Symptom profile of alcohol withdrawal delirium: factor analysis of Delirium Rating Scale-Revised-98 version

ABSTRACT

Background: The symptom profile of alcohol withdrawal delirium (AWD), relative to deliriums of other etiology, remains uncertain. Objective: To evaluate the factor structure of symptoms in patients with AWD, as assessed by the Delirium Rating Scale-Revised-98 (DRS-R-98). Method: A total of 112 patients aged 18 years or more with AWD were assessed on DRS-R-98. Results: The mean age of participants was 44.2 years. About two-third of the patients developed delirium within 24 hours of the last intake of alcohol and the mean duration of delirium at the time of assessment was 3.9 days. In 46% of cases the delirium was attributed solely to alcohol withdrawal; in the remaining subjects alcohol withdrawal was a major contributory factor. Three separate principal component analysis (whole sample, pure AWD and AWD with associated etiologies) were carried out. In all the factor analyses, one of the factors included cognitive symptoms (attention, orientation and visuospatial disturbances) along with or without short- and long-term memory impairment; the second factor included motoric symptoms along with sleep-wake cycle disturbances; the third factor included psychotic symptoms. For the whole group and subgroup of AWD with associated etiologies, items of higher level thinking (i.e. language disturbances and thought process abnormality) loaded along with cognitive symptoms. In pure AWD group, these items along with memory disturbances loaded with psychotic symptoms. Conclusions: Results of the current factor analyses suggest that the factor structure of pure AWD is different from AWD with associated etiologies. Hence, attention to the symptom profile of patients with AWD may provide clues to delirium etiology.     

Risk factors for delirium tremens in patients with alcohol withdrawal syndrome in a hospital setting

BackgroundThe clinical expressions of alcohol withdrawal syndrome (AWS) may vary and the factors determining these variations are not well-known. It would be useful to have a set of clinical tools capable of predicting which patients are likely to develop the more severe forms of the syndrome.AimTo analyse the clinical variables associated with the development of delirium tremens (DTs) in patients who were admitted to a general hospital with AWS.MethodsCohort study of AWS patients admitted to the Xeral Hospital in Lugo, Spain, between 1987 and 2003. The characteristics of patients with the syndrome who did not develop delirium tremens were contrasted with those who did. Cases presenting with DTs at diagnosis were excluded. The different clinical, epidemiological and biochemical variables reflective of alcohol consumption habits, basal health status and presentation features of syndrome were all recorded.ResultsData from 156 episodes of AWS that coursed without DTs were compared with 147 cases that coursed with it. Three independent variables for development of DTs were identified in a multivariate logistic regression model: number of seizures [1 or 2: OR 2.2 (CI 95% 1.2–3.8), p = 0.005; 3 or more: OR 2.6 (CI 95% 1.04–6.8), p = 0.04]; systolic blood pressure > 150 mm Hg [OR 1.9 (CI 95% 1.1–3.8), p = 0.03] and axillary temperature > 38 °C [OR 1.9 (CI 95% 1.05–3.5), p = 0.01]. ROC analysis revealed an area under the curve of 0.679.ConclusionThree clinical findings (seizures, blood pressure and temperature) can aid in identifying patients with AWS who are likely to develop DTs. The model's predictive capacity is not high.     

Prinzmetal's angina associated with alcohol withdrawal

A 39-year-old woman developed critical anginal attacks 2-7 days after abruptly stopping long-lasting excessive alcohol drinking. The coronary angiogram demonstrated spasms in the left anterior descending and the right coronary artery without signs of preexistent stenosis. In previous reports alcohol-related coronary spasm always followed ingestion of alcohol several hours before. Because of the time delay in this case, we suggest that not the intake but the withdrawal of alcohol was the factor provoking coronary spasm in our patient.     

Clinical profile and long-term outcome of granulomatosis with polyangiitis (GPA): A corporate hospital-based study from northern India

ObjectiveTo study the clinical profile and long-term outcome of granulomatosis with polyangiitis (GPA).MethodsRecords of patients with GPA attending our rheumatology clinic between April 2009 and February 2015 were retrieved. Clinical and laboratory data, details of treatment given and outcome were obtained and analysed. Remission and relapse were defined according to British Society for Rheumatology guidelines. Vasculitis damage index (VDI) was used for quantifying organ damage.ResultsThere were 45 patients (26 female, 19 male) with the mean age of 46 ± 12 years and median disease duration at diagnosis of 20 months. Lung, ear, musculoskeletal system, eye, nose and kidney were most frequently involved in that order. Disease was severe in 29 and limited in 16. Miscellaneous presenting features included saddle-nose deformity in 5 patients, digital gangrene in 2 and complete heart block, renal mass and renal infarction in 1 each. Tissue biopsy contributed to diagnosis in 26/30 (86%). Anti-neutrophil cytoplasmic antibody was positive in 33 (73%) patients. Prednisolone + cyclophosphamide (oral in 25, intravenous in 10) and prednisolone + rituximab were initially used for inducing remission in 35 and 4 patients, respectively. Rituximab was also used for induction in 4 patients who failed on cyclophosphamide. Mycophenolate or methotrexate were used as immunosuppressants in limited disease. Azathioprine was used for maintenance of remission. Median follow-up was 49 months. One patient died of intractable diffuse alveolar haemorrhage and stroke within 3 months. 34 patients achieved complete remission. Sustained remission (≥2 years) occurred in 24 (median 3.5 years). Major relapse occurred in 24 (53%). Of these, 3 had a second and 2 had a third relapse. Two patients relapsed after 11 years in remission. Preferred treatment for relapse included rituximab and cyclophosphamide. Mean VDI of patients in this series was 3.02.ConclusionGPA remits with standard treatment but relapses frequently, leading to substantial morbidity. Mortality is uncommon.     

Management of alcohol withdrawal delirium. An evidence-based practice guideline

BACKGROUND: Alcohol withdrawal delirium is the most serious manifestation of alcohol withdrawal. Evidence suggests that appropriate care improves mortality, but systematic reviews are unavailable. METHODS: Articles with original data on management of alcohol withdrawal delirium underwent structured review and meta-analysis. RESULTS: Meta-analysis of 9 prospective controlled trials demonstrated that sedative-hypnotic agents are more effective than neuroleptic agents in reducing duration of delirium and mortality, with a relative risk of death when using neuroleptic agents of 6.6. Statistically significant differences among various benzodiazepines and barbiturates were not found. No deaths were reported in 217 patients from trials using benzodiazepines or barbiturates. CONCLUSIONS: Control of agitation should be achieved using parenteral rapid-acting sedative-hypnotic agents that are cross-tolerant with alcohol. Adequate doses should be used to maintain light somnolence for the duration of delirium. Coupled with comprehensive supportive medical care, this approach is highly effective in preventing morbidity and mortality.     

Prolactin serum levels during alcohol withdrawal are associated with the severity of alcohol dependence and withdrawal symptoms

Background: Prolactin serum levels have been described to be elevated during alcohol withdrawal in alcohol‐dependent patients and normalize during abstinence. Alterations in prolactin levels may reflect disturbances of dopaminergic neurotransmission which is of crucial importance for alcohol‐seeking behavior. Methods: In this longitudinal observational study, we investigated prolactin serum levels in 99 male patients during the first 14 days of alcohol withdrawal and early abstinence and in 43 healthy controls. To assess the severity of alcohol dependence, the extent of withdrawal symptoms, craving, depressive symptoms, and anxiety, we employed a structured interview including psychologic measurements. Results: Prolactin serum levels were elevated during the whole study period in alcohol‐dependent patients compared to the healthy control group. Prolactin levels at admission (first day of alcohol withdrawal) were associated with the severity of alcohol withdrawal (CIWA‐Ar) and of alcohol dependence (SESA) but not with the other assessed psychologic parameters. Conclusions: The presented findings confirm that prolactin is significantly elevated in alcohol‐dependent patients during alcohol withdrawal and early abstinence, not showing a rapid decline after cessation of drinking. The association with the severity of withdrawal and dependence may reflect at least partially the individual alterations in the dopaminergic and glutamatergic pathways.     

Etiology,clinical profile,and outcome of liver disease in pregnancy with predictors of maternal mortality: A prospective study from Western India

Background

The aim of this study is to study the etiology, clinical profile, and prognostic factors related to maternal and fetal health in pregnant patients with liver disease in Western India.

Methods

This study included 103 consecutive pregnant patients with liver dysfunction from August 2013 to July 2015, who underwent regular biochemical tests, viral markers, ultrasound of abdomen, etc. and were followed up for 6 weeks postpartum or until death.

Results

Pregnancy-specific causes of liver dysfunction were found in 39 % (40/103) patients. Liver diseases were most frequent in third trimester 69.9 % (72/103). Etiologies in third trimester were viral hepatitis 36.1 % (26/72), pregnancy induced hypertension (PIH) 30.5 % (22/72), intrahepatic cholestasis of pregnancy 11.1 % (8/72), acute fatty liver of pregnancy (2/72), etc. Hepatitis E was the commonest agent among viral hepatitis 71.8 % (28/39). Causes of maternal mortality (n?=?25) were hepatitis E 40 % (10/25), PIH 32 % (8/25), and tropical diseases 20 % (5/25). Fetal mortality (n?=?31) was 38.7 % (12/31) in hepatitis E. Maternal mortality was significantly associated with presence of jaundice, fever, abdominal pain, oliguria, anemia, leukocytosis, and coagulopathy. Model for end-stage liver disease (MELD) score >21 predicted maternal mortality with 80 % sensitivity and 91 % specificity (area under the receiver operating characteristic curve?=?0.878 and p?<?0.001).

Conclusions

Liver disease was most common in the third trimester of pregnancy. Hepatitis E was the most common cause of liver disease in pregnant women in western India with significant maternal mortality, predicted by high MELD score.

     

Factors associated with post-electroconvulsive therapy delirium: A retrospective chart review study

Although electroconvulsive therapy (ECT) is generally a safe therapeutic method, unexpected adverse effects, such as post-ECT delirium, may occur. Despite its harmful consequences, there has been little discussion about the predictors of post-ECT delirium. Thus, the current study aimed to clarify the factors associated with post-ECT delirium by reviewing electronic medical records of 268 bitemporal ECT sessions from December 2006 to July 2018 in a university hospital.Demographic and clinical characteristics of sessions involving patients with or without post-ECT delirium were compared. Multiple logistic regression analysis was applied to analyze the correlation between variables and post-ECT delirium.Post-ECT delirium developed in 23 sessions (8.6%). Of all the demographic and clinical variables measured, only etomidate use was significantly different between delirium-positive and delirium-negative groups after Bonferroni correction. The regression model also indicated that etomidate use to be significantly associated with post-ECT delirium.In this study, etomidate was associated with a higher risk of developing post-ECT delirium, an association that appeared unrelated to other possible measured variables. Practitioners should take into account the risk of post-ECT delirium while choosing anesthetics, so as to prevent early discontinuation before sufficient therapeutic gain is achieved.     

The histories of withdrawal convulsions and delirium tremens in 1648 alcohol dependent subjects

A small proportion of alcohol-dependent men and women experience delirium tremens (DTs) and/or convulsions during alcohol withdrawal. While some characteristics of individuals most likely to show these severe sequelae of the abstinence syndrome have been described, it is not clear whether these risk factors operate independently in their association with severe withdrawal. The Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA) interview was used to evaluate 1648 alcohol dependent men and women (including 540 women). The background characteristics and drinking histories of the 160 men and 51 women (12.8% of the subjects) who reported ever having had at least one episode of DTs and/or convulsions during withdrawal were compared with the characteristics of the remaining alcohol dependent individuals. Compared to other alcohol-dependent subjects, those with histories of severe withdrawal reported a greater maximum number of drinks in any 24–hour period (40.9±25.71 versus 24.9 ±17.72), more withdrawal episodes (28.2 ±33.74 versus 15.9 ±26.84), more non-medicinal use of sedative-hypnotics (56.4% versus 32.9%) and a greater number of medical problems. Hierarchical logistic regression analysis revealed that the most powerful differences between those with histories of more and less severe withdrawals related to the maximum number of drinks per day and the total number of withdrawal episodes. The remaining variables still added significantly to the relationship to more severe withdrawal. The etiology of DTs and convulsions is complex and involves the interaction of diverse characteristics representing relatively unique domains. It is hoped that these data will help clinicians identify individuals most likely to have experienced severe withdrawal syndromes and will aid researchers attempting to understand more about the etiology of these problems.     

Baclofen in the treatment of alcohol withdrawal syndrome: a comparative study vs diazepam

Purpose

Benzodiazepines are the drugs of choice in the treatment of alcohol withdrawal syndrome (AWS). Recent data have shown that baclofen may reduce AWS symptoms. At present, no comparative studies between baclofen and any benzodiazepine used in AWS treatment are available. Accordingly, the present study was designed to compare efficacy, tolerability and safety of baclofen versus diazepam in the treatment of AWS.

Subjects and methods

Thirty-seven patients with AWS were enrolled in the study and randomly divided into 2 groups. Baclofen (30 mg/day for 10 consecutive days) was orally administered to 18 patients (15 males, 3 females; median age: 46.5 years). Diazepam (0.5-0.75 mg/kg/day for 6 consecutive days, tapering the dose by 25% daily from day 7 to day 10) was orally administered to 19 patients (17 men, 2 women; median age: 42.0 years). The Clinical Institute Withdrawal Assessment (CIWA-Ar) was used to evaluate physical symptoms of AWS.

Results

Both baclofen and diazepam significantly decreased CIWA-Ar score, without significant differences between the 2 treatments. When CIWA-Ar subscales for sweating, tremors, anxiety and agitation were evaluated singly, treatment with baclofen and diazepam resulted in a significant decrease in sweating, tremors and anxiety score, without significant differences between the 2 drug treatments. Both treatments decreased the agitation score, although diazepam was slightly more rapid than baclofen.

Conclusion

The efficacy of baclofen in treatment of uncomplicated AWS is comparable to that of the “gold standard” diazepam. These results suggest that baclofen may be considered as a new drug for treatment of uncomplicated AWS.     

Correlates of metabolic syndrome in patients with depression: A study from north-western India

Background and AimsMetabolic syndrome (MS) is found to be prevalent in patients with mental illness including depression. Data is sparse on the role of lifestyle factors on MS in depression.MethodsThis study was aimed to assess correlates of MS in patients with depression. Methodology: Three hundred eighty-two patients with depressive disorders were assessed for the prevalence of MS by using modified National Cholesterol Education Program- Adult Treatment Panel-III criteria (NCEP ATP-III). Their illness severity, functionality, physical activity and nutritional habits were also assessed.ConclusionsMajority of patients with depression (82.2%) were drug naive. One-fourth of the patients had metabolic syndrome (27.7%). Additionally, other 59% of patients had one or two metabolic abnormalities and one-third of patients were obese. Lower high density lipoprotein cholesterol level was the most common abnormality (65%), while abnormal blood pressure was the least common abnormality (18%). Significant correlates of MS were greater age, and age at onset of depression, greater illness duration, lesser physical activity and lower nutritional score.ConclusionNearly one-fourth of patients with depression had MS; another three-fifth of patients had one or two metabolic abnormalities. MS was more commonly seen with sedentary lifestyle and poor nutritional habits. It calls for comprehensive assessment and timely management of cardiovascular risk factors as well as lifestyle factors in depression.     

Liver disease in heavy drinkers with and without alcohol withdrawal syndrome

BACKGROUND: Withdrawal syndrome is a hallmark of alcohol dependence. The characteristics of alcohol consumption, closely related to dependence, could influence the development of alcoholic liver disease. The study aimed to investigate if patients with severe alcohol withdrawal syndrome have a peculiar profile of liver disease. METHODS: The study included 256 heavy drinkers (aged 19-75 years, 70.3% males) admitted to an Internal Medicine Department. Patients admitted for complications of liver disease were not included. Severe alcohol withdrawal syndrome (seizures, disordered perceptions, or delirium) developed in 150 patients (58.6%). Alcohol consumption (daily quantity, duration, and pattern [regular or irregular]) was assessed by questionnaire. Liver biopsy was performed in all cases. RESULTS: Patients with alcohol withdrawal syndrome showed a lower prevalence of liver cirrhosis and a higher prevalence of alcoholic hepatitis than patients without it. The negative association of alcohol withdrawal syndrome with liver cirrhosis persisted after we adjusted for sex, daily intake, duration, and pattern of alcohol consumption. Alcoholic hepatitis was independently associated with the irregular pattern of alcohol consumption, which was closely associated with severe alcohol withdrawal syndrome. CONCLUSIONS: The profile of liver injury is different in heavy drinkers who develop and who do not develop a severe alcohol withdrawal syndrome when admitted to the hospital.