Etiology and Weekly Occurrence of Alcohol-related Seizures

OBJECTIVES: 1) To determine the prevalence of identifiable causes of alcohol-related seizures other than alcohol withdrawal. 2) To test the hypothesis that patients with alcohol-related seizures present with greater frequency following Sundays when alcohol is not commercially available. METHODS: This was a retrospective chart review of 140 consecutive patients presenting with alcohol-related seizures during a six-month period. Identifiable causes of seizures other than alcohol withdrawal and the day of the week of presentation were documented. RESULTS: One hundred forty individual patients were eligible for study. Identifiable causes of seizures other than alcohol withdrawal were found in 53.6% of patients, and they were distributed as follows: 1) current or past history of significant head trauma 25.7%, 2) idiopathic seizure disorder 15.7%, 3) cerebrovascular accident 5.7%, 4) nontraumatic intracranical lesion 3.6%, and 5) toxic/metabolic abnormalities 2.9%. Alcohol is not available for purchase on Sundays because of the "Blue Laws" in Massachusetts. A total of 34.5% of patients with alcohol withdrawal seizures presented on Mondays (p < 0.001). Of patients with identifiable causes of seizures other than alcohol withdrawal, only 16% presented on Mondays (p > 0.10). CONCLUSIONS: Approximately 50% of seizures in alcohol-dependent patients are potentially unrelated to alcohol withdrawal. Patients with alcohol withdrawal seizures presented with greater frequency on Mondays following the 24-hour period when alcohol was not commercially available in Boston. This suggests that patients with alcohol withdrawal seizures may present with greater frequency following periods of decreased availability of alcohol.     

Clinical Characteristics as Predictors of Recurrent Alcohol-related Seizures

OBJECTIVE: To determine whether clinical data available in the emergency department can accurately predict a subset of patients at low risk of developing recurrent seizures following one or more initial alcohol-related seizures in the out-of-hospital arena. METHODS: This was a retrospective secondary analysis of data obtained from the placebo arms of two prospective, randomized trials of drug treatments for the prevention of recurrent alcohol-related seizures. Subjects with and without one or more recurrent alcohol-related seizures during the study period were compared according to the following characteristics: 1) age, 2) gender, 3) daily ethanol consumption, 4) years of ethanol abuse, 5) previous alcohol-related seizure, 6) previous seizure of other etiology, 7) temperature, 8) heart rate, 9) systolic blood pressure, 10) diastolic blood pressure, 11) respiratory rate, and 12) ethanol level. Data were analyzed with t-tests and chi-square where appropriate. RESULTS: One hundred five placebo-treated patients were analyzed and 31 (30%) developed recurrent alcohol-related seizures. None of the listed characteristics were statistically different between the two groups except for the initial ethanol level. Subjects with an ethanol level higher than 100 mg/dL were less likely (0%) to develop recurrent seizures than patients with a level equal to or below 100 mg/dL (36%) (p < 0.01). CONCLUSIONS: An initial ethanol level higher than 100 mg/dL was significantly associated with a low risk for recurrent alcohol-related seizures during the observation period. No other low-risk clinical characteristics could be identified.     

Aortoenteric fistula: a diagnostic dilemma

Objective To assess the sensitivity and specificity of computed tomography (CT) in the diagnosis of aortoenteric fistula (AEF) and to determine the most accurate CT signs of the disease. Methods Hospital records were reviewed over a 20-year period. Twenty-three patients in whom a final diagnosis of AEF was made at laparotomy or autopsy were identified. Ten of these had CT performed. Twelve control cases were also collected. The 22 cases, (10 cases of AEF and 12 controls), were reviewed retrospectively by two independent readers, who were blinded to the clinical features and outcome. Each case was examined for six specific radiological findings. The outcome of other adopted investigative modalities was also examined. Results The presence of peri-aortic ectopic gas (>2 weeks following surgery) in the context of gastrointestinal (GI) blood loss was 100% specific for AEF. If AEF was considered to be present where signs of peri-aortic infection were present in a patient with GI bleeding, CT had an overall specificity of 100% (95% confidence interval = 1.0–1.0) and sensitivity of 50%. Conclusion CT can rule in the diagnosis of AEF but cannot rule it out. CT is recommended as the first-line investigation in a stable patient with suspected AEF.     

Cerebral lymphoma in childhood: a diagnostic dilemma

A diffuse B cell lymphoma was recognized at autopsy in an otherwise healthy 3 1/2-year-old girl with a three-month history of recurrent seizures. This lymphoma, treated only by debulking, was found at autopsy to have originated in the right cerebral hemisphere and to have metastasized throughout the brain, the leptomeninges around the brain stem and cerebellum, and the ventricular system. Unusual features in this lymphoma included tumoral calcifications associated with necrosis, tumoral cystic changes, polyclonal tumor cells, and meningeal metastases.     

Laryngeal carcinoma in situ: a therapeutic dilemma

Two patients having laryngeal carcinoma in situ and seven having carcinoma in situ with microinvasion were treated with laser mucosal dissection of the vocal cords followed by vaporization of adjacent or deeper tissue that appeared abnormal through the operating microscope. In these early cases the depth of vaporization was usually superficial, so the normal architecture of the vocal cords was preserved. Five patients had recurrence or persistence of abnormal tissue; three required one additional laser treatment and two required two additional treatments. After follow-up periods ranging from 18 to 60 months, all patients are presently free of laryngeal abnormalities. No surgical procedures or radiation treatments were required. I believe transoral endoscopic laser treatment of laryngeal carcinoma in situ with or without microinvasion is both feasible and desirable.     

Midazolam andDiazepam for Pediatric Seizures in the Prehospital Setting

Objective. The objective of this study was to compare the efficacy andadverse events associated with the use of diazepam andmidazolam for the treatment of pediatric seizures in the prehospital setting. Methods. This was a retrospective cohort study of all patients younger than 18 years treated for a seizure with a benzodiazepine by emergency medical services in Multnomah County, Oregon, from 1998 to 2001. The emergency medical services system consists of a single private advanced life support transporting ambulance service with fire department first responders that are all advanced life support capable. The benzodiazepine used changed from diazepam to midazolam at the midpoint of this period. The primary outcomes were termination of the seizure by arrival to the emergency department (ED), recurrence of seizure while in the ED, or the requirement for active airway interventions including intubation. The two cohorts were also compared for demographics, past history of seizures, long-term use of seizure medications, response times, route of administration, use of second doses of benzodiazepines, andfinal disposition. Results. Forty-five patients were treated with diazepam, and48 were treated with midazolam. The two cohorts were comparable except the diazepam cohort had a significantly increased proportion of patients with previous afebrile seizures (53% vs. 25%; p = 0.005). The midazolam cohort had an increased use of nonintravenous route for initial dosing (65% vs. 42%; p = 0.02). The two cohorts were equivalent in rates of termination of seizures before to ED arrival, recurrence of seizures in the ED, requiring airway support or a second dose of benzodiazepine, andadmission to the hospital. Conclusions. Diazepam andmidazolam appear to be equivalent in treating seizures andcausing adverse events. Paramedics appear to be administering midazolam intramuscularly more often than they use diazepam rectally.     

A rare case of streptomycin-induced toxic epidermal necrolysis in a patient with tuberculosis: a therapeutic dilemma

OBJECTIVE: To report a case of streptomycin-induced toxic epidermal necrolysis (TEN). CASE SUMMARY: A 55-year-old woman was admitted for treatment of active pulmonary tuberculosis (TB). She was given standard oral anti-TB chemotherapy including isoniazid, rifampin, pyrazinamide, and streptomycin. On the fourth day of therapy, she experienced high fever at 39 degrees C, chills, vomiting, pruritus, and diffuse erythema, followed by extensive bullae formation and skin denudation. Diagnosis of TEN was considered, and all anti-TB drugs were discontinued. Skin biopsy disclosed complete epidermal necrosis with dermal-epidermal cleavage and absence of inflammatory infiltrate, highly suggestive of TEN. The patient was transferred to the intensive care unit. Her general condition and skin lesions improved. A staged-fashion exposure test to the 4 anti-TB drugs allowed the incrimination of streptomycin as the offending agent. DISCUSSION: Anti-TB drugs, mainly rifampin, ethambutol, and isoniazid, have been incriminated in TEN. Streptomycin-induced TEN remains an extremely rare event. However, minor allergic skin reactions (rash, urticaria) have been described with this drug. Our patient presents a rare case of streptomycin-related TEN. Even though dangerous, a step-wise exposure test was necessary to allow safe treatment of active pulmonary TB. It also provided a strong argument of a cause-effect relationship between TEN and streptomycin. An objective causality assessment using the Naranjo rating scale revealed that the adverse drug event was highly probable. CONCLUSIONS: Streptomycin should be added to the list of drugs that induce TEN.     

Electrocardiography in the patient with the Wolff-Parkinson-White syndrome: diagnostic and initial therapeutic issues

The Wolff-Parkinson-White syndrome (WPW), estimated to occur in approximately 0.1% to 3% of the general population, is a form of ventricular preexcitation involving an accessory conduction pathway. The definition of WPW relies on the following electrocardiographic features: (1) a PR interval less than 0.12 seconds (2) with a slurring of the initial segment of the QRS complex, known as a delta wave, (3) a QRS complex widening with a total duration greater than 0.12 seconds, and (4) secondary repolarization changes reflected in ST segment-T wave changes that are generally directed opposite (discordant) to the major delta wave and QRS complex changes. The accessory pathway bypasses the atrioventricular (AV) node, creating a direct electrical connection between the atria and ventricles. The majority of patients with preexcitation syndromes remain asymptomatic throughout their lives. When symptoms do occur they are usually secondary to tachyarrhythmias; the importance of recognizing this syndrome is that these patients may be at risk to develop a variety of supraventricular tachyarrhythmias which cause disabling symptoms and, in the extreme, sudden cardiac death. The tachyarrhythmias encountered in the WPW patient include paroxysmal supraventricular tachycardia (both the narrow QRS and wide QRS complex varieties), atrial fibrillation, atrial flutter, and ventricular fibrillation. Diagnostic and urgent, initial therapeutic issues based on initial electrocardiographic information are presented via 5 illustrative cases.     

Shoulder pain and Pancoast tumor: a diagnostic dilemma

Shoulder pain with radiation into the arm and hand in an ulnar nerve dermatomal pattern should be an indicator to the possible existence of a Pancoast tumor. The chiropractic physician should be aware of this malignant tumor and the characteristic clinical syndrome it produces. The physician should furthermore make every possible effort to include the apical region of the lung on any shoulder or cervical spine radiographs performed. By this careful technique and detailed interpretation of the films, the early and accurate diagnosis of a Pancoast tumor with appropriate referral can be made.     

Acute kidney injury in the critically ill, morbidly obese patient: diagnostic and therapeutic challenges in a unique patient population

The growing burden of morbid obesity (body mass index >40 kg/m2) on critical care resources translates to a significant incidence of acute kidney injury (AKI) in morbidly obese (MO), critically ill patients. This article examines the literature pertinent to AKI in critically ill MO patients. After a concise review of the available epidemiologic data regarding the incidence of acute renal injury in MO individuals, the authors review the limitations and available tools for estimation of renal function in the MO population (with emphasis on the critical illness). Also described are several specific types of renal injury previously described in this population that are applicable to the critical care setting. Lastly, the authors review some of the challenges and limitations in providing renal support to critically ill MO individuals, and identify potential areas for future research in this population.     

The search for insight: Clients' psychological experiences of alcohol withdrawal in a voluntary, residential, health care setting

This study utilized a life history approach to describe clients' psychological experiences of the alcohol withdrawal process while voluntarily residing in a specialist alcohol withdrawal facility. Reflection on the past and anticipation of the future frequently occupied the thoughts of participants as they sought insight in to their lives. These insights were associated with a range of emotions that included embarrassment, shame, optimism, feelings of support and a sense of loss of control. The findings provide additional information on the human experience of alcohol withdrawal and, thus, increase empathy, understanding and knowledge. This increased understanding can be utilized to improve the quality of nursing care provided to this complex client group.     

Vagal Stimulation Reduces the Severity of Maximal Electroshock Seizures in Intact Rats: Use of a Cuff Electrode for Stimulating and Recording

J. Zabara showed that repetitive vagal stimulation (VS) prevents or ameliorates convulsive seizures in dogs. We have studied the effects of VS on maximal electroshock seizures (MES) in intact rats: (1) A 5 wire cuff electrode was developed for stimulating and recording from the vagus. Compound action potentials (AP) were recorded and strength-duration curves obtained for A and C fibers. There is a monotonic relationship with a negative slope between heart rate (HR) and AP amplitude. C fibers remain excitable for 25 days after cuff implant. (2) The anticonvulsant efficacy of VS is directly related to the fraction of vagal C fibers stimulated and the frequency of stimulation. (3) The anticonvulsant efficacy of VS has been established using two rat models of human epilepsy. VS abolishes the extensor component of the tonic phase of a MES and shortens or prevents tonic seizures induced by pentylenetetrazol (PTZ). (4) VS appears to act via release of large quantities of the inhibitory mediators GABA and glycine throughout large volumes of the brain. (5) It is rational to test VS in man as a treatment for intractable seizures.     

Malignant melanoma and pigmented lesions: a diagnostic and management dilemma

We document two cases of malignancy occurring at the site of partially removed benign nevi. Because of the difficulty in clinical diagnosis and the uncertainty in its behavior, we propose that any recurring melanocytic nevus expanding beyond the original surgical scar be re-excised and the specimen carefully analyzed to ensure complete removal.     

The role of carbamazepine and oxcarbazepine in alcohol withdrawal syndrome

Objective: The goal of this review is to evaluate the efficacy and safety of carbamazepine and oxcarbazepine in treatment of alcohol withdrawal syndrome (AWS) and determine the role in therapy of both agents. Methods: Relevant literature was identified through a search of MEDLINE (1966–June 2008), PubMed (1966–June 2008); Cochrane database was performed to identify English‐language publications. Search terms included carbamazepine, oxcarbazepine, AWS, alcoholism, substance syndrome withdrawal. Results: In seven studies, including 612 patients, carbamazepine demonstrated significant reduction in alcohol withdrawal scores. However, in comparative trials with a benzodiazepine agent, carbamazepine’s ability to prevent alcohol withdrawal seizures (OR = 0·93; 95% CI = 0·06–14·97, P = NS) and delirium tremens (DTs; OR = 1·25; 95% CI = 0·28–5·64, P = NS) was uncertain as a result of insufficient patient enrolment. In three trials, carbamazepine failed to reduce alcohol withdrawal symptoms possibly as a result of delayed administration, inadequate dosage or inadequate sample size. At daily doses of 800 mg either fixed or tapered over 5–9 days, carbamazepine was well tolerated, and safely administered when blood alcohol concentration dropped below 0·15%. The role of oxcarbazepine in AWS is undefined because of inconsistent findings in two trials. Conclusion: Carbamazepine has demonstrated safety, tolerability and efficacy in treatment of moderate to severe symptoms of alcohol withdrawal in the inpatient setting. However, trials of carbamazepine provide inconclusive evidence for prevention of alcohol withdrawal seizures and DTs in comparison with benzodiazepines. Benzodiazepines remain the primary treatment of moderate to severe AWS.     

Acute neck swelling: A diagnostic dilemma in a regional hospital

This case study describes an incident of acute neck swelling in a patient presenting to the ED of a regional hospital after hours. Maintaining and securing her airway proved to be challenging, as did arriving at the correct cause of her airway obstruction and neck swelling.     

A comparative study using Disulfiram and Naltrexone in alcohol-dependent adolescents

Abstract

Aims: There are currently three agents approved by US-FDA for the pharmacotherapy of alcohol dependence, namely Naltrexone, Disulfiram and Acamprosate. The present study aimed to clinically compare Disulfiram (DSF) and Naltrexone (NTX) and their efficacy in relapse prevention in adolescents in a routine clinical setting.

Design: Fifty-two adolescents with alcohol dependence with supportive family members that would ensure medical compliance and follow up were randomized to 6 months of treatment with DSF or NTX. Weekly group psycho-education was also provided. The psychiatrist, patient and family member were not blind to the treatment prescribed. Measurements: Alcohol consumption, craving and adverse events were recorded weekly for 4 months and then fortnightly. Serum gamma glutamyl transferase (GGT) was measured at the start and end of the study.

Results: At the end of the study, 46 patients were still in contact. Relapse occurred at a mean of 93 days with DSF compared to 63 days for NTX. 84.61% patients on DSF remained abstinent compared to 53.85% with NTX.

Conclusions: DSF was superior to NTX in promoting abstinence in adolescents with alcohol dependence having good family support.     

Bacterial biofilms: a diagnostic and therapeutic challenge

Bacteria have traditionally been regarded as individual organisms growing in homogeneous planktonic populations. However, bacteria in natural environments usually form communities of surface-adherent organisms embedded in an extracellular matrix, called biofilms. Current antimicrobial strategies often fail to control bacteria in the biofilm mode of growth. Treatment failure is particularly frequent in association with intracorporeal or transcutaneous medical devices and compromised host immunity. The rising prevalence of these risk factors over the last decades has paralleled the increase in biofilm infections. This review discusses the shortcomings of current therapies against biofilms both in theory and with clinical examples. Biofilm characteristics are described with a focus on new diagnostic and therapeutic targets.     

Bacterial biofilms: a diagnostic and therapeutic challenge

Bacteria have traditionally been regarded as individual organisms growing in homogeneous planktonic populations. However, bacteria in natural environments usually form communities of surface-adherent organisms embedded in an extracellular matrix, called biofilms. Current antimicrobial strategies often fail to control bacteria in the biofilm mode of growth. Treatment failure is particularly frequent in association with intracorporeal or transcutaneous medical devices and compromised host immunity. The rising prevalence of these risk factors over the last decades has paralleled the increase in biofilm infections. This review discusses the shortcomings of current therapies against biofilms both in theory and with clinical examples. Biofilm characteristics are described with a focus on new diagnostic and therapeutic targets.