from a residential detoxification service in Melbourne, Australia, and completed both subjective methods of sleep and distress, in addition to wearing an actigraphy device. Results Daytime dysfunction, sleep quality, and sleep disturbances were the components that were most disturbed in the month prior to admission, and poor sleep efficiency was detected during acute withdrawal using actigraphy. A significant association was found between sleep and psychological distress in this group. Conclusions Specific disturbances in sleep are experienced prior to and during acute alcohol withdrawal, suggesting that tailored interventions may be effective in the treatment of sleep deficits during these periods.

Benzodiazepines are first-line therapy for treatment of alcohol withdrawal syndrome (AWS). Longer acting benzodiazepines may provide a smoother withdrawal, while shorter-acting benzodiazepines may be preferred in patients who are elderly or have significant hepatic impairment. Front loading, fixed dose and symptom-triggered benzodiazepine dosing strategies may be used when treating moderate to severe AWS in the hospital setting. Other drugs may be appropriate as adjuncts to benzodiazepine therapy or in the treatment of mild to moderate AWS.

Ethanol causes diverse neurologic conditions caused by acute and chronic brain damage. This review provides an overview of Wernicke encephalopathy and other ethanol-related brain changes, such as chronic brain atrophy, Marchiafava-Bignami disease, osmotic demyelination syndrome, chronic hepatic encephalopathy, and acute alcohol withdrawal. As clinical symptoms of this spectrum of diseases have nonspecific neurologic alterations, radiologists should have current radiologic information and understand the imaging findings pertaining to the pathophysiology to support diagnosis.

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.

Summary Objective To describe nursing utilisation of a purpose-designed alcohol withdrawal management chart in terms of completeness of recording assessment measures, and use of recommended dose of diazepam and observation intervals. A secondary objective was to compare utilisation between the emergency department short stay ward and hospital wards. Methods A retrospective review was performed on data collected on a standardised chart for management of alcohol withdrawal. The convenience sample was 200 consecutive patients admitted through the emergency department from October till December 2007 and placed on the alcohol withdrawal chart. Assessment items, drug doses, observation intervals and admitting ward were recorded. Deviations from recommendations were calculated. Results A total of 3096 assessments were recorded. There was 85% compliance in completing assessment items and 84% compliance with recommended dose of diazepam. Incomplete assessments were mainly due to the patient being sleeping or because the patient's temperature was not recorded. There was similar performance between the short stay ward and hospital wards. Compliance with observation intervals was much lower at 49%, with observations being made early as well as late. Conclusions High compliance was achieved with the assessment tool and dosing regime, but not with recommended observation intervals. High compliance may be related to the brevity and standardisation of assessment and use of a single page format but requires further study.

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

This article describes a case of koro-like symptoms from Oman associated with alcohol withdrawal and illustrates how the socio-cultural practices of Ramadan-fasting affected the patterning and timing of presentation of severe alcohol withdrawal symptoms. The patient was severely distressed by the delusion that his penis had been amputated. The acute anxiety involving this delusion appears to be conceptually and phenomenologically similar to koro.

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.

In the elderly population, alcohol-related problems may be misinterpreted as normal consequences of aging. However, alcohol is a commonly abused substance among older adults, and age-related changes predispose these patients to a greater sensitivity to its effects. All older patients should be screened for alcohol dependence and abuse on admission to an acute care facility. If identified, the plan of care must include close observation for acute alcohol withdrawal and prompt intervention if it occurs.

Collaborative drug therapy management (CDTM) is a method for developing a patient-centered practice in which the pharmacist's activities are integrated with those of other health care providers. The goals of this continuing feature are to refine the concept of CDTM and provide patient-care applications from the authors' experience in Washington state. Questions or suggestions should be addressed to Timothy S. Fuller, FASHP, Fuller and Associates, 1948 Boyer Avenue East, Seattle, WA 98112-2924 (tel.206-860-8308). E-mail: timfuller@kendra.com

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.

Scenario: A 53-year-old male arrived at the mentally ill/chemically addicted unit with acute alcohol withdrawal. His electrocardiogram (ECG) showed the cardiac rhythm below. The patient was a recovering alcoholic but a week earlier had left his family and checked into a motel to drink alcohol. He had stopped eating and had been drinking continuously when he noticed chest palpitations and shortness of breath the day before Thanksgiving. However, he delayed going to the hospital until after Thanksgiving because he wanted to watch the football games. Before the diagnosis of alcoholism 2 years earlier, the business executive had no medical issues; in fact, he had been very healthy and had run marathons. A regular feature of the American Journal of Critical Care, the ECG Puzzler addresses electrocardiogram (ECG) interpretation for clinical practice. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature.

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.

Acutely intoxicated chronic alcoholics were studied in a double-blind experiment to assess the influence of clonidine on short-term memory. The study suggests clonidine may delay recovery of short-term memory function. Since clonidine is widely used in the treatment of acute alcohol withdrawal, clinicians should be aware of this potential side effect.

People who suffer acute alcohol withdrawal should be admitted to a hospital if they have a concurrent medical or surgical complication or severe symptoms. Careful assessment, supportive care, and pharmaco­ therapy, especially loading with a long half-life benzodiazepine such as diazepam, are the essential components of treatment. Patients with milder withdrawal can be managed effectively and safely on an out-patient basis or with nonmedical treatment. The need for pharmacotherapy should be determined on an individual basis. The management of alcohol with­ drawal includes offering and initiating long-term treatment to reduce alcohol consumption.

[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.

We have previously hypothesized that increased sensitivity to the dysphoric-like or aversive effects of alcohol withdrawal following an initial exposure to alcohol might be associated with a genetic propensity to avoid alcohol. A decrease in brain reward function, as measured by an elevation in intracranial self-stimulation (ICSS) reward threshold, is one of the few methods available to model dysphoric-like or aversive effects of drug withdrawal in rats. We compared brain reward function during withdrawal following an initial exposure to alcohol in alcohol-naive rats selectively bred for high (HAD1 line) versus low (LAD1 line) voluntary alcohol consumption. Male HAD1 (n = 5) and LAD1 (n = 6) rats were implanted with unilateral electrodes in the medial forebrain bundle and trained to bar press for delivery of a 100 μA current that varied in frequency from 45 to 200 Hz. Responding for ICSS was generally stable within subjects across multiple experimental sessions on a given day and across several consecutive days prior to alcohol or water administration. ICSS responding was assessed in both rat lines prior to and at 12, 14, 16, 18, 20, and 24 h following a single intragastric infusion of alcohol (4.0 g/kg body weight) or water. Rats of the LAD1 line, but not those of the HAD1 line, exhibited a decrease in brain reward function as evidenced by a decrease in bar-press responding for ICSS and an increase in ICSS stimulation threshold during alcohol withdrawal. The results suggest that rats selectively bred for low alcohol drinking may experience dysphoric-like effects during withdrawal from an initial exposure to alcohol, while rats selectively bred for high alcohol drinking may not.

Background: We have previously reported an association between greater alcohol withdrawal magnitude after a single alcohol exposure and a genetic predisposition toward low alcohol drinking in rats selectively bred for differences in alcohol intake when acoustic startle reactivity to a tone stimulus was used to index acute alcohol withdrawal. The purpose of this study was to examine whether the quality of the acoustic startle stimulus (noise versus tone) is important for detecting a genetic relationship between alcohol withdrawal magnitude and alcohol drinking behavior. Methods: Alcohol-naive male rats selectively bred for high alcohol intake [alcohol-preferring (P), high-alcohol-drinking (HAD)1, and HAD2] or low alcohol intake [alcohol-nonpreferring (NP), low-alcohol-drinking (LAD)1, and LAD2] received a single intragastric infusion of water or alcohol (4.0 g/20.3 ml/kg; 25% v/v), and acoustic startle test sessions were given at 14, 16, 18, 20, and 24 hr after infusion. Each test session consisted of a 5-min acclimation period followed by random presentation of various white noise stimuli (90, 100, 110, and 120 dB.) Results: Line differences in acoustic startle magnitude under control conditions were present in all three pairs of selectively bred lines; P rats showed a greater startle magnitude relative to NP rats, whereas both LAD lines showed a greater startle magnitude relative to both HAD lines. During alcohol withdrawal, the P, HAD1, and HAD2 lines showed enhanced startle magnitude compared with their water-treated controls. No change in startle magnitude during alcohol withdrawal was found in the NP, LAD1, or LAD2 lines. Conclusions: In contrast to our prior findings, these results showed a genetic association between high alcohol drinking and a greater startle response magnitude to a noise stimulus during alcohol withdrawal. It seems that the genetic association between alcohol drinking and alcohol withdrawal, as assessed by the acoustic startle response, depends on the quality of the acoustic startle stimulus.

Studies on the neuropsychological performance in detoxified alcoholic patients often begin by acknowledging that there is a cognitive impairment to be found. Only little attention has been paid to date to the question as to how acute alcohol withdrawal might affect cognitive functions. Twenty-nine alcohol-dependent inpatients, nine in moderate alcohol withdrawal, treated with carbamazepine (group 1), 10 in mild alcohol withdrawal without pharmacological treatment (group 2), 10 in mild alcohol withdrawal with carbamazepine treatment (group 3) and 31 healthy subjects as controls (group 4) underwent repeated investigations using memory tests. The tests were performed on the first, third, seventh and fourteenth days of withdrawal. Immediate free recall of a word-list was impaired in the three patient groups in comparison with the control group on the 1st day. Thereafter no significant differences could be revealed between patients and controls. In a word-list recognition test the memory functions were not impaired in group 1 and group 2 in comparison with the control subjects. However, patients in group 3 showed impairment in this recognition test in comparison with the healthy subjects on the first and third days. The present study suggests that acute alcohol withdrawal impairs memory functions, especially free recall. This should be considered in treatment interventions in the early days of withdrawal.

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 …

Chlormethiazole is an extremely useful and flexible drug for use in the management of acute alcohol withdrawal. It is not a treatment for alcohol abuse and should not be used in this patient group, other than in the withdrawal period, and then for less than 10 days. It is extremely safe when used correctly by practitioners familiar with its properties. Problems can arise, however, if used by practitioners unaware of its limitations and the precautions needed for safe prescribing.

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