Clinical perspectives on the management of common psychiatric disorders in India

Psychiatric disorders are common health problems in patients of all age groups, under-diagnosis and under-treatment of these disorders can result in disability and serious complications. With an objective of creating a comprehensive evidence-based consensus on common mental health disorders and their management in the Indian setting, 10 expert groups meetings involving 98 psychiatrists across India were conducted in the month of May 2020. Clinical insights related to burden, signs and symptoms, diagnosis and management were summarized based on the discussions during these meetings. Experts agreed that depressive disorders and anxiety disorders represent two important psychiatric disorders in India. Selective serotonin reuptake inhibitors (SSRIs) are commonlyused for the treatment of depression. Benzodiazepines are effective for the treatment of comorbid anxiety in patients with depression, but their long-term use causes adverse events such as dependence and withdrawal reaction. Obsessive compulsive disorder (OCD), bipolar disorder, substance use especially alcohol withdrawal syndrome, and sleep disorders are other common psychiatric disorders found among Indian patients. Lithium and valproate represent the commonly used and effective pharmacological treatments for bipolar disorder. SSRIs are preferred drugs in the treatment of OCD,whereas benzodiazepines such as chlordiazepoxide and diazepam represent important pharmacological treatment optionsfor alcohol withdrawal. Early identification and timely and effective treatment of psychiatric disorders is important for prevention of complications. Treatment should be individualized based on efficacy, tolerability profile of the medicine, risk of drug interactions, and cost. This consensus may be useful to psychiatrists and general practitioners treating common psychiatric conditions in Indian patients.

Study of clinical and etiological profile of new onset seizure in adults reporting to tertiary care centre, Mysore

Background: Overall incidenceof seizure is found to be 0.2-0.6 per 1000 population per year. A first seizure mandates individual counselling about the risk of recurrence, the pros and cons of drug treatment. Seizures are usually a manifestation of an underlying pathology which may be genetic, structural or metabolic.Objectives of current study wereto study the clinical profile of new onset seizures in adults (greater than 19 years) attending to tertiary care Centre, Mysore and to determine the etiology of new onset seizures in adults reporting to tertiary care centre, Mysore.Methods:All participants fulfilling the inclusion criteria were interviewed as per proforma. Participant抯 demographic, social and medical details were recorded in proforma sheet and patients were subjected to neuroimaging studies, EEG and other necessary blood investigations. In all cases the seizure type is classified according to ILAE Classification 2017.Results:Among 100 cases evaluated for new onset, Majority of the patients were 41 to 60 years. Generalised seizures (95%) were more common than focal seizures.Among neurological etiological causes, vascular causes (34%) were most common. Most common Non-neurological cause for seizures was alcohol withdrawal (46.67%).Conclusions: If proper analysis of etiologyis made, seizures can be treated accordingly thus reducing the morbidity and mortality associated with it. Primary care physicians play a pivotal role in identifying patients with adult onset seizures and should encourage these patients to undergo neuroimaging so as to arrive at an appropriate etiological diagnosis.

Dilema terapéutico: síndrome de abstinencia alcohólica y encefalopatía hepática concurrentes. A propósito de un caso / Therapeutic dilemma: alcohol withdrawal syndrome and concurrent hepatic encephalopathy. A case report

RESUMEN El trastorno por consumo de alcohol es una de las principales causas de morbimortalidad en el mundo. La enfermedad hepática alcohólica es una complicación común de este trastorno y la encefalopatía hepática es una seria comorbilidad de la cirrosis alcohólica. Los factores precipitantes pueden relacionarse con infección, sangrado gastrointestinal, deshidratación o efectos de psicofármacos (p. ej., benzodiacepinas e hipnóticos no benzodiacepínicos). Se expone un caso del manejo hospitalario de un paciente con un trastorno severo por consumo de alcohol, cirrosis y encefalopatía hepática, quien desarrolla síntomas de abstinencia alcohólica durante su hospitalización y la complejidad del manejo antagónico de un delirium gabaérgico propio de la encefalopatía hepática en el contexto de un delirium glutamatérgico-noradrenérgico por abstinencia alcohólica.

ABSTRACT Alcohol use disorder is one of the main causes of morbidity and mortality in the world. Alcoholic liver disease is a common complication of this disorder, and hepatic encephalopathy is a serious complication of alcoholic cirrhosis. Precipitating factors may be related to infection, gastrointestinal bleeding, dehydration or the effects of psychotropic drugs (e.g. benzodiazepines and non-benzodiazepine hypnotics). We present a case of the hospital management of a patient with a severe alcohol use disorder, cirrhosis and hepatic encephalopathy who developed alcohol withdrawal symptoms while in hospital, and discuss the complexity of the antagonistic management of a GABAergic delirium characteristic of hepatic encephalopathy in the context of a glutamatergic-noradrenergic delirium due to alcohol withdrawal.

A study of alanine aminotransferase - aspartate aminotransferase as a marker of advanced alcoholic liver disease

Background: Alcohol is one of the most common etiology for chronic liver disease. There are several enzymes which remain elevated in both excessive Alcohol consumption and Alcohol induced liver cirrhosis1. But none is sensitive or specific. The ratio of Aspartate transaminase (AST) with Alanine transaminase (ALT) is one of the best marker for alcohol liver disease. Current study mainly compares the ratio of AST/ALT with both Alcoholic liver disease and excessive Alcohol consumption patients.Methods: Observational, cross sectional study conducted on 50 patients diagnosed with alcoholic liver disease and 50 patients of alcohol withdrawal syndrome. Either admitted or seen on outpatient basis at Bangalore medical college and research institute and data was compared among the groups and appropriate statistical methods are applied.Results: The mean ratio of AST/ALT ratio in 50 patients of alcoholic liver disease group was 3.45, whereas the mean ratio in 50 patient of alcohol withdrawal was about 99. When compared statistically this ratio was significant in chronic liver disease group.Conclusions: Most of the patients with heavy alcohol drinking had high AST and alt levels. But ratio of AST/ALT levels was significant high and suggest chronic liver disease secondary to alcohol.

Clinical profile and evaluation of new onset seizure in adults

Background: Seizures beginning in adult life are likely to be an identifiable cause as compared to those beginning in childhood which is more likely to be idiopathic. Aim and objectives: To study the clinical profile and analyze the etiological agents of New Onset Seizures. Materials and methods: This descriptive study was done in the Government HQRS Hospital and AIMSR, Chittoor, Andhra Pradesh to know the various etiologies in patients presented with newonset seizures. In these cases history and clinical examination and special investigations like CT brain, MRI brain, EEG, Serology, CSF analysis were done to find out the etiology. Results: Out of 100 patients, 55% were males, 45%were females with male to female ratio of 1.2:1. The majority of males were in 2nd decade and females were in 4th decade. Patients' age ranged from 18 years to 80 years, with the mean of 40.11 years with 77% of the patients were in the below 50 years. Alcohol withdrawal was the leading cause of seizures which account for 34% followed by idiopathic seizures (29%), neuro infection (16%), CVA 12% and metabolic (9%). Conclusion: Alcohol withdrawal is the most common cause of seizure in new-onset seizure patients who coming to Government HQRS Hospital and AIMSR Chittoor, Andhra Pradesh

Efeito do álcool na ilusão da máscara côncava: uma revisão / Effect of alcohol on the hollow-face illusion: a review / Efecto del alcohol en la ilusión de la máscara cóncava: una revisión

A ilusão da máscara côncava ocorre quando o observador a determinada distância percebe uma máscara facial côncava como convexa. Isso pode ser explicado pela sobreposição dos processos de alta ordem da percepção visual sobre os de baixa ordem. Pesquisas com indivíduos intoxicados e em Síndrome de Abstinência do Álcool (SAA) revelaram um prejuízo em perceber essa ilusão. O objetivo foi realizar uma revisão da literatura sobre o tema. Após buscas em bases indexadas, cinco pesquisas foram encontradas. Os resultados para os alcoolistas em SAA moderada revelaram uma menor frequência nas respostas de percepção da ilusão. Os resultados foram contraditórios quanto ao grupo de alcoolistas com SSA leve. Pesquisas futuras com metodologias diferentes são necessárias para testar as hipóteses explicativas da ilusão da máscara côncava em alcoolistas. É importante considerar os processos de tomada de decisão do observador diante da observação dos objetos como base a Teoria de Detecção de Sinal (TDS)

The hollow-face illusion happens when the observer perceives a concave facial mask as convex, at a given distance. This can be explained by the overlap of top-down on bottom-up visual processes. Researches demonstrated that intoxicated and Alcohol Withdrawal Syndrome (AWS) individuals had deficit in perceiving this illusion. This study aimed to review the literature on this topic. A survey of indexed databases found five studies. The results for alcoholics with moderate AWS were similar and showed a lower frequency in the answers of illusion perception. However, results were contradictory to the alcoholic group with mild AWS. Future researches with different methodologies are necessary to test the hollow-face illusion hypotheses in alcoholics. Therefore, it is also important to consider the observer's decision-making processes in the objects observation based on the Signal Detection Theory (SDT)

La ilusión de la máscara cóncava ocurre cuando el observador a cierta distancia percibe una máscara facial cóncava como convexa. Esto puede ser explicado por la superposición de los procesos de alto orden de la percepción visual sobre los de bajo orden. Las investigaciones con individuos intoxicados y en el Síndrome de Abstinencia del Alcohol (SAA) revelaron un perjuicio en percibir esa ilusión. El objetivo fue realizar una revisión de la literatura sobre el tema. Después de buscar en bases indexadas, se encontraron cinco encuestas. Los resultados para los alcohólicos en SAA moderada revelaron una menor frecuencia en las respuestas de percepción de la ilusión. Los resultados fueron contradictorios en cuanto al grupo de alcohólicos con SSA leve. Las investigaciones futuras con metodologías diferentes son necesarias para probar las hipótesis explicativas de la ilusión de la máscara cóncava en alcohólicos. Es importante considerar los procesos de toma de decisión del observador ante la observación de los objetos como base la Teoría de Detección de Señal (TDS)

Perspectivas del síndrome de supresión etílica: tratamiento a la mexicana / Perspectives about withdrawal alcoholic syndrome: Mexican treatment

Resumen El síndrome de supresión etílica es un problema de salud pública de especial atención en hospitales de segundo nivel en México. Clasificado como un padecimiento neuropsiquiátrico, la evidencia actual refleja daño sistémico más allá del sistema nevioso central. El manejo de estos pacientes se efectúa en las salas de hospitalización de Medicina Interna, cuando los síntomas son severos, requiere un abordaje multisistémico en la Unidad de Cuidados Intensivos. Si bien los criterios diagnósticos de la Sociedad Americana de Psiquiatría no se han modificado en las últimas ediciones (DSM-4 y 5), el tratamiento durante la última década se ha extendido por el gran espectro de opciones terapéuticas. El costo de hospitalización es elevado debido a las múltiples comorbilidades acompañantes encontradas en el paciente alcohólico. La finalidad de este trabajo es realizar una reseña de la perspectiva internacional y nacional de las diferentes guías en el manejo del cuadro, remembrando que sobre el clínico avezado recae la decisión terapéutica individualizada en cada caso.

Abstract Alcohol withdrawal syndrome is a public health problem of special attention in second level hospitals in Mexico. Classified as a neuropsychiatric condition, the current evidence reflects systemic involvement beyond the central nervous system. The management of these patients is carried out in the internal medicine hospitalization rooms; when the symptoms are severe, it requires a multisystemic approach in the Intensive Care Unit. Although the diagnostic criteria of the American Psychiatric Society have not been modified in the last editions (DSM-4 and 5), treatment during the last decade has been extended by the wide spectrum of therapeutic options in its management. The cost of hospitalization is high due to the multiple accompanying comorbidities found in the alcoholic patient. Therefore, the purpose of this paper is to review the international and national perspective of the different guidelines in the management of the disease, recalling that on the seasoned clinician falls the individualized therapeutic decision in each case.

Efeito do álcool na ilusão da máscara côncava: uma revisão / Effect of alcohol on the hollow-face illusion: a review / Efecto del alcohol en la ilusión de la máscara cóncava: una revisión

A ilusão da máscara côncava ocorre quando o observador a determinada distância percebe uma máscara facial côncava como convexa. Isso pode ser explicado pela sobreposição dos processos de alta ordem da percepção visual sobre os de baixa ordem. Pesquisas com indivíduos intoxicados e em Síndrome de Abstinência do Álcool (SAA) revelaram um prejuízo em perceber essa ilusão. O objetivo foi realizar uma revisão da literatura sobre o tema. Após buscas em bases indexadas, cinco pesquisas foram encontradas. Os resultados para os alcoolistas em SAA moderada revelaram uma menor frequência nas respostas de percepção da ilusão. Os resultados foram contraditórios quanto ao grupo de alcoolistas com SSA leve. Pesquisas futuras com metodologias diferentes são necessárias para testar as hipóteses explicativas da ilusão da máscara côncava em alcoolistas. É importante considerar os processos de tomada de decisão do observador diante da observação dos objetos como base a Teoria de Detecção de Sinal (TDS)

The hollow-face illusion happens when the observer perceives a concave facial mask as convex, at a given distance. This can be explained by the overlap of top-down on bottom-up visual processes. Researches demonstrated that intoxicated and Alcohol Withdrawal Syndrome (AWS) individuals had deficit in perceiving this illusion. This study aimed to review the literature on this topic. A survey of indexed databases found five studies. The results for alcoholics with moderate AWS were similar and showed a lower frequency in the answers of illusion perception. However, results were contradictory to the alcoholic group with mild AWS. Future researches with different methodologies are necessary to test the hollow-face illusion hypotheses in alcoholics. Therefore, it is also important to consider the observer's decision-making processes in the objects observation based on the Signal Detection Theory (SDT)

La ilusión de la máscara cóncava ocurre cuando el observador a cierta distancia percibe una máscara facial cóncava como convexa. Esto puede ser explicado por la superposición de los procesos de alto orden de la percepción visual sobre los de bajo orden. Las investigaciones con individuos intoxicados y en el Síndrome de Abstinencia del Alcohol (SAA) revelaron un perjuicio en percibir esa ilusión. El objetivo fue realizar una revisión de la literatura sobre el tema. Después de buscar en bases indexadas, se encontraron cinco encuestas. Los resultados para los alcohólicos en SAA moderada revelaron una menor frecuencia en las respuestas de percepción de la ilusión. Los resultados fueron contradictorios en cuanto al grupo de alcohólicos con SSA leve. Las investigaciones futuras con metodologías diferentes son necesarias para probar las hipótesis explicativas de la ilusión de la máscara cóncava en alcohólicos. Es importante considerar los procesos de toma de decisión del observador ante la observación de los objetos como base la Teoría de Detección de Señal (TDS)

To Study Predictors For Withdrawal Seizures In Patients Of Alcohol Withdrawal Syndrome

Introduction– The alcohol withdrawal seizure(WS) occurs during the early phase of withdrawal and is characterized by reduction in the seizure threshold and it emerges within 48 hours of cessation of prolonged drinking (Brathen G et al,1999;Victor M et al,1967.)The appearance of a withdrawal seizure represents a strong risk factor for progression into a severe withdrawal state with following development of DT in up to 30% of cases(Victor M et al,1967). Aim– The purpose of the current study is to identify the most parsimonious collection of risk factors present at the time of hospital admission that were predictive for the development of WS. METHODOLOGY– 102 subjects admitted at deaddiction centre, SMS hospital were selected using a screening performa which was followed by a comprehensive assessment of alcohol use followed by relevant laboratory investigations with blood pressure and pulse rate recording. Severity of alcohol withdrawal syndrome (AWS) was determined in analogy to the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA–Ar) scale. Patients were put on standard treatment based upon institute guidelines and withdrawal was assessed for 1 week. Patients were monitored for withdrawal seizure and diagnosis was made as per criteria of ICD 10. RESULTS– Age of onset of drinking, duration of alcohol abuse and daily ethanol intake were found to be significantly correlated to the development of WS. Systolic BP, Diastolic BP, Heart rate had significant correlation to the occurrence of WS which can be attributed to the autonomic hyperactivity during the withdrawal state. CIWA–Ar score also came out to be a significant risk factor to the development of WS.Previous history of seizures, delirium tremens, previous alcohol withdrawal syndrome and previous detoxification episodes were also a significant risk factor for the occurrence of WS . CONCLUSION– The various variables that were found to be significantly correlated to the occurrence of WS are mentioned as follows: age, duration of abuse, daily alcohol intake, CIWA–Ar score>15, systolic & diastolic BP, previous history of WS and DT, previous history of alcohol withdrawal syndrome and previous detoxification episodes.

Effects of Alcohol Dependence or Withdrawal on Median Effective Dose of Propofol in Rats / 中国药房

OBJECTIVE:To determine the median effective dose (ED50) of propofol with single intravenous injection in alcohol dependence or withdrawal model rats,and to observe the anaesthetic effect of 2-fold ED50 propofol. METHODS:Fifty SD rats were divided into drinking group(n＝23)and control group(n＝27)based on whether the consumption of alcohol was greater than 3.0 g/(kg·d). Drinking group continued to drink freely and intermittently to establish alcohol dependence model. Control group was only given drinking water for ethanol elution 16 rats were randomly selected from each group to determine ED50 of propofol with single intravenous injection by sequential method,and initial dose was 6.02 mg/kg. After eluting for a week,alcohol dependence rats stopped drinking for 24 hours and had alcohol withdrawal symptoms to establish alcohol withdrawal model. ED50 of propofol in alcohol withdrawal group and control group were determined with same method. After eluting for a week,anaesthetic effect [disappearance time and reappearance time of forepaw righting reflex(FRR),time of activity complete recovery] of 2-fold ED50 propofol with single intravenous injection were observed in alcohol dependence group,alcohol withdrawal group and control group,and corresponding time point and the frequency of respiration before administration were also observed. Changes of liver function indexes(serum albumin,alanine transaminase,total bilirubin,γ glutamyl transaminopeptidase)and liver histomorphology were observed 48 h after medication,10 in each group. RESULTS:ED50 of propofol in alcohol dependence model rats was 9.563 mg/kg,which was higher than 5.623 mg/kg of control group. ED50 of propofol in alcohol withdrawal model rats was 4.086 mg/kg,which was lower than 5.297 mg/kg of control group. Compared with control group,reappearance time of FRR was prolonged significantly in alcohol dependence group and alcohol withdrawal group (P＜0.05). There was no statistical significance in disappearance time of FRR or activity complete recovery time (P＞0.05). The frequency of respiration during FRR disappearance was lower than before propofol injection,FRR reappearance and activity complete recovery (P＜0.01). After intravenous injection of 2-fold ED50 propofol,reappearance time of FRR in alcohol dependence group and alcohol withdrawal group were longer than control group(P＜0.05)；the alcohol dependence group was longer than the alcohol withdrawal group(P＜0.05).The time of activity complete recovery in alcohol dependence group was longer than control group and alcohol withdrawal group (P＜0.05). The frequency of respiration in 3 groups during FRR disappearance were all lower than before propofol injection,FRR reappearance and activity complete recovery(P＜0.01). There was no significant difference in the change of liver function indexes or liver histomorphology. CONCLUSIONS:ED50 of propofol is increased in alcohol dependence rats,while ED50 of propofol is decreased in alcohol withdrawal rats. 2-fold ED50 of propofol has no significant toxicity to liver function.

Pharmaceutical Care Performed by Clinical Pharmacist for One Patient with Alcohol Withdrawal and Emergency Dyspnea / 中国药师

Objective:To provide reference for the sedation therapy and clinical monitoring for the patients with liver cirrhosis and alcohol withdrawal.Methods:Clinical pharmacist participated in the treatment process of emergency dyspnea in one patient with liver cirrhosis and alcohol withdrawal,and the thoughts and practice methods of clinical pharmacist participating in clinics were shared.Results:Based on the literatures,clinical pharmacist thought the emergency dyspnea was caused by overdose of sedatives.Therefore,medication monitoring and education on the drugs were provided for the patient,and pharmaceutical suggestions were put forward for the next treatment.Conclusion:Clinical pharmacists can help physicians analyze the causes of adverse reactions,and provide pharmaceutical care and medication education to ensure the safety and effectiveness of drug treatment.

Manejo del síndrome de abstinencia alcohólica en los pacientes críticos / Management of the syndrome of alcohol withdrawal in critical patients

El manejo del síndrome de abstinencia alcohólica es un desafío en los pacientes críticos. Con frecuencia, se desconocen los antecedentes de consumo de alcohol o este dato es incompleto, lo que limita la identificación de quienes pueden desarrollar este síndrome. El cese abrupto del consumo de alcohol coloca a estos pacientes en alto riesgo de sufrir síndrome de abstinencia alcohólica grave. Típicamente, las benzodiacepinas son consideradas las drogas de primera línea para el manejo de estos casos. Sin embargo, si el paciente progresa a un estado más grave con convulsiones o delirium tremens, puede ser necesario administrar medicación adyuvante a las benzodiacepinas, como el propofol o la dexmedetomidina, o emplear estas últimas drogas como terapias alternativas en aquellos que no responden a las benzodiacepinas. La aparición de convulsiones representa un fuerte factor de riesgo para la progresión a un síndrome de abstinencia alcohólica grave, con el desarrollo posterior de delirium tremens hasta en el 30% de los casos. El delirium tremens es el cuadro más grave y ocurre en el 5-20% de los pacientes con este síndrome, con una mortalidad hasta del 25% sin tratamiento y que se reduce al 0-1% con tratamiento. Es importante conocer el antecedente del consumo de alcohol para evitar el síndrome de abstinencia alcohólica o tratar rápidamente sus síntomas más graves, y mejorar la supervivencia de estos pacientes.(AU)

Alcohol withdrawal syndrome (AWS) is a well-known and a challenging condition occurring in critically ill patients. Frequently, history of alcohol abuse is unknown when the patient is admitted to the intensive care unit, limiting the identification of those who could develop AWS. The abrupt cessation of a heavy or constant drinking put these patients in high risk of suffering from this syndrome in its severe form. Typically, benzodiazepines are considered the first line of treatment. However, if clinical conditions progress to epileptic seizures or delirium tremens or are refractory to benzodiazepines, adjuvant drugs like propofol or dexmedetomidine might be an option to control the severe symptoms. Delirium tremens can occur in up to 30% of patients; it is the most severe picture with a mortality of 25% without treatment and that can be reduced to almost 0-1% with treatment. It is important to appropriately identify alcohol abuse in order to avoid the early clinical manifestations of AWS or rapidly treat its most severe symptoms and improve survival.(AU)

Abstinência alcoólica: implicações da síndrome na percepção binocular de profundidade ou relevo da máscara côncava / Alcohol withdrawal: syndrome implications in the binocular perception of depth or relief of concave mask / Abstinencia del alcohol: implicaciones de síndrome en percepción de profundidad binocular o relieve de máscara hueca

Esta pesquisa teve por objetivo investigar a percepção binocular da ilusão da máscara côncava em indivíduos com Síndrome de Abstinência do Álcool comparativamente aos saudáveis. Indivíduos saudáveis, com Síndrome de Abstinência do Álcool leve e com moderada, observaram com os dois olhos, a face côncava de uma boneca disposta dentro de uma caixa, a classificam como côncava ou convexa e atribuíram centímetros a sua classificação. Apenas os observadores com Síndrome de Abstinência do Álcool moderada apresentaram um déficit em realizar a inversão visual da máscara côncava, diferindo estatisticamente do grupo de observadores saudáveis. Os grupos não diferiram quanto às atribuições métricas de profundidade ou relevo à máscara côncava. Constatou-se que a máscara côncava é um instrumento efetivo na detecção de possíveis prejuízos perceptuais em indivíduos com Síndrome de Abstinência do Álcool moderada.

This research aimed to investigate the binocular perception of the hollow-mask illusion in individuals with alcohol withdrawal syndrome compared to healthy. Healthy subjects, with mild and moderate alcohol withdrawal syndrome, observed with both eyes, the concave face of a doll willing inside of a box. They classified the mask as concave or convex and attributed centimeters your ranking. Only observers with moderate alcohol withdrawal syndrome showed a deficit in visual inversion of the concave mask statistically different from the healthy group observers. The groups did not differ with respect to metrics assignments depth or relief with the hollow mask. It was found that the concave mask is an effective tool in detecting possible perceptual impairments in subjects with moderate alcohol withdrawal syndrome.

Esta investigación tiene como objetivo investigar la percepción binocular de la ilusión de la máscara hueca en las personas con síndrome de abstinencia de alcohol en comparación con los sanos. Los individuos sanos, con síndrome de abstinencia de alcohol leve e moderado, observado con los dos ojos, la cara cóncava de una muñeca dispuestos en una caja, para clasificar como cóncava o convexa y atribuyeron centímetros su ranking. Solamente los observadores con síndrome de abstinencia de alcohol moderada mostraron un déficit en la realización de la inversión visual de la máscara cóncava, estadísticamente diferentes entre el grupo de los observadores sanos. Los grupos no mostraron diferencias con respecto a profundidad métricas asignaciones o criados con la máscara hueca. Se encontró que la máscara cóncava es una herramienta eficaz en la detección de posibles deficiencias de percepción en los individuos con síndrome de abstinencia alcohólica moderada.

Management of Alcohol Withdrawal Syndrome and Alcohol Withdrawal Seizure

Alcohol withdrawal syndrome (AWS) is a common condition occurring after intentional or unintentional abrupt cessation of alcohol in an alcohol-dependent individual. AWS represents a major problem in our society and alcohol withdrawal seizure is the major cause of seizures encountered by neurology residents in the emergency department. Patients with AWS present with mild symptoms of tremulousness and agitation or more severe symptoms including withdrawal seizures and delirium tremens. Particularly, severe AWS can produce significant rates of the morbidity (complications) and mortality. When diagnosed and managed insufficiently, the morbidity and mortality rates increase. Nevertheless, patients with AWS may be neglected and are often marginalized and the teaching about AWS to neurology residents is usually minimal. Also, attending neurologists are often poorly informed on the topic. Although there is insufficient consensus about the optimal investigation and management, the purpose of this review is to serve as a summary of the appropriate identification and management of this important condition in a neurological setting.

Central Pontine Myelinolysis Induced by Alcohol Withdrawal: A Case Report

Central pontine myelinolysis (CPM) is a demyelinating disorder characterized by the loss of myelin in the center of the basis pons, and is mainly caused by the rapid correction of hyponatremia. We report the case of a young woman who presented with gait disturbance and alcohol withdrawal, and who was eventually diagnosed with CPM. Generally, the cause and pathogenesis of CPM in chronic alcoholics remain unclear. In this cases, the CPM may be unrelated to hyponatremia or its correction. However, it is possible that the osmotic pressure changes due to refeeding syndrome after alcohol withdrawal was the likely cause in this case. This case illustrates the need for avoiding hasty, and possibly incomplete diagnoses, and performing more intensive test procedures to ensure a correct diagnosis.

La psiquiatría de enlace y el diagnóstico del delirium tremens / Liaison psychiatry in diagnosing delirium tremens

La manifestación clínica más grave y potencialmente fatal de la abstinencia de alcohol es el delirium tremens (DT), cuadro observado en aproximadamente el 5% al 10% de los pacientes con trastorno por consumo de alcohol que requieren hospitalización. El diagnóstico adecuado del DT requiere conocer los factores de riesgo, el cuadro clínico típico y la evolución y la gravedad de los síntomas de abstinencia. Las benzodiazepinas son el tratamiento farmacológico de elección para los pacientes con DT. Su eficacia fue confirmada mediante numerosos estudios. Si bien hay drogas alternativas que también pueden ser efectivas, las benzodiazepinas son elegidas debido a su perfil farmacocinético y de seguridad favorable. Las drogas alternativas son utilizadas como complemento de las benzodiazepinas para el tratamiento de los pacientes con cuadros de abstinencia complicados o resistentes. Los esquemas que incluyen dosis de carga administradas por vía oral o intravenosa son los preferidos para los pacientes con DT. El aumento rápido de la dosis de benzodiazepinas de acuerdo con la gravedad de los síntomas evaluados mediante escalas estructuradas y el empleo de drogas adyuvantes alternativas permiten el control oportuno del DT. Cerca del 10% de los pacientes que presentan resistencia a las benzodiazepinas requieren tratamiento en unidades de terapia intensiva con dosis intravenosas elevadas de benzodiazepinas y otras drogas, evaluación minuciosa y, de ser necesario, ventilación mecánica. La suplementación vitamínica y la atención adecuada por parte del personal de enfermería también son componentes esenciales del tratamiento. Los psiquiatras de enlace deberían integrar equipos multidisciplinarios destinados al tratamiento agudo de los pacientes con DT. No obstante, solo los psiquiatras de enlace con capacidades y conocimiento que se desempeñan de acuerdo con los protocolos estandarizados pueden lograr que determinados pacientes con DT reciban tratamiento adecuado. El psiquiatra de enlace también debe procurar un periodo de abstinencia seguro que proteja la dignidad del paciente y lo prepare para resolver la dependencia

The most serious and potentially life-threatening manifestation of alcohol withdrawal is delirium tremens (DT) or alcohol withdrawal delirium, which occurs in about 5% to 10% of hospitalized patients with alcohol problems. A consideration of risk factors, the typical clinical picture, evolution of withdrawal-symptoms and their severity aid in the proper recognition of DT. Benzodiazepines are the mainstay of medication treatment of DT. Their efficacy has been established by a large body of evidence. Although alternative medications might be equally effective, benzodiazepines are preferred because of their favourable pharmacokinetic and safety. Alternative medications are used as adjuncts to benzodiazepines in the treatment of complicated and refractory withdrawal states. Oral or intravenous loading-dose regimens are preferred for treatment of DT. Rapidly escalating doses of benzodiazepines titrated to symptom-severity on structured scales and the use of adjunctive alternative medications ensures prompt control of DT. About 10% of patients who are benzodiazepine-resistant require treatment in intensive care units with massive intravenous doses of benzodiazepines and additional medications, careful monitoring and mechanical ventilation if necessary. Vitamin supplementation and adequate medical, nursing and supportive care are other essential components of management. Liaison psychiatrists are expected to form an integral part of the multidisciplinary team, which manages patients with DT in acute-care settings. Only skilled and knowledgeable liaison psychiatrists relying on standardized treatment protocols can make certain that patients with DT receive adequate care. The liaison psychiatrist also needs to ensure a safe and humane withdrawal that protects the patient's dignity and prepares the patient for on-going treatment of dependence.

Effects of Early Administration of Dexmedetomidine on Benzodiazepine Requirements of ICU Patients with Alcohol Withdrawal Syndrome / 中国药师

Objective:To evaluate the effects of early administration of dexmedetomidine on benzodiazepine ( BZD) requirements of intensive care unit ( ICU) patients with alcohol withdrawal syndrome ( AWS) .Methods:Totally 60 adult patients with severe AWS were chosen and randomly divided into groups A and group B with 30 patients in each .The patients in group A received benzodiazepine simultaneously with early administration of dexmedetomidine , and those in group B received only benzodiazepine .After the first admin-istration of dexmedetomidine , the 24-h cumulative BZD requirement , stay length in ICU and hospital , condition of mechanical ventila-tion and incidence of hypotension and bradycardia were recorded .Results:The 24-h cumulative BZD requirement in group A was obvi-ously lower than that in group B [(8.6 ±1.2) mg vs (25.6 ±4.9) mg, P<0.05].The number of patients with mechanical ventila-tion in the two groups was similar, while the duration of intubation in group A was less than that in group B [(24.9 3.1) h vs (48.8 6.9) h, P<0.05].Additionally, group A had higher incidence of bradycardia when compared with group B (57% vs 13%, P<0.05).Conclusion:As the adjuvant treatment for alcohol withdrawal syndrome , early administration of dexmedetomidine can notably decrease the benzodiazepine requirement of ICU patients .

Research of microRNAs on alcohol dependence / 中华行为医学与脑科学杂志

Objective To evaluate the microRNA role in the pathogenesis of alcohol dependence.Methods By computer retrieval Medline,mirbase,PubMed,Chinese journal full-text database (CNKI),ten thousand database and VIP database,manual retrieval relevant references.Literature retrieval time limit are built from the library until July 2014.English database to Alcoholism,Alcohol Dependence,Alcohol Abstinence,Alcohol Amnestic Disorder Fetal Alcohol Spectrum Disorders,mirna as keywords retrieval;Chinese database to Alcoholism,Alcohol Dependence,Alcohol Abstinence,Alcohol Amnestic Disorder Fetal Alcohol Spectrum Disorders,microRNA,etc.Retrieved from the database to the related literature in July 2014.Results A total of 26 studies were recruited including 8 Chinese literatures and 18 English literatures.Conclusion Abnormal expression of miRNAs will become the next research direction.MicroRNAs may become new biomarker of alcohol dependence on diagnosis,may also makes the molecular drug targets,or the molecular simulation for new drug research and development,this could be for the treatment of alcohol dependence provides a new means.

Ilusão da máscara côncava durante a síndrome de abstinência leve do álcool / Hollow-face illusion during during mild alcohol withdrawal syndrome

A ilusão da máscara côncava caracteriza-se pela inversão visual da profundidade durante a observação do reverso de uma máscara da face humana, que é percebido como convexo. O objetivo deste trabalho foi investigar a percepção monocular da profundidade ou relevo de uma máscara côncava, sob quatro condições de iluminação distintas, em 8 indivíduos com a Síndrome de Abstinência do Álcool (SAA) leve comparativamente a 8 participantes saudáveis. As contribuições nesta área de investigação são escassas e os resultados encontrados são controversos. Além disso, resta investigar a condição monocular de observação do estímulo. A máscara côncava foi posicionada no interior deuma caixa e observada através de um visor. Não foram observadas diferenças significativas entre os indivíduos com a SAA leve e os observadores saudáveis. A maioria dos observadores realizou a inversão visual da profundidade da máscara côncava, percebendo a face ilusória convexa. Ressalta-se a supremacia dos processos cognitivos, de alta ordem (top-down), sobre os processos sensoriais, de baixa ordem (bottom-up), na ilusão da máscara côncava. A observação monocular facilitou a ilusão e não foi adequada para investigar os prejuízos no processamento cognitivo de informações visuais causados pela SAA leve

The hollow-face illusion is the visual depth inversion that happens when a hollow mask of a human face is perceived as convex. The aim of thiswork was to investigate the monocular perception of depth or relief of a hollow mask, under four distinct illumination conditions, in 8 individuals with mild alcohol withdrawal, comparing to 8healthy participants. Scientific contributions in this research area are scarce and the results are controversial. Furthermore, it remains to investigate the status of monocular observationof the stimulus. The hollow mask was placed inside of a box and observed through a viewfinder. There was not significant differences between the individuals with mild alcohol withdrawal and the healthy observers. The significant majority of the observers made the visual depth inversion,perceiving the convex illusory face. It is important to notice the dominance of the high order, cognitive process (top-down) over low ordersensorial process (bottom-up) in the hollow-face illusion. The monocular observation facilitated illusion and it was not suitable to investigate the impairments in the cognitive processing of visual information caused by mild SAA

The Relationship of Alcohol Withdrawal Delirium and Alcohol Withdrawal Symptoms in Patients with Alcohol Dependence

OBJECTIVE: This study was performed to analyze the clinical variables associated with occurrence of delirium tremens (DT) in inpatients with alcohol dependence initially admitted with diseases unrelated to alcohol. METHODS: This study included 132 inpatients seeking treatment for medical problem with acute alcohol withdrawal. The cases were divided into two groups : with DT group (n=44), without DT group (n=88). We compared the epidemiologic data, alcohol withdrawal symptoms and serum analysis data between two groups. We used the logistic regression to predict risk factors for DT. RESULTS: The DT group had more severe alcohol withdrawal symptoms, more amount of drinking alcohol, more number of drinking per month, higher blood urea nitrogen (BUN), creatinine, amylase, C-reactive protein and lower serum total protein than the without-DT group. According to the result of a logistic regression, occurrence of DT showed correlation with the following factors : sweating, hallucination, agitation, amount of alcohol consumption, number of drinking per month. CONCLUSION: Our study suggests development of DT was correlated with severe alcohol withdrawal symptoms, high BUN, creatinine and low total serum protein. Therefore, during assessment of alcohol dependent patients, clinicians should keep these parameters in mind in order to prevent DT.