Fatores Precipitantes de Delirium em Pacientes Idosos Hospitalizados / Precipitating Factors of Delirium in Elderly Hospitalized / Patients Factores precipitantes del delirio en pacientes ancianos hospitalizados

Objetivo: Caracterizar os fatores precipitantes e modificáveis de delirium em idosos internados acompanhados pela equipe móvel de Geriatria e Gerontologia. Método: estudo transversal, descritivo, exploratório e prospectivo realizado em um hospital de alta complexidade de São Paulo, com idosos hospitalizados. Os dados foram analisados por estatística descritiva. Resultados: foram avaliados 12 idosos, sendo 91,7% do sexo feminino, internados predominantemente em enfermarias cirúrgicas 83,3%. Os fatores precipitantes observados foram os ambientais presentes em 100% dos sujeitos do estudo, sendo possível realizar alguma intervenção em 83,3% dos casos, seguida pela categoria das doenças intercorrentes onde 45,4% dos casos foram passíveis de intervenção. Conclusão: no presente estudo, ao caracterizar os fatores precipitantes e modificáveis de delirium em idosos hospitalizados, espera-se evidenciar a possibilidade da implementação de prevenção e tratamento do quadro apontado, visando despertar os profissionais que atuam na prestação dos cuidados para a relevância do problema

ObjectiveTo characterize the precipitating and modifiable factors of delirium in hospitalized elderly accompanied by the mobile team of Geriatrics and Gerontology. Method: crosssectional, descriptive, exploratory and prospective study conducted in a highly complex hospital in São Paulo, with hospitalized elderly. The data were analyzed using descriptive statistics. Results: 12 elderly people were assessed, 91.7% of whom were female, predominantly hospitalized in surgical wards 83.3%. The precipitating factors observed were the environmental factors present in 100% of the study subjects, and it is possible to perform some intervention in 83.3% of the cases, followed by the category of intercurrent diseases where 45.4% of the cases were subject to intervention. Conclusion: in the present study, by characterizing the precipitating and modifiable factors of delirium in hospitalized elderly people, it is expected to highlight the possibility of implementing prevention and treatment of the mentioned condition, aiming to awaken the professionals who work in the provision of care for the relevance of the problem

Objetivo: Caracterizar los factores desencadenantes y modificables del delirio en ancianos hospitalizados acompañados del equipo móvil de Geriatría y Gerontología. Método: estudio transversal, descriptivo, exploratorio y prospectivo realizado en un hospital de alta complejidad en São Paulo, con ancianos hospitalizados. Los datos se analizaron mediante estadística descriptiva. Resultados: se evaluaron 12 ancianos, 91,7% de sexo femenino, predominantemente hospitalizados en quirófano 83,3%. Los factores precipitantes observados fueron los factores ambientales presentes en el 100% de los sujetos de estudio, siendo posible realizar alguna intervención en el 83,3% de los casos, seguido de la categoría de enfermedades intercurrentes donde el 45,4% de los casos fueron sometidos a intervención. Conclusión: en el presente estudio, al caracterizar los factores precipitantes y modificables del delirio en ancianos hospitalizados, se espera resaltar la posibilidad de implementar la prevención y el tratamiento de la condición mencionada, con el objetivo de despertar a los profesionales que laboran en la prestación de cuidados para la relevancia del problema.

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)

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.

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.

Predicting Acute Intoxication of Glufosinate-containing Herbicides: A Comparative Study of a Group with Complication Versus the Others without Complication in Single Institution

PURPOSE: Glufosinate-containing herbicides intoxication causes mild to severe complication, depending on patients' factors. However, it is not clearly known whether there are factors affecting glufosinate-containing herbicides intoxicated patients who develop complications. Thus, we sought to identify independent factors comparing the complicated group with the non-complicated group and to predict which patients will develop subsequent medical complication. METHODS: The medical records of patients with exposure to Glufosinate-containing herbicides at a tertiary academic university hospital in Korea from January 2012 to April 2015 were reviewed retrospectively. Demographic and clinical data of 75 patients were then analyzed by univariate and multivariate stepwise logistic regression analyses to identify potential predictors of significant complications following acute Glufosinate-containing herbicides poisoning for comparison of complicated patients with non-complicated patients. RESULTS: Of 75 patients, 44 (58.6%) had medical complications and 6 (8%) were dead. Neurologic complications (n=26, 35%) were the most common including seizure (n=18), delirium tremens (n=5), and amnesia (n=4). The results of univariate analysis showed that an advanced age (>60 years old), higher ingested amount of the herbicide (>100 mL), vomiting at arrival, medical history of hypertension, metabolic acidosis, and systemic inflammatory response score (SIRS)> or =2 were significant factors. However, the results of multivariate analysis showed that an advanced age (p60 years, and amount ingested>100 mL were significant predictive factors for significant medical complications in patients with Glufosinate-containing herbicides poisoning.

Estudio retrospectivo de cohorte sobre el antecedente de síndrome de abstinencia al alcohol y su asociación con delírium trémens en hospitalizaciones posteriores, Medellín, 2010-2012 / History of alcohol withdrawal syndrome and its association with delirium tremens on later hospitalizations: retrospective cohort study

Introducción: el consumo excesivo de alcohol es un problema de salud pública a nivel mundial que ocasiona anualmente, según la Organización Mundial de la Salud, 2,5 millones de muertes. En Colombia, el 11% de los mayores de 15 años cumple los criterios de abuso de alcohol del DSM-IV, con las consecuencias personales, legales y sociales que este implica, incluyendo las complicaciones asociadas al consumo crónico como el síndrome de abstinencia al alcohol y el delírium trémens. Objetivo: determinar si el antecedente de síndrome de abstinencia al alcohol se asocia con una mayor aparición de delírium trémens en pacientes atendidos por este síndrome en la ciudad de Medellín entre agosto de 2010 y julio de 2012. Materiales y métodos: se realizó un estudio de cohorte retrospectivo, comparando pacientes con y sin antecedente de síndrome de abstinencia al alcohol y el desarrollo de delírium trémens, además de otras posibles asociaciones como disfunción hepática y desequilibrios electrolíticos. El análisis de los datos fue de tipo bivariado, por medio de las pruebas estadísticas c2, Fisher y Mann Whitney. Resultados: se incluyeron 60 pacientes, en las características de base el 67% presentaron síndrome de abstinencia a alcohol, y 22% tuvieron antecedente de delírium trémens. Durante la estancia hospitalaria 56% de los sujetos desarrollaron delírium trémens. El antecedente de síndrome de abstinencia al alcohol no se asoció con desarrollar delírium trémens (p=0,26). En tanto que el antecedente de delírium trémens se comportó como un factor de riesgo para presentarlo nuevamente (p=0,02). Conclusión: el antecedente de síndrome de abstinencia al alcohol no se encontró relacionado con el desarrollo de delírium trémens en hospitalizaciones posteriores, en tanto que el antecedente de delírium trémens está asociado con la aparición de nuevos episodios. (MÉD.UIS. 2014;27(1):17-23).

Introduction: alcohol abuse is a public health problem around the world, which causes 2.5 million deaths per year according to the World Health Organization. In Colombia, 11% of the male population older than 15 years fulfills the DSM-IV criteria for alcohol abuse, with the personal, legal and social consequences that it entails, including those associated with chronic comsumption, such as withdrawal syndrome and delírium trémens. Objective: to establish if the history of alcohol withdrawal syndrome is related to a higher risk for development of delírium trémens in patients treated by this syndrome from the city of Medellin, between August of 2010 and July of 2012. Methods: this is a retrospective cohort study, with a comparison between patients with history of alcohol withdrawal syndrome and patients in their first episode, and the development of delírium trémens and the risk factors related with this. We did a bivariate analysis of the factors with the Mann Whitney, C2 and Fisher test. Results: 67% of the patients had a history of alcohol withdrawal syndrome and 22% showed previous episodes of delírium trémens. During hospitalization 56% of the subjects developed delírium trémens. The study showed that history of withdrawal syndrome is not a risk factor for the appearance of delírium trémens (p=0.26). In contrast, the record of delírium trérmens is a risk for new episodes (p=0.02). Conclusion: the history of alcohol withdrawal syndrome appears not to be a risk factor for the development of delírium trémens in a new hospitalization. On the other hand, the history of delírium trémens was associated with new episodes of delírium. (MÉD.UIS. 2014;27(1):17-23).

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.

A case of prolonged delirium tremens

We present a case of delirium tremens lasting for five weeks in an alcohol-dependent individual. The patient required high-dose benzodiazepines, which is atypical and rare. The clinical presentation and management of this patient is discussed.

Risk Factors of Suicide Attempt in Male Patients with Alcohol Dependence / 신경정신의학

OBJECTIVES: The aim of this study was to evaluate the risk factors of suicide attempt in patients with alcohol dependence. METHODS: A total of 68 patients admitted to the hospital for alcohol dependence were divided into two groups according to history of suicide attempt. In this study, sociodemographic variables, characteristics of alcohol drinking, and clinical scales were compared between the two groups. RESULTS: Regarding sociodemographic and clinical features, the alcoholic group with history of suicide attempt included more patients with no spouse, using medical aid in social security, and history of depressive disorder. Regarding characteristics of alcohol drinking, ages of first alcohol problems and first admission for alcohol problems were significantly younger in the attempter group. Patients in the attempter group had been drinking more and had higher frequency of delirium tremens and psychiatric admission. Regarding clinical scales, significantly higher scores for suicide ideation, depression, anxiety, and impulsiveness were observed in the attempter group. Among the scores for Temperament and character inventory, the score for persistence was significantly lower in the attempter group. After controlling for other compounding factors, depressive disorder [p=0.006, odds ratio (OR)=32.2] and suicide ideation (p=0.029, OR=1.2) were significant factors showing correlation with suicide attempt. CONCLUSION: Results of this study suggest that assessment and management of the depressive disorder and suicide ideation are necessary for suicide prevention in patients with alcohol dependence.

Guía de práctica clínica para la detección temprana, diagnóstico y tratamiento de la fase aguda de intoxicación de pacientes con abuso o dependencia del alcohol Parte I: Tamización, detección temprana y factores de riesgo en pacientes con abuso o dependencia del alcohol / Clinical practice guide for early detection, diagnosis and treatment of the acute intoxication phase in patients with alcohol abuse or dependencepart i: screening, early detection and risk factors in patients with alcohol abuse or dependence

Introducción: El alcohol es la segunda sustancia psicotrópica más usada en el mundo y el tercer factor de riesgo para muerte prematura y discapacidad. Su uso nocivo es un problema de salud pública mundial, dado su impacto personal, laboral, familiar, económico y social. Hasta el 70 % de las personas en riesgo de tener problemas con el alcohol no se detectan en la práctica médica, lo que hace pensar que se requieren medidas de tamizaje específicas que permitan la detección temprana y lleven a un tratamiento oportuno. Este artículo presenta la evidencia encontrada en tamización de abuso y dependencia de alcohol y en tamización e identificación de factores de riesgo; también presenta la evidencia relacionada con síndrome de abstinencia, delirium tremens y encefalopatía de Wernicke, con el fin promover una de detección temprana y un tratamiento oportuno. Método: Revisiones sistemáticas de la evidencia disponible y evaluación de las guías pertinentes identificadas en la literatura, para decidir, en cada pregunta, si se adopta o se adapta a una recomendación ya existente, o si se desarrollan recomendaciones de novo. Para las recomendaciones de novo y aquellas adaptadas, se realizó una síntesis de la evidencia, se elaboraron tablas de evidencia y se formularon las recomendaciones basadas en evidencia. Resultados: Se encuentra evidencia y se realizan recomendaciones para tamización pertinente y búsqueda de factores de riesgo, con el fin de realizar un diagnóstico y un manejo oportuno de abuso y dependencia a alcohol y sus complicaciones: síndrome de abstinencia, delirium tremens y encefalopatía de Wernicke...

Introduction: Worldwide, alcohol is the second most-used psychotropic substance and the third risk factor for early death and disability. Its noxious use is a world public health problem given its personal, labor, family, economic and social impact. 70 % of people under risk of having alcohol problems go undetected in medical practice, a fact that underlines the need for specific screening measures allowing early detection leading to timely treatment. This article presents evidence gathered by alcohol abuse and dependence screening as well as by risk factor identification and screening. It also presents evidence concerning withdrawal symptoms, delirium tremens and Wernicke’s encephalopathy in order to promote early detection and timely treatment. Methodology: Systematic revision of the evidence available together with an evaluation of pertinent guidelines found in literature so as to decide whether to adopt or adapt the existing recommendation for each question or to develop de novo recommendations. For de novo recommendations as well as those adapted, it was carried out an evidence synthesis, together with evidence tables and formulation of recommendations based on the evidence. Results: Evidence was found and recommendations were made for the pertinent screening and search of risk factors, in order to perform a diagnosis and carry out a timely management of alcohol abuse, dependence and ensuing complications: withdrawal syndrome, delirium tremens and Wernicke’s encephalopathy...

Guía de práctica clínica para la detección temprana, diagnóstico y tratamiento de la fase aguda de intoxicación de pacientes con abuso o dependencia del alcohol: Parte II: Evaluación y manejo de los pacientes con intoxicación aguda por alcohol / Clinical practice guide for early detection, diagnosis and treatment of the acute intoxication phase in patients with alcohol abuse or dependence Part II: evaluation and management of patients with acute alcohol intoxication

Introducción: El alcohol es la segunda sustancia psicotrópica más usada en el mundo y el tercer factor de riesgo para muerte prematura y discapacidad. Su uso nocivo es un problema de salud pública mundial, dado su impacto personal, laboral, familiar, económico y social. Es de suma importancia la identificación de intoxicación aguda por alcohol, el síndrome de abstinencia alcohólica y sus complicaciones, como delirium tremens y encefalopatía de Wernicke, para garantizar de esta manera un tratamiento oportuno para estos pacientes. Este artículo busca presentar la evidencia encontrada para el abordaje y el tratamiento de estas presentaciones clínicas. Método: Revisiones sistemáticas de la evidencia disponible y se evaluaron las guías pertinentes identificadas en la literatura, para decidir, en cada pregunta, si se adopta o se adapta a una recomendación ya existente, o bien, si se desarrollan recomendaciones de novo. Para las recomendaciones de novo y aquellas adaptadas, se realizó una síntesis de la evidencia, se elaboraron tablas de evidencia y se formularon las recomendaciones basadas en evidencia. Resultados: Se encuentra evidencia y se realizan recomendaciones para abordaje y tratamiento pertinente de intoxicación alcohólica aguda, síndrome de abstinencia, delirium tremens y encefalopatía de Wernicke...

Introduction: Worldwide, alcohol is the second most-used psychotropic substance and the third risk factor for early death and disability. Its noxious use is a world public health problem given its personal, labor, family, economic and social impact. The identification of acute alcohol intoxication is extremely important, as well as the alcohol withdrawal syndrome and its complications, such as delirium tremens and Wernicke’s encephalopathy in order to grant a timely treatment for those patients. This article introduces the evidence found so as to face and treat these clinic manifestations. Methodology: Systematic revision of the evi dence available together with an evaluation of pertinent guidelines found in literature so as to decide whether to adopt or adapt the existing recommendation for each question or to develop de novo recommendations. For de novo recommendations as well as those adapted, it was carried out an evidence synthesis, together with evidence tables and formulation of recommendations based on the evidence. Results: Evidence was found and recommendations were made for the diagnosis and treatment of acute alcohol intoxication, withdrawal syndrome, delirium tremens and Wernicke’s encephalopathy...

Recuperación de la adicción al alcohol: una transformación para promover la salud / Recovering from Alcohol Addiction: A Transformation to Promote Health / Recuperação do vício no álcool: uma transformação para promover a saúde

Se presenta una metasíntesis cuyo objetivo es establecer las características del proceso de recuperación en las personas que tienen adicción al alcohol. La metodología metasintética se fundamenta en la integración e interpretación de los hallazgos de algunos estudios cualitativos que permiten reconocer elementos sustanciales en la creación de nuevas interpretaciones en el fenómeno de recuperación de la adicción al alcohol. Para ubicar las fuentes se realizó una búsqueda en las bases de datos Ovid, Medline, Cinalh, Psych Info, Lilacs y Scielo, que comprendió el periodo 1988 a 2008, y en el que se ubicaron once artículos mediante las palabras clave: abuso de alcohol, adicción, dependencia, recuperación, experiencia e investigación cualitativa; de estos únicamente seis cumplieron con los criterios de calidad para ser incluidos en la metasíntesis. Los hallazgos permiten señalar que la recuperación es concebida como una trasformación con movimiento ascendente, conceptualización que implica reconocer la potencialidad de los aspectos positivos de las personas, alcanzar la madurez psicológica y espiritual, y lograr la paz y la libertad para actuar. En conclusión, este proceso de transformación inmerso en la recuperación debe ser reconocido por el profesional de enfermería para establecer, entre ese otro y ella, una fructífera interacción que permita el desarrollo del cuidado.

A meta-synthesis is presented to determine the features of the recovery process in persons who are addicted to alcohol. The metasynthesis method is founded on the integration and interpretation of findings from certain qualitative studies that shed light on substantial elements in the creation of new interpretations of the phenomenon of recovery from alcoholism. A search of the Ovid, Medline, Cinalh, PsychInfo, Lilacs and Scielo databases, covering the period from 1988 to 2008, was conducted to locate these sources and eleven (11) articles were found using the key words: alcohol abuse, addiction, dependency, recovery, experience and qualitative research. Only six of these words met the quality criteria to be included in the meta-synthesis. The findings indicate recovery is perceived as a transformation with an upward movement, a notion that implies recognizing the potential of a person's positive aspects, achieving psychological and spiritual maturity, and acquiring the peace and freedom to act. In conclusion, nursing professionals must recognize this process of transformation immersed in the recovery process, so as to establish fruitful interaction between themselves and the other person that allows care to develop.

Este artigo apresenta metassíntese, cujo objetivo é estabelecer as características do processo de recuperação nas pessoas que são viciadas no álcool. A metodologia metassintética se fundamenta na integração e interpretação dos descobrimentos de alguns estudos qualitativos que permitem reconhecer elementos substanciais na criação de novas interpretações no fenômeno de recuperação do vício no álcool. Para localizar as fontes, realizou-se uma busca nas bases de dados Ovid, Medline, Cinalh, Psych Info, Lilacs e SciELO, que compreendeu o período de 1988 a 2008, na qual se localizaram onze artigos a partir das palavras-chave: abuso de álcool, vício, dependência, recuperação, experiência e pesquisa qualitativa; destes onze, unicamente seis cumpriam os critérios de qualidade para serem incluídos na metassíntese. Os descobrimentos indicam que a recuperação é concebida como uma transformação com movimento ascendente, conceptualização que implica reconhecer a potencialidade dos aspectos positivos das pessoas, atingir a maturidade psicológica e espiritual, bem como a paz e a liberdade para agir. Em conclusão, esse processo de transformação imerso na recuperação deve ser reconhecido pelo profissional de enfermagem para estabelecer, entre este outro e ela, uma frutífera interação que permita o desenvolvimento do cuidado.

Risk Factors Associated with the Development and the Course of Alcohol Withdrawal Delirium / 신경정신의학

OBJECTIVES: The aim of this study was to analyze the clinical variables associated with the occurrence, duration, and severity of alcohol withdrawal delirium (AWD) in patients with alcohol dependence. METHODS: We conducted a retrospective case-control study in alcohol dependent inpatients admitted to the psychiatric department, between 2006 and 2012 (n=863). Multivariable logistic and linear regression models were used for analysis of risk factors associated with development of AWD and the duration of illness, respectively. And multivariable logistic regression models were applied for assessment of risk factors associated with seclusions or physical restraints, which reflect the severity of AWD. RESULTS: Significant predictors for the occurrence of AWD included higher body temperature, lower platelet count, lower serum potassium, higher drinking amount, history of AWD, and history of head trauma or structural brain lesion. Variables associated with prolongation of delirium included higher body temperature, higher drinking amount, and less use of benzodiazepine during the AWD episode. Significant predictors for severe AWD included higher systolic blood pressure, longer duration of harmful alcohol use, and higher drinking amount. CONCLUSION: Easily determinable parameters, such as vital signs and past history related to drinking are significantly associated with not only development of AWD, but also its severity and duration. Therefore, when initially assessing alcohol dependent patients, clinicians should keep these parameters in mind in order to prevent occurrence of risky withdrawal delirium and behavioral problems.

Clinical Factors Correlated to Delirium Tremens during Acute Alcohol Withdrawal of Inpatients with Alcohol Dependence / 신경정신의학

OBJECTIVES: The aim of this study was to explore clinical factors or high-risk factors associated with occurrence of delirium tremens (DT) during acute alcohol withdrawal in inpatients with alcohol dependence. METHODS: This study included 164 inpatients seeking treatment for acute alcohol withdrawal in the detoxification unit. All subjects were evaluated prospectively for known risk factors for DT and their occurrence of DT. Correlations were determined between risk factors obtained at admission and development of DT. RESULTS: Among all subjects, 42 patients (25.6%) suffered from delirium tremens within seven days after admission. DT patients had more severe alcohol withdrawal symptoms, the presence of past DT, and higher levels of aspartate aminotransferas, alanine aminotransferase, gamma-glutamyl-transpeptidase, and homocysteine, compared with patients who did not suffer DTs. According to results of a multiple regression, occurrence of DT showed correlation with the following factors at admission: tremor, a past history of DT, higher homocysteine level, and nausea and vomiting. CONCLUSION: Development of DT showed correlation with symptoms of severe alcohol withdrawal, past history of DT, and higher homocysteine level. Among these, a severity of alcohol withdrawal symptoms and a history of DT are factors that can be easily evaluated on the day of admission in order to predict the potential for occurrence of DT.

Alcohol-Related Neurologic Disorders: Ten Years of Experiences

Alcohol-related disorders are among the most costly health problems worldwide. Ingested alcohol is mainly metabolized by an oxidative pathway in the liver. Alcohol and its metabolic products (e.g., acetaldehyde and reactive oxygen species) have toxic effects on multiple organs, especially the nervous system. The diverse mechanisms of alcohol-related neurologic disorders include the direct toxic effects of alcohol, the alcohol withdrawal effect, nutritional deficiency secondary to alcoholism, and abnormalities of serum electrolytes and osmolality. We analyzed 156 cases of alcoholrelated neurologic disorders among admitted patients that had been referred in Korea during the previous 10 years. The duration of alcohol consumption ranged from 0.5 to 47 years (mean=17.8 years) and the mean amount of alcohol intake per day was 245.5 g. The 156 patients had the following diseases: Wernicke's encephalopathy (n=81, 51.9%), peripheral neuropathy (n=68, 43.6%), delirium tremens (n=59, 37.8%), Rum fit (n=31, 19.9%), pellagra encephalopathy (n=29, 18.6%), Korsakoff's psychosis (n=22, 14.2%), cerebellar atrophy (n=11, 7.0%), and alcoholic myopathy (n=6, 3.8%). We report on these cases and review the literature on alcohol-related neurologic disorders.

Alcohol Related Seizures in Chronic Alcoholics / 대한간질학회지

PURPOSE: Alcohol related seizures (ARS) are common problems in community. We reviewed the clinical characteristics of ARS in chronic alcoholics and evaluated the predictors of delirium tremens and recurrence of seizures. METHODS: We thoroughly reviewed all medical records of patients with alcohol related seizures at admission and some outpatient records for follow-up data. For the patients who had been lost during follow-up, telephone interviews were performed. We described the clinical characteristics of ARS during admission and analyzed the correlation between initial findings of ARS. RESULTS: Forty eight patients with ARS were admitted and followup data were available in 33 patients by out-patient records or telephone interviews. Forty-four patients were male and the mean age was 47.4+/-10.4 years old. Nine out of 33 patients became completely abstinent after discharge. Ten out of 24 current drinkers developed recurrent seizures and 20 out of 48 patients developed delirium tremens (DT) during admission. The number of seizures and age ofpatients were significantly related with DT. Patients with much weekly- consumption of alcohol were prone to develop recurrent seizures. CONCLUSIONS:These results suggest that careful attention should be paid to the patients with older age and multiple seizures at each event about the development of DT and to the patients with much weekly-consumption of alcohol about the recurrence of seizures during follow-up.

Effect of Withania somnifera Dunal in ethanol-induced anxiolysis and withdrawal anxiety in rats.

Withania somnifera (WS) or its psychotropic preparation is known to play a critical role in morphine, alcohol and benzodiazepines addiction. This study investigates the role of WS in acute ethanol and withdrawal from chronic ethanol consumption using elevated plus maze paradigm in rats. Acute administration of ethanol (1.5-2 g/kg, ip) triggered anxiolytic effect and withdrawal from prolonged ethanol (9% v/v ethanol, 15 days) consumption elicited enhanced behavioral despair (anxiety). Acute administration of WS (50 mg/kg, oral) potentiated the anxiolytic action of subeffective dose of ethanol (0.5 or 1 g/kg, ip). Moreover, the ethanol withdrawal anxiety was markedly antagonized in dose dependent manner by WS at 200 and 500 mg/kg or higher dose of ethanol (2.5 g/kg). However, co-administration of subeffective doses of WS (50 mg/kg, oral) and ethanol also attenuated withdrawal-induced anxiety due to chronic ethanol (9% v/v ethanol, 15 days) consumption. The results suggest the protective effect of WS in the management of ethanol withdrawal reactions.

Uso potencial dos anticonvulsivantes no tratamento ambulatorial da dependência de álcool / Potential use of the anticonvulsants in the outpatient treatment of alcohol dependence

Atualmente três medicações (dissulfiram, naltrexona e acamprosato) são aprovadas pela Food and Drug Administration (FDA) para tratar a dependência de álcool. As drogas anticonvulsivantes clássicas são raramente empregadas como alternativa por causa dos seus efeitos colaterais, mas a sua última geração pode ser útil. Os anticonvulsivantes podem ser uma alternativa aos benzodiazepínicos (BZD) e a outros tratamentos farmacológicos na prevenção de complicações na desintoxicação por apresentarem ausência de propriedades aditivas e um melhor perfil de efeitos adversos do que os anticonvulsivantes clássicos. Anticonvulsivantes como carbamazepina, ácido valpróico, gabapentina e topiramato demonstraram-se excelentes tratamentos para síndrome de abstinência do álcool e prevenção de recaídas. Embora nenhum desses agentes tenha sido aprovado pela FDA, existe uma crescente evidência na literatura que apóia o seu uso.

Currently three medications (disulfiram, naltrexone and acamprosate) are approved by the FDA to treat alcohol dependence by the FDA. The classical anticonvulsive drugs are rarely employed as an alternative because of their side effects, but the latest generation of anticonvulsants could be useful. The anticonvulsants can be a alternative to BZD and other pharmacological treatments in the prevention of complications during the detoxification therapy, because of the absence of addictive properties and a better adverse effects profile than classical anticonvulsant drugs. Anticonvulsants such as carbamazepine, valproic acid, gabapentin and topiramate have shown to be excellent treatment for alcohol withdrawal and for the prevention of alcohol relapse. Although none of these agents have been approved by the FDA yet, there is growing evidence in the literature to support their use.

Aspectos neurofarmacológicos do uso crônico e da Síndrome de Abstinência do Alcool / Neuropharmacological aspects of chronic alcohol use and withdrawal syndrome

O objetivo deste artigo é o de revisar e descrever as principais alteracões neurofarmacológicas causadas pela exposicão crônica ao álcool, assim como os fenômenos ocorridos durante o período de abstinência. São apresentados dados referentes às alteracões neuroadaptativas e de tolerância ocorridas nos principais sistemas de monoaminas, aminoácidos neurotransmissores e canais de cálcio, o que está relacionado a uma piora no prognóstico de portadores de comorbidades psiquiátricas com o consumo de álcool. São também descritos alguns estudos relevantes que demonstram o envolvimento de outros mecanismos de acão do álcool no sistema nervoso central, como o envolvimento de opióides, entre outras substâncias. O artigo reafirma a importância, para clínicos e pesquisadores, de um sempre maior entendimento do mecanismo de acão central do álcool, pois dele depende a busca por novas opcões farmacológicas, tanto para a reducão dos danos provocados pelo seu uso crônico, como para o tratamento da síndrome de abstinência a esta substância.

Complicacões psiquiátricas do uso crônico do álcool: síndrome de abstinência e outras doencas psiquiátricas / Psychiatric complications of alcoholism: alcohol withdrawal syndrome and other psychiatric disorders

A síndrome de abstinência alcoólica é um quadro agudo, caracterizado por um conjunto de sinais e sintomas autolimitados, com gravidade variada, secundário à interrupcão total ou parcial do consumo de álcool, podendo ser associado a inúmeros problemas clínicos e/ou outros transtornos psiquiátricos. O objetivo deste artigo é rever as principais complicacões psiquiátricas secundárias à síndrome de abstinência alcoólica, como convulsões e delirium tremens, bem como algumas outras condicões psiquiátricas associadas à dependência de álcool, como as síndromes de Wernicke Korsakoff e de Marchiava Bignami. Pretende-se, com isso, auxiliar no diagnóstico precoce e tratamento adequado, minimizando assim a morbidade e a mortalidade associadas a tais complicacões.