Serum alcohol levels, toxicology screens, and use of the breath alcohol analyzer

The emergency physician sees a large number of patients with problems related to the ingestion of alcohol, drugs, and toxins, and must be prepared to deal with them in an efficient and cost-effective manner. This article discusses a rationale for ordering serum alcohol levels and toxicology screens, as well as use of the breath alcohol analyzer. A serum alcohol level should be reserved for patients in whom the alcohol level is necessary to confirm a diagnosis or to guide treatment. An alcohol level is indicated when alcohol use is combined with a significant alteration in mental status, multiple drug overdose, head injury, coma, major trauma, seizures, or psychosis. The breath alcohol analyzer is useful when rapid determination of alcohol levels is desired, particularly with coma or coexisting head trauma. A low or negative level in this case rapidly alerts the physician to the presence of another condition that may require additional testing. Toxicology screening should be performed when suspected drug or toxin ingestion is combined with coma, convulsions, head injury with altered mental status, unstable vital signs, alterations in acid-base or electrolyte status, or psychosis. The screen also may be used to determine the need for a specific antidote or means of increasing excretion of a toxin, or to determine the presence of a drug that should be quantified to guide management. Open communication with the laboratory and the use of rapid screening tests markedly increase the benefit of toxicology screening.     

Outcomes for older trauma patients in the emergency department screening positive for alcohol,cocaine, or marijuana use

Background: Substance use among older adults is an increasing concern, with the prevalence of substance use in older populations expected to double in the next decade. Drug and alcohol use is associated with trauma risk and outcomes, but little is known about the specific risk for older trauma patients. Objectives: To evaluate the association between drug and alcohol use and trauma outcomes among adults aged 55 years and older. Methods: This retrospective observational study included older adults from the Illinois Trauma Registry between 1999 and 2009. Exclusion criteria were age younger than 55 years or absent date of birth, ethanol level, or urine drug screen (UDS). Alcohol intoxication was defined as ethanol level greater than 80?mg/dL. UDS was used to screen cocaine and marijuana use. Analyses, for both the alcohol and the marijuana/cocaine groups, compared outcomes for patients with negative vs. positive screens. Results: 21?320 patients were included in the alcohol analysis and 17?077 in the drug analysis. Compared to non-intoxicated patients, alcohol-intoxicated patients had significantly (p?0.001) lower in-hospital mortality, decreased ICU admission, decreased intubation rate, and shorter hospital length of stay. Patients screening positive for cocaine or marijuana had significantly longer lengths of stay with increased ICU admission compared with those who screened negative. Conclusion: Among older trauma patients, this study shows significant associations with multiple trauma outcomes, including one between elevated ethanol concentrations and improved outcomes. Future research into the causes of these findings could inform the care of older trauma patients and aid in prevention of injuries.     

Comparison of Objective Screening and Self-Report for Alcohol and Drug Use in Traumatically Injured Patients

Alcohol and drug use is prevalent in trauma patients. Concerns over the validity of self-reporting drug use could make nonlaboratory screening problematic. This study sought to validate patient self-report of substance use against objective screening to determine the reliability of self-report in trauma patients. Patients admitted to either the Trauma or Burn services who were at least age 18 were screened for alcohol and drug use with validated screening tools. Exclusion criteria were altered mental status, non English speaking, inability to answer questions for other reasons, under police custody, or admission for <24 hours. Results from admission blood alcohol concentration (BAC) and urine drug screen (UDS) were also collected and compared to self-reported use to determine its reliability. Alcohol use was queried in 128 patients, 101 of whom had a BAC drawn. Of those 101, 34 (33.7%) had a BAC ≥ 0 mg%. Alcohol Use Disorder Identification Test creening revealed 13 (12.9%) patients who were self-reported non drinkers, none of which had a BAC > 0 mg%. Drug use was queried in 133 patients, 93 of whom had a UDS. A positive was found in 26 (28.0%) of the patients, only 12 (46.2%) of whom reported drug use in the past year. Although substance use in trauma patients is prevalent, self-report screening techniques for drugs may be inadequate at determining those patients whom could benefit from brief interventions while in the hospital. Further investigation is needed to determine the discrepancy between alcohol and drug use screening in trauma patients and more acceptable means of drug use discussion.     

Alcohol abuse in elderly emergency department patients.

OBJECTIVES: To determine the prevalence of alcohol abuse in elderly emergency department (ED) patients; to determine the prevalence of alcohol abuse for various categories of illness and injury among these patients; and to determine the frequency of detection of elderly alcohol abusers by ED physicians. DESIGN: Cross-sectional prevalence study. SETTING: The emergency department of a 625-bed university hospital that serves a mixed urban and rural population. PATIENTS: 205 patients aged 65 and over who came to the ED during an 8-week period. MEASURES: A structured interview, which included the CAGE questionnaire and other questions regarding alcohol use, was administered. Emergency department records and past medical records were reviewed. RESULTS: The prevalence of lifetime alcohol abuse (CAGE positive or self-reported drinking problem) was 24%. The prevalence of current alcohol abuse (CAGE positive or self-reported drinking problem and alcohol use within the last year) was 14%. There was a particularly high prevalence (22%) among those presenting with gastrointestinal problems and a surprisingly low prevalence (7%) among those who presented with falls or other trauma. Physicians detected only 21% of the current alcohol abusers. CONCLUSIONS: Alcohol abuse is a prevalent and important problem among elderly ED patients. It is not well detected by physicians in this setting. Alcohol abuse appears to be less common among elderly trauma patients than their younger counterparts, but is very common among patients with gastrointestinal problems.     

Detoxification of Alcoholics: Improving Care by Symptom-Triggered Sedation

This study evaluated a staff training program on alcohol detoxification. Training consisted of didactic presentations on the pathophysiology of alcohol withdrawal syndrome and information on use of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A). Treatment course was assessed on 100 patients admitted before or after the training. Whereas 73% of patients were given drug therapy before, only 13% of patients received drug therapy after. Significantly more benzodiazepine was administered before training (M = 108.48 mg) than after training (M = 42.97 mg). After excluding those who received no drug therapy, patients who received benzodiazepine after the training received significantly higher amounts of benzodiazepine (M = 252.50 mg) than those who received drug before (M = 144.64 mg). The average number of hours from the first benzodiazepine dose to the last was reduced from 13 to 5 hr. Clinical implications of matching patient symptomatology with appropriate drug therapy, thus preventing both over- and under-treatment for alcohol withdrawal symptoms, are discussed.     

Alcohol Biomarkers in Patients Admitted for Trauma

Background:  To assess the value of blood alcohol levels (BAL) and carbohydrate-deficient transferrin (CDT) in trauma patients.
Methods:  A prospective study was conducted among 213 patients admitted to a university hospital after trauma. Outcomes of interest included the development of alcohol withdrawal, infections, respiratory problems, cardiac events, thromboembolism, and length of stay.
Results:  The majority (78%) of the trauma patients in the study was males over the age of 18. Seventy-five percent were reported drinking an alcohol-containing beverage in the previous 30 days, 34% had ≥5 heavy drinking days, and 18.7% met current DSM-IV criteria for alcohol abuse and 13.1% current criteria for dependence. Twenty-two percent ( n  = 48) had a positive BAL and 14% ( n  = 30) a CDT level > 2.5%. Twelve percent ( n  = 27) of the sample developed alcohol withdrawal and 55% ( n  = 113) had one or more adverse health events during their hospitalization. The development of alcohol withdrawal was associated with an admission CDT >2.5% (χ²: 4.77, p  < 0.029) and/or a positive BAL (χ²: 54.01, p  < 0.001). The alcohol biomarkers identified 13 male and 3 female high-risk patients (7.4% of the total sample) who denied excessive alcohol use, and who would have been missed if these markers were not used. A composite morbidity trauma score composed of 25 adverse health events was associated with a positive BAL ( p  < 0.022).
Conclusion:  The study provides additional empirical evidence that supports the use of BAL in all patients admitted for trauma. The usefulness of CDT in trauma patients remains unclear and will require larger samples in more critically ill patients.     

SBIRT Outcomes in Houston: Final Report on InSight, a Hospital District-Based Program for Patients at Risk for Alcohol or Drug Use Problems

Background: Screening, Brief Intervention, and Referral to Treatment (SBIRT) services have been implemented as the standard of care for patients in the Harris County Hospital District (HCHD). The present analysis addresses alcohol and drug use for patients admitted over a 39‐month period from July 1, 2005 through September 30, 2008. Methods: Patients were screened for alcohol and drug use at medical admission. Those who were positive received further assessment and were transitioned to receive services as appropriate. A sample of consenting patients who were positive and received services was contacted at 6 months for a follow‐up interview. Using an intent‐to‐treat (ITT) protocol, the analysis included all patients who were assigned for follow‐up, including those with completed follow‐ups as well as those who could not be contacted at follow‐up. Patients not contacted at follow‐up were assumed to have maintained their baseline drug and alcohol consumption levels. Results: Of 59,760 patients who were screened by generalists (primarily nurses, physicians, and medical care technicians), 15,241 (26%) were positive and received further assessment and services. The 6‐month follow‐up interview completion rate was 66%. The ITT sample consisted of all 1,937 patients who were assigned for follow‐up. There was an overall reduction in the number of patients reporting any days of heavy drinking from 70% at intake to 37% at 6‐month follow‐up and a reduction in the mean number of days of heavy drinking from 7.8 days at intake to 4.1 days at follow‐up. The number of patients reporting any days of drug use was 82% at intake versus 33% at follow‐up, and the mean number of days of drug use declined from 8.3 days at intake to 4.2 days at follow‐up. Conclusions: The results were consistent with but of greater magnitude than most other studies reporting positive outcomes for SBIRT patients. Drug use and heavy alcohol use were found to decrease substantially from admission to follow‐up. This finding holds good for all levels of drug or alcohol misuse severity, with the highest severity patients showing the largest decreases. Future studies are needed to control for potential regression to the mean effects and to develop improved understanding of differences in outcomes by race/ethnicity.     

Substance abuse in an inpatient psychiatric sample.

The relationship between psychoactive drug abuse and psychopathology is complex. There have been few systematic explorations of substance abuse in psychiatric populations since the recent epidemic of cocaine abuse. To update and further explore the relationship between psychiatric illness and substance abuse, 100 consecutively admitted patients to an inpatient psychiatry unit were administered a drug and alcohol use/abuse questionnaire. Sixty-four percent endorsed current or past problems with substance abuse and 29% met DSM-III-R criteria for substance abuse in the 30 days prior to admission. For the major diagnostic categories, there were no significant differences between groups in percentages of patients with substance abuse disorders. There was a trend (p less than or equal to .2) toward an increased number of lifetime psychiatric hospitalizations in the substance-abusing group. Alcohol was the most common drug of choice followed by stimulants, cannabis, and sedative hypnotics. Differences in drug choices between diagnostic categories are discussed. Forty-three percent of urine drug screens obtained were positive, and of those with positive urine drug screens, 42% denied drug use upon admission. Only 40% of patients with current or past substance abuse problems had received treatment for their chemical dependency. In our sample, while substance abuse was very prevalent, it was underreported and undertreated.     

Treatment of hepatitis C virus and human immunodeficiency virus coinfection: from large trials to real life

To analyse the barriers for anti-hepatitis C virus (anti-HCV) treatment in human immunodeficiency virus (HIV)-HCV coinfected patients, we surveyed 71 physicians specializing in infectious disease (39%), internal medicine (27%), HIV/AIDS information and care (17%), haematology (10%) and hepatology (6%). A standard data collection form was used to identify patients observed in 7 days in November 2004. Three hundred and eighty patients with the following characteristics were included: male gender 71%; mean age 41.5 years; HIV diagnosed 12 years ago; routes of transmission via injection drug use (78%); undetectable HIV viral load (235/373, 63%) or <10 000 copies/mL (86/373, 23%). HCV RNA was positive in 325 of 369 (88%) patients; HCV genotype was 1 or 4 in 65% and liver biopsy had been carried out in 56%. There were several explanations for the nontreatment of HCV in 205 of the 380 (54%) patients, with 2.4 reasons per patient: anti-HCV treatment was deemed questionable (n = 109) because of minor hepatic lesions, alcohol consumption, or active drug use; no liver biopsy had been performed (n = 68); treatment was contraindicated (n = 62), mainly for psychiatric reasons; there was physician conviction of poor patient compliance (n = 62) and patient refusal (n = 33). Patients having received anti-HCV treatment (n = 91) compared with those who had never received any (n = 205) were more commonly of European origin, had better control of their HIV infection, were followed by a hepatologist more often, had a liver biopsy more often and had more commonly a high HCV viral load (P < 0.001). In 'real life' in France in 2004, more than half of the HIV-HCV coinfected patients have never received anti-HCV treatment. The main reasons are a treatment that may be deemed questionable (minimal hepatic lesions, alcohol, active drug use), a lack of available liver biopsy, a psychiatric contraindication and physician conviction of poor patient compliance.     

Motor vehicle collision fatalities involving alcohol and illicit drugs in Greece: the need for management protocols and a reassessment of surveillance

Aims The frequency and the effect of alcohol and illicit drugs on injury type, severity and location of death in motor vehicle collision (MVC) fatalities were investigated. Design Retrospective case–control study based on autopsy and toxicology. Settings Single faculty accepting referrals from Greater Athens and prefectures. Participants Consecutive pre‐hospital and in hospital fatalities. Measurements Demographics, toxicology, abbreviated injury scale (AIS), injury severity score (ISS), and location of death. Findings Of the 1860 screened subjects, 612 (32.9%) constituted the positive toxicology group (PTG) for alcohol or illicit drugs or both and the 1248 (67.1%) the negative toxicology group (NTG). The median age was 34 (4–90) years for the PTG and 45 (3–97) years for the NTG. The PTG included significantly higher proportions of males and motorcyclists. The PTG had a 50% increased risk for a severe (AIS≥3) cervical spine and 85% for a severe upper extremity injury, compared to the NTG. A total of 29.2% of the PTG and 22.4% of the NTG deaths were non‐preventable (ISS = 75). The frequency of severe trauma (ISS≥16) was comparable between PTG and NTG (P = 0.87). The PTG presented with a median ISS of 43 (6–75) versus 41 (2–75) of the NTG, hence without significant difference (P = 0.11). The pre‐hospital death rate was 77.8% for the PTG versus 58% of the NTG (P < 0.001). The analysis confirmed that the odds of positive toxicology were considerably higher in the subjects who arrived dead at the hospital (OR 2.62, P < 0.001). Conclusions In the greater Athens region, almost a third of motor vehicle collision‐related fatalities involved alcohol, illicit drugs or both. Individuals screened positive for alcohol or drugs were 2.6 times more likely to die before hospital admission than those with a negative toxicology screen, despite comparable injury severity. Specific evidence‐based management protocols and reassessment of surveillance are required.     

Treatment of hepatitis C infection for current or former substance abusers in a community setting

Summary.  Substance abusers account for the largest number of hepatitis C infected cases in developed countries. We describe a care model for treating current or former substance abusers with antiviral therapy for hepatitis C virus (HCV) infection. The care model involved hepatitis nurses, a psychologist, infectious disease specialist and primary care physicians. Clients met selection criteria including regular attendance at clinic appointments and social stability. Use of alcohol and illicit substances was monitored with urine toxicology screens. The association between substance use, rates of completion of therapy and rates of response were assessed using multivariable regression analyses. A total of 109 clients (75 with genotype 1/4 and 34 with genotype 2/3) received at least one injection with pegylated interferon between November 2002 and January 2006. Treatment completion rates of 61 and 74% were achieved for genotypes 1/4 and 2/3, respectively. Treatment response rates in an intention to treat analysis were 51% for genotypes 1/4 and 68% for genotypes 2/3. A positive urine toxicology screen indicating use of illicit substances 6 months prior to initiating therapy was significantly associated with lower rates of treatment completion but not lower rates of sustained virological response. A positive urine screen indicating use of alcohol prior to therapy was significantly associated with lower rates of completion and lower rates of response. Rates of completion and response are comparable to non-substance abusing populations. Antiviral therapy for HCV infection can be successful within the context of ongoing care for substance abuse for carefully selected patients .     

HIV Testing in Substance Abusers

HIV testing among substance abusers in the United States is a significant public and individual health issue in need of further examination. We analyzed interview data gathered over 15 months in 1992 and 1993 from 2315 patients on presentation for addiction treatment to determine the frequency of and factors associated with previous HIV testing. Among this group of alcohol, heroin, and cocaine abusers, 53% (1231) reported previous HIV testing. Although in bivariate and multivariable analyses those with identifiable risk factors for HIV were more likely to have been tested, 27% of injection drug users, 38% with multiple sexual partners, and 39% of those with a history of a sexually transmitted disease (STD) had not been HIV tested. Other factors associated with previous HIV testing included having a primary care physician, the primary care physician’s awareness of the patient’s substance abuse problem, and having received prior addiction care. However, 38% of substance abusers who had previously received addiction treatment beyond detoxification had not been tested. Of those tested, 10% (n = 122) reported a positive test, and 7% (n = 81) had not received the test results. Of those with positive test results, 37% were not injection drug users. Promotion of HIV testing among alcohol and other drug abusers in both medical and substance abuse treatment settings should be a priority.     

Long-Term Opioid Contract Use for Chronic Pain Management in Primary Care Practice. A Five Year Experience

Background The use of opioid medications to manage chronic pain is complex and challenging, especially in primary care settings. Medication contracts are increasingly being used to monitor patient adherence, but little is known about the long-term outcomes of such contracts. Objective To describe the long-term outcomes of a medication contract agreement for patients receiving opioid medications in a primary care setting. Design Retrospective cohort study. Subjects All patients placed on a contract for opioid medication between 1998 and 2003 in an academic General Internal Medicine teaching clinic. Measurements Demographics, diagnoses, opiates prescribed, urine drug screens, and reasons for contract cancellation were recorded. The association of physician contract cancellation with patient factors and medication types were examined using the Chi-square test and multivariate logistic regression. Results A total of 330 patients constituting 4% of the clinic population were placed on contracts during the study period. Seventy percent were on indigent care programs. The majority had low back pain (38%) or fibromyalgia (23%). Contracts were discontinued in 37%. Only 17% were cancelled for substance abuse and noncompliance. Twenty percent discontinued contract voluntarily. Urine toxicology screens were obtained in 42% of patients of whom 38% were positive for illicit substances. Conclusions Over 60% of patients adhered to the contract agreement for opioids with a median follow-up of 22.5 months. Our experience provides insight into establishing a systematic approach to opioid administration and monitoring in primary care practices. A more structured drug testing strategy is needed to identify nonadherent patients.     

A phase I study of ethyl acetate extract of the chinese antirheumatic herb Tripterygium wilfordii hook F in rheumatoid arthritis.

OBJECTIVE: To explore the efficacy and safety of ethyl acetate (EA) extracts of the Chinese herbal remedy Tripterygium wilfordii Hook F (TWHF) for treatment of patients with a variety of inflammatory and autoimmune diseases including rheumatoid arthritis (RA). METHODS: The roots of TWHF were extracted sequentially by ethyl alcohol and ethyl acetate and the content of the extract documented. An open label, dose escalation Phase I study was performed in 1993 in 13 patients with established RA. Clinical manifestations and laboratory findings were examined before and every 4 weeks after starting treatment with the EA extract. RESULTS: Three patients withdrew from the trial during the first 16 weeks of the dose escalation. These patients received a maximum dosage of 180 mg/day. There were no adverse effects or disease improvement observed in these patients. Nine of the remaining 10 patients tolerated the EA extract up to a dosage of 570 mg/day. There were no withdrawals related to adverse events in the trial except for one patient who developed diastolic hypertension at a dose of 180 mg/day of EA extract. Six of 10 patients treated with 180 mg/day of EA extract showed disease improvement. Eight of the 9 patients who received EA extract at doses > 360 mg/day experienced improvement in both clinical manifestations and laboratory findings. One patient met American College of Rheumatology criteria for remission. CONCLUSION: The EA extract of TWHF at dosages up to 570 mg/day appeared to be safe, and doses > 360 mg/day were associated with clinical benefit in patients with RA.     

Alcohol abuse: comparison of two methods for assessing its prevalence and associated morbidity in hospitalized patients

PURPOSE: To evaluate two methods for assessing the prevalence of alcohol abuse in hospitalized patients based upon scores on standardized alcoholism screening instruments compared with diagnostic discharge data, and to determine the risk for comorbid conditions in patients who abuse alcohol. PATIENTS AND METHODS: Of 2,534 consecutive patients admitted to five adult inpatient services of an academic center, 1,964 were screened for alcohol abuse using the CAGE and the SMAST. Their discharge diagnoses were obtained and analyzed for the presence of alcohol-related diagnoses and other comorbid conditions. RESULTS: A total of 1.4% of patients had a principal alcohol-related diagnosis (ARD), 6% had a secondary but no principal ARD, and 15% screened positive for alcohol abuse but had no ARD. The overall prevalence of alcohol abuse was 22.4%. Patients with a principal ARD had a higher risk for dementia, chronic obstructive pulmonary disease (COPD), pancreatitis, sequelae of liver disease, and illegal drug abuse. Patients with a secondary ARD were at risk for 19 comorbid conditions, including pancreatitis, injury, pneumonia, COPD, and poly-drug abuse. Patients who screened positive for alcohol abuse but had no ARD were significantly more likely to have a diagnosis of hypertension, arrhythmia, breast cancer, or pelvic inflammatory disease. CONCLUSION: Discharge diagnoses alone markedly underestimate the prevalence of alcohol abuse in hospitalized patients. Patients from the three groups are at higher risk for comorbid conditions, and secondary prevention of alcohol abuse can be achieved by routinely screening every patient using recognized alcoholism screening instruments.     

Treatment of cocaine and alcohol dependence with psychotherapy and disulfiram

Aims. To evaluate disulfiram and three forms of manual guided psychotherapy for individuals with cocaine dependence and concurrent alcohol abuse or dependence. Design. Randomized controlled trial. Setting. Urban substance abuse treatment center. Participants. One hundred and twenty-two cocaine/alcohol abusers (27% female; 61% African-American or Hispanic). Interventions. One of five treatments delivered over 12 weeks: cognitive behavioral treatment (CBT) plus disulfiram; Twelve Step facilitation (TSF) plus disulfiram; clinical management (CM) plus disulfiram; CBT plus no medication; TSF plus no medication. Measurements. Duration of continuous abstinence from cocaine or alcohol; frequency and quantity of cocaine and alcohol use by week, verified by urine toxicology and breathalyzer screens. Findings. Disulfiram treatment was associated with significantly better retention in treatment, as well as longer duration of abstinence from alcohol and cocaine use. The two active psychotherapies (CBT and TSF) were associated with reduced cocaine use over time compared with supportive psychotherapy (CM). Cocaine and alcohol use were strongly related throughout treatment, particularly for subjects treated with disulfiram. Conclusions. For the large proportion of cocaine-dependent individuals who also abuse alcohol, disulfiram combined with outpatient psychotherapy may be a promising treatment strategy. This study underlines (a) the significance of alcohol use among treatment-seeking cocaine abusers, (b) the promise of the strategy of treating co-morbid disorders among drug-dependent individuals, and (c) the importance of combining psychotherapy and pharmacotherapy in the treatment of drug use disorders.     

Complications of diagnostic physostigmine administration to emergency department patients

STUDY OBJECTIVES: Literature exists describing the complications associated with therapeutic physostigmine administration. No series exists detailing strictly diagnostic use. Our objective was to document the complications associated with diagnostic physostigmine administration in emergency department (ED) patients suspected of having antimuscarinic delirium. METHODS: Two reviewers blinded to the study purpose performed a retrospective chart review on all adult patients administered physostigmine diagnostically over a 79-month period at a tertiary-care hospital. Twenty percent of charts were reviewed by both abstractors. The data abstracted from the chart included total dose of physostigmine, effect on mental status, any subsequent complications, or any use of atropine. Discharge summaries, toxicology consultations, and urine drug screens were used to determine the cause of the altered mental status. RESULTS: Thirty-nine adult patients were administered varying doses of physostigmine (range 0.5 to 2 mg). The reviewers were able to determine the cause of the altered mental status in 35 patients. The cause was purely antimuscarinic in 19 patients, purely nonantimuscarinic in 10 patients, mixed antimuscarinic and nonantimuscarinic in 2 patients, psychiatric in 4 patients, and unknown in 4 patients. A total of 22 patients had full reversal of delirium, and this group comprised all 19 patients with a purely antimuscarinic cause and 3 patients in whom a cause was never determined. One (2.6%) in 39 patients had a brief convulsion without adverse sequelae. This patient was poisoned with an antimuscarinic drug. No patient had dysrhythmias, had signs of cholinergic excess, or was administered atropine. CONCLUSION: Diagnostic physostigmine administration was without significant complication when given to ED patients suspected of having antimuscarinic delirium. Although a relatively small series, it contributes to the safety profile of physostigmine.     

Management of Ventricular Fibrillation with Transvenous Defibrillators Without Baseline Electrophysiologic Testing or Antiarrhythmic Drugs

Tranvenous Defibrillators Without EP Testing. Introduction : Baseline electrophysiologic study (EPS) is routinely performed in patients resuscitated from ventricular fibrillation (VF) to risk stratify and select patients for chronic antiarrhythmic drug therapy. The role of EP testing prior to insertion of a multiprogrammable implantable cardioverter defibrillator (ICD), however, is unclear.
Methods and Results: This study was a retrospective review of outcome in 66 survivors of an initial episode of out-of-hospital VF not associated with a Q wave myocardial infarction or reversible causes, treated with transvenous ICDs as first-line therapy. Patients were excluded from the study if they had a previous history of monomorphic ventricular tachycardia (VT), a clinical history suggestive of supraventricular tachycardia, or had undergone preoperative EP testing. Fifty-two of the patients (79%) were male with an average age of 58 ± 11 years. Coronary artery disease was present in 43 patients (66%), cardiomyopathy in 15 patients (23%), and valvular heart disease in 1 patient (1.5%). Seven patients (11%) had no detectable structural heart disease. The mean left ventricular ejection fraction was 0.40 ± 0.16. With an average follow-up of 25 ± 12 months, survival free of death from any cause was 100%. Twenty-three patients (35%) experienced 48 episodes of recurrent rapid VT or VF (average cycle length: 236 ± 47 msec) treated by their device. The mean time to first therapy was 223 ± 200 days. Only one of these patients also received antitachycardia pacing for two episodes of VT. One patient (1. 5%) temporarily received amiodarone after removal of an infected device that was subsequently replaced. No other patient received antiarrhythmic drug therapy.
Conclusion : After a cardiac arrest due to primary VF, select patients treated with multiprogrammable ICDs can be managed successfully without baseline EPS or antiarrhythmic drug therapy.     

Injury among detoxification patients: alcohol users' greater risk

BACKGROUND: Little information exists about serious injury in alcohol or drug abusers who seek detoxification. This study examined injury prevalence, and the impact of alcohol use on injury, among alcohol- and drug-dependent persons. METHOD: We enrolled patients at a detoxification unit into a prospective cohort study and performed follow-up interviews to determine the prevalence of injury. Baseline and follow-up (6, 12, 18, and 24 month) data were examined separately by using multivariate logistic regression to determine factors associated with self-reported episodes of serious injury. The main independent variable was self-reported first and second substances of choice at admission: alcohol only, drug only, or both. RESULTS: Overall, 24% of the 470 subjects reported at least one instance of serious injury over the 6-month period before detoxification. Similarly, approximately 20% of subjects had serious injury during each 6-month follow-up period. Injury in the past 6 months was highest among the 63% of subjects who reported alcohol as a drug of choice (28-29% vs. 16% for drug only), even after we controlled for potential confounders. Analysis of 2-year follow-up data revealed a similar association, after we controlled for baseline injury and alcohol consumption. CONCLUSIONS: Injury is a serious problem for a substantial proportion of patients who undergo detoxification, particularly those with alcohol dependence. This marked risk for serious injury persisted for 24 months after detoxification. Patients at detoxification, particularly those with alcohol problems, represent a high-risk population for injury that may benefit from interventions to reduce these preventable complications.