Risk for delirium tremens in patients with alcohol withdrawal syndrome 1

To determine the characteristics associated with an increased risk for delirium tremens (DT) we performed a case‐control study at the detoxification units of two hospitals. Cases met DSM‐IV criteria for DT. For each case (n = 15), 3 controls (n = 45) were chosen. Eligibility criteria were applied equally to cases and controls. Cases were more likely than controls to report a prior complicated withdrawal (DT or alcohol withdrawal seizure) (53 vs. 27%, OR 3.1, 95% CI 0.94–10.55), have a systolic blood pressure greater than 145 mm Hg on admission (60 vs. 27%, OR 4.1, 95% CI 1.21–14.06), and have comorbidity scores of at least 1 (60 vs. 18%, OR 6.9, 95% CI 1.92–25.08). Zero cases (0%) and 15 (33%) controls had no prior complicated withdrawals and no adverse clinical features (systolic blood pressure >145 or comorbidity score >1). Compared to this group, the odds of being a case and having both prior complicated withdrawal and at least 1 adverse clinical feature was 44.8 (95% CI4.36–460). Elevated blood pressure, prior complicated alcohol withdrawal and medical comorbidity, alone and in combination, are associated with an increased risk of delirium tremens.     

Independent Clinical Correlates of Severe Alcohol Withdrawal

This retrospective cohort study sought to identify clinical variables that independently correlate with severe alcohol withdrawal and to quantify risk in a clinically useful manner. The records of 284 inpatients admitted to an acute detoxification unit at a Veterans Affairs teaching hospital were reviewed. Clinical data were recorded on standardized forms at the time of admission and abstracted by a physician reviewer. Alcohol withdrawal severity was prospectively measured with the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. Seventy-one patients (25% of cohort) had severe withdrawal. We identified six independent correlates of severe withdrawal: use of a morning eye-opener (adjusted odds ratio [OR], 5.6; 95% confidence interval [CI], 1.2–25.9), an initial CIWA-Ar score q 10 (OR, 5.1; 95% CI, 2.4–10.6), a serum aspartate aminotransferase 80 U/L (OR, 4.2; 95% CI, 2.0–8.8), past benzodiazepine use (OR, 3.6; 95% CI, 1.3–9.9), self-reported history of delirium tremens (OR, 2.9; 95% CI, 1.3–6.2), and prior participation in two or more alcohol treatment programs (OR, 2.6; 95% CI, 1.3–5.6). Significantly higher risk was observed in subjects with three or more independent correlates. In conclusion, several readily available clinical variables correlate with the occurrence of severe alcohol withdrawal. Ascertainment of these variables early in the course of alcohol withdrawal has the potential to improve triage and treatment decisions.     

Independent clinical correlates of severe alcohol withdrawal

This retrospective cohort study sought to identify clinical variables that independently correlate with severe alcohol withdrawal and to quantify risk in a clinically useful manner. The records of 284 inpatients admitted to an acute detoxification unit at a Veterans Affairs teaching hospital were reviewed. Clinical data were recorded on standardized forms at the time of admission and abstracted by a physician reviewer. Alcohol withdrawal severity was prospectively measured with the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA‐Ar) scale. Seventy‐one patients (25% of cohort) had severe withdrawal. We identified six independent correlates of severe withdrawal: use of a morning eye‐opener (adjusted odds ratio [OR], 5.6; 95% confidence interval [CI], 1.2–25.9), an initial CIWA‐Ar score ≥ 10 (OR, 5.1; 95% CI, 2.4–10.6), a serum aspartate aminotransferase ≥ 80 U/L (OR, 4.2; 95% CI, 2.0–8.8), past benzo‐diazepine use (OR, 3.6; 95% CI, 1.3–9.9), self‐reported history of “delirium tremens”; (OR, 2.9; 95% CI, 1.3–6.2), and prior participation in two or more alcohol treatment programs (OR, 2.6; 95% CI, 1.3–5.6). Significantly higher risk was observed in subjects with three or more independent correlates. In conclusion, several readily available clinical variables correlate with the occurrence of severe alcohol withdrawal. Ascertainment of these variables early in the course of alcohol withdrawal has the potential to improve triage and treatment decisions.     

Reports of withdrawal syndrome with the use of SSRIs: a case/non-case study in the French Pharmacovigilance database

The SSRIs can be associated with withdrawal reactions and the objective of this study is to test the existence of an association between reports of withdrawal syndromes with the selective serotonin re-uptake inhibitors in the French spontaneous reports database. All reactions are coded according to the WHO ART dictionary. Cases are reports of reactions of interest (withdrawal syndrome). Non-cases are all reports of reactions other than those being studied. We calculated the odds ratio (OR) as the ratio of the odds of the association of reports of withdrawal syndrome with SSRIs in cases and non-cases. SSRIs are clearly associated with a higher risk of withdrawal syndrome (OR: 5.05, 95% CI: 3.81-6.68) and in particular with venlafaxine and paroxetine (OR: 12.16, 95% CI: 6.17-23.35 and OR: 8.47, 95% CI: 5.63-12.65, respectively). The risk of withdrawal reactions appears to be greater with short half-life drugs such as paroxetine and venlafaxine. The precise mechanisms have not been identified.     

Cough due to ace inhibitors: a case-control study using automated general practice data

Objectives: To determine the risk of coughing as an adverse reaction to ACE inhibitors under everyday circumstances in a large population, and to study whether this adverse effect was duration or dose dependent. Design: A population-based case-control study. Setting: Ten general practices of 14 Dutch general practitioners (GP), in which all consultations, morbidity and medical interventions, including drugs prescribed, were registered over the 18 month period from 1st September, 1992 to 1st March, 1994. Subjects: 1458 patients with incident coughing and up to four controls per case were obtained (total 4182 controls), matched for GP. All cases and controls were 20 years or older and had no record of respiratory infection, influenza, tuberculosis, asthma, chronic bronchitis, emphysema, congestive heart failure, sinusitis, laryngitis, haemoptysis or respiratory neoplasms during the study period. Results: Cases were 2.1-times more likely than controls to have been exposed to ACE inhibitors (95% CI 1.5–3.1), but after adjustment the odds ratio was 1.4 (95% CI 0.9–2.1). The crude odds ratio for captopril was 1.3 (95% CI 0.7–2.5), for enalapril 2.6 (95% CI 1.6–4.2) and for lisinopril 2.0 (95% CI 0.5–9.3). The adjusted odds ratio for captopril was 0.9 (95% CI 0.4–1.7), for enalapril 1.7 (95% CI 1.03–2.8) and for lisinopril 1.7 (95% CI 0.4–7.9). For patients who had been on ACE inhibitor treatment for no longer than 2 months the odds ratio was 4.8 (95% CI 1.7–13.3). The odds ratio declined to 2.0 (95% CI 1.1–3.8) for those who had taken an ACE inhibitor for 2–6 months, and to 1.6 (95% CI 0.9–2.7) for those on ACE-inhibitors for more than 6 months. Conclusion: The risk of coughing was increased twofold among ACE inhibitor users, but the odds ratios were no longer significant after controlling for several confounding factors. The risk of developing cough due to ACE-inhibitors declines with the duration of treatment, possibly due to depletion of susceptible persons.     

Patient characteristics associated with prescribing of a newly introduced drug: the case of rofecoxib

Objective To identify socio-demographic characteristics of the first patients receiving a new drug—rofecoxib.Outcome measurement Patients starting on rofecoxib or another non-steroidal anti-inflammatory drug (NSAID) and who had not received any NSAIDs the 90 days prior to starting.Results Starting on rofecoxib was associated with an increasing age (OR in age 80 years and older 8.7; 95% CI 6.7–11.2), a poor self-perceived health (OR=2.4; 95% CI 1.8–3.3), female gender (OR=1.4; 95% CI 1.2–1.6), private insurance (OR=1.3; 1.1–1.5) and previous acetaminophen use (OR=1.3; 1.1–1.7).Conclusion This study noted that specific patient characteristics were associated with getting rofecoxib prescribed shortly after marketing. General practitioners should be aware of selectively prescribing new drugs to specific patients because it may place patients at unintentional and avoidable risk.     

Effect of anticholinergic burden on treatment modification,delirium and mortality in newly diagnosed dementia patients starting a cholinesterase inhibitor: A population‐based study

Few studies have evaluated the association between anticholinergic burden and treatment modification after starting a cholinesterase inhibitor in clinical practice. We aimed to evaluate the effect of anticholinergic burden on anti‐dementia treatment modification, delirium and mortality. We retrospectively analysed older adults (n = 25 825) who started a cholinesterase inhibitor during 2003–2011 from Korean National Health Insurance Service Senior Cohort Database. High anticholinergic burden was defined as an average daily Anticholinergic Cognitive Burden (ACB) score of >3 during the first 3 months. We investigated the impact of high anticholinergic burden on the rate of treatment modification, delirium and mortality in comparison with minimal ACB (ACB score ≤1) in propensity‐matched cohorts (N = 7438). Approximately 6.0% of patients with dementia were exposed to a high anticholinergic burden within the first three months of treatment. In high anticholinergic burden cohorts, significantly more patients experienced treatment modification (34.9% vs. 32.1%) or delirium (5.6% vs. 3.6%) and the mortality rate was also higher (16.8% vs. 14.1%) than controls. A multivariate Cox proportional hazard regression analysis showed that an average ACB score >3 within the first three months significantly increased the risk of treatment modification (hazard ratio (HR): 1.12, 95% confidence interval (CI): 1.02‐1.24), delirium (HR: 1.52, CI: 1.17‐1.96) and mortality (HR: 1.23, CI: 1.06‐1.41). This study showed that high anticholinergic burden negatively affected the treatment response to cholinesterase inhibitors and that an average ACB score >3 was an independent prognostic factor for delirium or mortality in dementia patients.     

Combination ceftaroline and daptomycin salvage therapy for complicated methicillin-resistant Staphylococcus aureus bacteraemia compared with standard of care

Complicated methicillin-resistant Staphylococcus aureus bloodstream infections (MRSA-BSIs), particularly those with delayed culture clearance, are associated with high mortality. Combination therapy with daptomycin and ceftaroline (DAP+CPT) represents a novel therapeutic approach to MRSA-BSI owing to synergistic bactericidal activity. This study aimed to compare DAP+CPT with historical standard of care (SoC) for treatment of complicated MRSA-BSI. This single-centre retrospective cohort study included patients with complicated MRSA-BSI at University of Colorado Hospital. Patients receiving DAP+CPT for ≥48 h between November 2013 and March 2020 or SoC with vancomycin or DAP ± gentamicin and/or rifampicin from November 2011 to December 2013 were compared. The primary outcome was clinical failure defined as a composite of MRSA-related mortality and recurrent infection at 60 days. A total of 60 patients received DAP+CPT (n = 30) or SoC (n = 30). Median age was 56 years and median Pitt bacteremia score was 3. Common infectious sites were endovascular (63%) and musculoskeletal (40%). DAP+CPT was associated with a numerically lower incidence of clinical failure compared with SoC (20% vs. 43%; P = 0.052). Multivariable analysis controlling for immunocompromised status (OR, 6.90, 95% CI 1.08–44.15), Charlson comorbidity index (OR, 1.12, 95% CI 0.90–1.39) and source control (OR, 0.35, 95% CI 0.08–1.46) associated DAP+CPT with 77% lower odds of clinical failure (OR, 0.23, 95% CI 0.06–0.89). In patients with complicated MRSA-BSI with delayed clearance, DAP+CPT trended towards lower rates of clinical failure than SoC and was significantly associated with decreased clinical failure after adjustment for baseline differences.     

Association of a CB1 cannabinoid receptor gene (CNR1) polymorphism with severe alcohol dependence

Due to the involvement of the endogenous cannabinoid system in brain reward mechanisms a silent polymorphism (1359G/A; Thr453Thr) in the single coding exon of the CB1 human cannabinoid receptor gene (CNR1) was analysed in 121 severely affected Caucasian alcoholics and 136 most likely non-alcoholic controls. The observed frequency of the A allele was 31.2% for controls and 42.1% for alcoholics with severe withdrawal syndromes (P=0.010). Post-hoc exploration indicated that this allelic association resulted from an excess of the homozygous A/A genotype in patients with a history of alcohol delirium (P=0.031, DF 2), suggesting s an increased risk of delirium (OR=2.45, 95% CI 1.14--5.25). This finding suggests that the homozygous genotype CNR1 1359A/A confers vulnerability to alcohol withdrawal delirium.     

Delirium during heroin withdrawal with doxepin: A short report

Doxepin was evaluated in a group of 10 patients for its efficacy in decreasing withdrawal symptoms during ambulatory heroin withdrawal. Although no subjective relief was reported by the subjects, during the 10 days trial, four of the patients developed full blown delirium during the trial's first three days. Since delirium is rarely one of the complications of heroin withdrawal the question whether doxepin enhanced or induced its appearance in these patients, remains unanswered. Until this issue is resolved we suggest cessation of doxepin usage in the initial withdrawal phase from heroin.     

Plasma homovanillic acid: a significant association with alcoholism is independent of a functional polymorphism of the human catechol-O-methyltransferase gene.

The central dopamine system seems to influence addictive disorders. Plasma homovanillic acid (HVA) is an indicator of central dopaminergic activity. In this study the hypothesis that plasma HVA is associated with alcoholism or with delirium tremens (DT) during alcohol withdrawal was tested. A functional genetic polymorphism of the enzyme catechol-O-methyltransferase (COMT) that participates in converting dopamine into its final metabolite HVA was investigated for an association with alcoholism or DT during alcohol withdrawal. In addition, a relation between the functional polymorphism of COMT and plasma HVA concentrations was studied. Plasma HVA concentrations and COMT genotypes were determined in 142 German alcoholics and 101 German healthy controls. Alcoholic patients were examined after a minimum of 3 weeks after cessation of drinking. Mean plasma HVA concentrations were significantly lower in alcoholic patients compared to healthy controls. A group of alcoholics with a history of DT during alcohol withdrawal (n=62) did not differ significantly in plasma HVA concentrations from alcoholics with a history of only mild withdrawal symptoms (n=67). The functional polymorphism of the human COMT gene was neither significantly associated with the diagnosis of alcoholism or DT during alcohol withdrawal nor with plasma HVA concentrations.     

Intramuscular/oral lorazepam in acute alcohol withdrawal and incipient delirium tremens

Summary

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 (5?mg). 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.     

Development and implementation of an alcohol withdrawal protocol using a 5-item scale,the Brief Alcohol Withdrawal Scale (BAWS)

Background: The standard of care for management of alcohol withdrawal is symptom-triggered treatment using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). Many items of this 10-question scale rely on subjective assessments of withdrawal symptoms, making it time-consuming and cumbersome to use. Therefore, there is interest in shorter and more objective methods to assess alcohol withdrawal symptoms. Methods: A 6-item withdrawal scale developed at another institution was piloted. Based on comparison with the CIWA-Ar, this was adapted into a 5-item scale named the Brief Alcohol Withdrawal Scale (BAWS). The BAWS was compared with the CIWA-Ar and a withdrawal protocol utilizing the BAWS was developed. The new protocol was implemented on an inpatient unit dedicated to treating substance withdrawal. Data was collected on the first 3 months of implementation and compared with the 3 months prior to that. Results: A BAWS score of 3 or more predicted CIWA-Ar score ≥8 with a sensitivity of 85.3% and specificity of 65.8%. The demographics of the patients in the 2 time periods were similar: the mean age was 45.9; 70.6% were male; 30.9% received concurrent treatment for opioid withdrawal; and 14.2% were receiving methadone maintenance. During the BAWS phase, patients received significantly less diazepam (mean dose 81.4 vs. 60.3 mg, P < .001). There was no significant difference in length of stay. No patients experienced a seizure, delirium, or required transfer to a higher level of care during any of the 664 admissions in either phase. Conclusions: This simple protocol utilizing a 5-item withdrawal scale performed well in this setting. Its use in other settings, particularly with patients with concurrent medical illnesses or more severe withdrawal, needs to be explored further.     

主动脉夹层术后谵妄的临床特点和相关危险因素研究

目的 研究主动脉夹层术后谵妄的发生率、临床特点以及相关危险因素.方法 以2013年1-12月北京安贞医院主动脉夹层术后患者为研究对象,以意识错乱评估方法作为谵妄诊断工具,分析术后谵妄的发生率和危险因素.结果 共有84例患者纳入研究,发生术后谵妄28例,发生率为33.3％.21例（75.0％）为一过性谵妄（＜24 h）;7例（25.0％）为持续性谵妄.术后谵妄最常见的表现是精神运动性兴奋（23例,82.1％）;其次是睡眠-觉醒周期紊乱（21例,75.0％）;多数患者有思维紊乱或者不连贯、定向力障碍、意识水平改变.将术后谵妄的危险因素分为术前、术中和术后危险因素,并对其进行单因素分析和多因素回归分析.与谵妄发生有关的术前危险因素包括左心室射血分数≤30％[P=0.023,比值比（OR）=1.99,95％置信区间（CI）：1.29～3.31]、脑梗死（P=0.002,OR=2.86,95％ CI：1.43 ～ 5.72）;术中危险因素包括手术持续时间（P=0.023,OR =0.90,95％ CI：0.49 ～ 1.67）、深低温停循环时间（P =0.019,OR=1.18,95％ CI：1.06 ～2.97）;术后危险因素包括机械通气时间（P =0.043,OR=1.17,95％ CI：1.00 ～1.37）、血氧饱和度（P=0.001,OR=2.77,95％ CI：1.51 ～5.11）、重症监护病房时间（P=0.036,OR=1.10,95％ CI：1.10～1.21）,上述各因素对术后谵妄的影响差异有统计学意义（P＜0.05）.Logistic多因素回归分析结果表明脑梗死（P=0.017,OR=1.48,95％ CI：1.07 ～2.04）、深低温停循环时间（P=0.002,OR=2.86,95％ CI：1.43 ～5.72）、重症监护病房时间（P=0.030,OR =2.18,95％ CI：1.07 ～4.44）是术后谵妄的独立危险因素.结论 既往脑梗死、深低温停循环时间、重症监护病房持续时间是术后谵妄的独立危险因素.     

Dexmedetomidine in the prevention of postoperative delirium in elderly patients following non-cardiac surgery: A systematic review and meta-analysis

The efficacy of dexmedetomidine in the prevention of postoperative delirium (POD) remains ambiguous, however, it has been used to reduce the incidence of delirium in elderly patients. Here, we conducted a meta-analysis study for assessing the effects of dexmedetomidine on POD among elderly patients following non-cardiac surgery. A systematic literature search was performed against the PubMed, EMBASE, Cochrane Library, and Web of Science databases, and all relevant literature published till November 30, 2019, were considered. Our analysis included 16 randomised controlled trials conducted with 4534 patients for exploring the effects of dexmedetomidine on POD in elderly patients following non-cardiac surgery. It was observed that the overall incidence of POD was significantly lower in the dexmedetomidine group than in the control group (risk ratio [RR] 0.51, 95% confidence interval [CI] 0.43–0.61, P < .01). Similar results were obtained from subgroup analysis upon comparison of the placebo (RR 0.52, 95% CI 0.41–0.66, P < .01, moderate quality of evidence), propofol-treated (RR 0.55, 95% CI 0.38–0.78, P < .01, low quality of evidence), and midazolam-treated (RR 0.38, 95% CI 0.20–0.71, P < .01, low quality of evidence) groups. Trial sequential analysis revealed that the cumulative z-value superseded the monitoring boundary and reached the required information size. However, patients who received dexmedetomidine had a higher incidence of bradycardia and hypotension. In conclusion, the meta-analysis revealed that dexmedetomidine appears to decrease the risk of POD in elderly patients following non-cardiac surgery. However, as some of the studies were heterogeneous and of low quality, high-quality trials are necessary for drawing more definitive conclusions.     

Evaluation of the effect of phosphodiesterase inhibitors on mortality in chronic heart failure patients

We examined the influence of phosphodiesterase inhibitors (PDIs) on mortality in patients with overt chronic heart failure. A total of 13 randomised, placebocontrolled trials of PDIs involving 2808 patients were selected.Meta-analysis, using data for all patients, showed that there was a non-significant (P=0.16) increase of about 17% in the mortality rate of patients receiving a PDI [odds ratio (OR) 1.17, 95% confidence interval (CI) 0.94–1.46]. However, the observed treatment effects were found to be heterogeneous due to the results from the trials on vesnarinone. The heterogeneity became non-significant (P=0.77) when these trials were removed, and a significant increase in the mortality rate was observed under treatment with the other PDIs (OR 1.41, 95% CI 1.11–1.79). In the subgroups of patients with or without additional vasodilator (VD) treatment, similar results were observed (PDI with VD: OR 1.3, 95% CI 1.03–1.7; PDI without VD: OR 2.04, 95% CI 1.1–3.8).These results indicate that PDIs (with the exception of vesnarinone) should not be prescribed for long-term use in patients with overt chronic heart failure. Additional vasodilator treatment in patients receiving PDIs for chronic heart failure does not explain the increased mortality seen with PDIs. This toxicity must, therefore, arise by other mechanisms. Further experimental and clinical evaluation is needed to confirm the beneficial influence of vesnarinone on survival in chronic heart failure patients and to identify the mechanism(s) differentiating this agent's therapeutic effect from that of other PDIs.     

Diazepam prevents progression of kindled alcohol withdrawal behaviour

The purpose of the present experiment was to study the kindling hypothesis of alcohol withdrawal stating that exposure to repeated episodes of alcohol withdrawal results in an increased severity of subsequent withdrawal reactions. Two groups of male Wistar rats were subjected to 13 episodes of 2 days severe alcohol intoxication and 5 days alcohol withdrawal. Animals in the control group (n=80) developed clinical withdrawal signs following each intoxication episode. In the diazepam group (n=80) the withdrawal reactions during episodes 1–9 were blocked by intraperitoneal diazepam administration (0–30 mg/kg) 8, 11 and 15 h into withdrawal. During episode 10–13 diazepam treatment was terminated and convulsive withdrawal behaviour was observed 9–15 h after last alcohol dose. The probability of seizure activity during these four withdrawal episodes was calculated as 0.239 and 0.066 in the control and the diazepam groups, respectively. Based on Monte Carlo simulation techniques, this difference was found to be statistically significant (P<0.05). No differences in the non-convulsive alcohol withdrawal symptoms tremor, hyperactivity and rigidity were detected between controls and diazepam animals after diazepam treatment. It was concluded that the increased convulsive behaviour in the control group was caused by cumulated kindling-like cerebral alterations during the previous repeated alcohol withdrawal phases.     

Influence of DRD2 and ANKK1 polymorphisms on the manifestation of withdrawal syndrome symptoms in alcohol addiction

BackgroundWeinvestigated the relationship between withdrawal syndrome symptoms and dopamine receptor 2 DRD2 gene polymorphisms -141 C I/D (rs1799732) exon 8 G/A (rs6276) and ANKK1 (Ankyrin Repeat and Kinase Domain Containing 1) gene polymorphism Taq 1 A (rs1800497).MaterialA total number of 213 patients who met the ICD 10 criteria for given phenotypes were enrolled in the study. Those phenotypes included: dissocial personality disorder, early onset, alcohol withdrawal syndrome with seizures, alcohol withdrawal syndrome with delirium tremens, and alcohol withdrawal syndrome with seizures and delirium tremens.ResultsOur results show statistically significant associations between SNP in exon 8 A/G in the DRD2 gene and alcohol withdrawal syndrome with seizures, and between SNP in promoter -141 C I/D in the DRD2 gene and early onset of alcohol dependence (AD). The A/A genotype in exon 8 A/G polymorphism seems to be a positive predictive factor for the presence or the lack of seizures in alcohol withdrawal syndrome. The A/G genotype is possibly a protective factor for this AD phenotype.ConclusionsThese results suggest that both investigated DRD2 polymorphisms have an impact onthe AD phenotype. The findings of the presented study reconfirm that dopamine receptor 2 gene polymorphisms are associated with alcohol addiction and alcohol withdrawal syndrome.     

Impact of hospitalization on blood pressure control in Italy: results from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA)

STUDY OBJECTIVES: To evaluate whether hospitalization affects blood pressure control in hypertensive patients, and to identify factors associated with attainment of adequate blood pressure control and with aggressive pharmacologic treatment. DESIGN: Retrospective study. SETTING: Eighty-one hospitals throughout Italy. PATIENTS: A total of 3,304 patients (59% women, 41% men) with a diagnosis of hypertension and uncontrolled blood pressure values at hospital admission. MEASUREMENTS AND MAIN RESULTS: Patients' blood pressures were surveyed during study periods from 1988-1997. Controlled blood pressure was defined according to the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (systolic < 140 mm Hg, diastolic < 90 mm Hg). Aggressive pharmacologic treatment was defined as an increase in the number of antihypertensive drugs that the patient was receiving at hospital discharge compared with the number of drugs on admission. Adequate blood pressure control was achieved in only 767 (23.2%) patients, but the proportion increased in each subsequent survey Age (odds ratio [OR] for 10-year increase 0.82, 95% confidence interval [CI] 0.76-0.88) and male sex (OR 0.79, 95% CI 0.65-0.94) were associated with reduced likelihood of achieving adequate blood pressure control. In contrast, coronary heart disease (OR 1.38, 95% CI 1.14-1.66), year of survey (1995 vs 1988: OR 1.47, 95% CI 1.19-1.82; 1997 vs 1988: OR 1.27, 95% CI 1.02-1.42), length of hospital stay (medium vs lower tertile OR 1.20, 95% CI 0.96-1.49; higher vs lower tertile OR 1.42, 95% CI 1.13-1.77), and increase in number of antihypertensive drugs prescribed (OR 1.21, 95% CI 1.02-1.42 for one drug increase) were associated with improved blood pressure control. In 1753 (53.1%) patients, the number of antihypertensive drugs increased during their hospital stay. Younger age, fewer drugs on admission, lower comorbidity index, diagnosis of chronic heart failure, lengthy hospital stay, and increasing baseline values of systolic and diastolic blood pressure were associated with aggressive pharmacologic treatment. CONCLUSION: Adequate blood pressure control was achieved in only 25% of patients with hypertension despite a trend toward improvement in recent years. Advanced age was one of the main factors associated with less aggressive pharmacologic treatment and with inadequate blood pressure control.     

Polysomnographic study of terminal sleep following delirium tremens

Polysomnographic recording was performed during terminal sleep following delirium tremens (DT) in nine chronic alcoholics. After terminal sleep all the alcoholics fully recovered from DT. The duration of terminal sleep and DT differed among patients, but no significant correlation was found between the two. The most prominent feature in the different stages of terminal sleep was a considerable decrease in slow wave sleep, especially stage 4 sleep. A slight decrease was observed in REM sleep, while stages 1 and 2 increased. A small amount of stages 1-REM and 2-REM was observed and a statistically significant correlation was noted between the appearance of these sleep stages. Intermittent wakefulness occurred in many patients.The disappearance of sleep cycles was observed in some patients. Therefore, terminal sleep following DT probably consists of recovery sleep from sleep deprivation caused by DT and disturbances of consciousness. Sleep cycles regularly occur in the former, but not in the latter.