Tasas de incidencia de ingresos asociados a síndrome de abstinencia alcohólica en España: análisis del conjunto mínimo básico de datos 1999-2010 / Incidence rates of admissions associated with alcohol withdrawal syndrome in Spain: Analysis of minimum basic data set 1999-2010

Introducción: No existen datos acerca de la incidencia de ingresos asociados a síndrome de abstinencia alcohólica (SAA) ni sobre su evolución en los últimos años en España. Objetivos: Analizar las características, tasas de incidencia y tendencia evolutiva de los ingresos hospitalarios asociados a SAA en hospitales públicos españoles. Material y método: Análisis de la base de datos del CMBD de hospitales públicos españoles de los ingresos hospitalarios con SAA (CIE9-MC 291.81), delirio por abstinencia alcohólica (CIE9-MC 291.0) o alucinosis por abstinencia alcohólica (CIE9-MC 291.3), entre los años 1999 y 2010. Resultados: Se registraron 56.395 ingresos asociados a SAA. La edad media fue de 50,9 años (DE 12,5) y el 88% eran hombres. El servicio de ingreso más frecuente fue Medicina Interna (24,9%). La estancia media global fue de 12,6 días (DE 14,4) y la mortalidad del 4,7%. El 62,6% desarrollaron SAA durante un ingreso por otro motivo, en su mayoría por enfermedades relacionadas con el alcohol. Los diagnósticos secundarios en pacientes que ingresaron por SAA tenían relación directa o indirecta con el consumo de alcohol en más de la mitad de los casos. La tasa de incidencia de ingresos en España asociados a SAA se mantuvo estable entre 1999 y 2010, con un ligero descenso en los 3 últimos años del periodo. Las comunidades con mayor incidencia fueron Canarias, Baleares y Galicia. Conclusiones: La incidencia de ingresos asociados a SAA en hospitales públicos españoles se ha mantenido estable con pequeñas modificaciones en el periodo 1999-2010. Existen diferencias en la incidencia de ingresos asociados a SAA entre las diferentes comunidades autónomas

Background: There are no data on the incidence of admissions associated with alcohol withdrawal syndrome (AWS) or about its trend over time in Spain. Objective: To analyze the characteristics, incidence rates and trends over time of hospital admissions associated with AWS in Spanish public hospitals. Material and method: Analysis from the Spanish public hospitals minimum basic data set of hospital admissions with AWS (CIE9-MC 291.81), alcohol withdrawal delirium (CIE9-MC 291.0) and alcohol withdrawal hallucinosis (CIE9-MC 291.3), since 1999 to 2010. Results: We identified 56,395 admissions associated with AWS. Mean age was 50.9 (SD 12.5) and 88% were male. The most frequent admission department was Internal Medicine (24.9%). The mean hospital stay was 12.6 days (SD 14.4) and mortality was 4.7%; 62.6% of cases developed AWS during an admission for another reason, mostly due to alcohol-related pathologies. Secondary diagnoses in patients hospitalized for AWS were related to alcohol consumption in more than half of the cases. The incidence rate of admissions associated with AWS in Spain remained stable from 1999 to 2010, with a small decline in the last 3 years of the period. The communities with the highest incidence were the Canary Islands, the Balearic Islands and Galicia. Conclusions: The incidence rate of admissions associated with AWS in Spanish public hospitals in the period 1999-2010 has remained stable with slight changes. There are differences in the incidence of AWS among the different autonomous communities

Caspase-cleaved keratin-18 fragments increase during alcohol withdrawal and predict liver-related death in patients with alcoholic liver disease.

Noninvasive assessment of disease activity in patients with nonalcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD) is still unsettled, but essential for the evaluation of disease progression. We here studied the association of total (M65) and caspase-cleaved (M30) serum keratin-18 fragments (n = 204) with histological parameters (n = 106) in heavy drinkers primarily admitted for alcohol withdrawal before and after alcohol detoxification. An age-, sex-, and fibrosis-stage matched NAFLD cohort (n = 30) was used for comparison. The prognostic value of M30 and M65 levels were assessed in an additional prospectively followed-up cohort of 230 patients with alcoholic cirrhosis (AC) using competing risk analyses. Among the histological parameters, both M30/65 correlated significantly and better than any other serum marker with apoptosis and liver damage, such as ballooning (r = 0.65; P < 0.001), followed by lobular inflammation (0.48; P < 0.001), steatosis (0.46; P < 0.001), but less with fibrosis (0.24; P < 0.001). Area under the receiver operating characteristics curves to detect ballooning, steatosis, or steatohepatitis (SH) were slightly better for M30 (P < 0.005). Optimal M30 cut-off values for mild and severe ballooning were 330 and 420 U/L, and 290 and 330 U/L for SH grades 1 and 2. No significant differences of M30/65 were found between the matched NAFLD and ALD cohort. In contrast to aspartate-amino-transferase and M65, M30 levels increased significantly from 391 to 518 U/L during alcohol detoxification. Moreover, levels of M30 and M65 predicted non-hepatocellular carcinoma liver-related mortality in patients with AC during a mean observation interval of 67.2 months. CONCLUSION: Our data suggest M30 as highly specific marker of liver apoptosis both in ALD and NAFLD. In addition, hepatocellular apoptosis, as determined by M30 levels, occurs during alcohol withdrawal, and survival data point toward a novel underestimated role of apoptosis in patients with ALD. (Hepatology 2017;66:96-107).

Delirium Tremens Leads to Poor Outcomes for Acute Coronary Syndrome.

OBJECTIVES: The mortality rate for patients with delirium tremens (DT) is 5%. As these patients present with elevated cardiac indices, coexisting DT in acute coronary syndrome (ACS) likely worsens outcomes. Our aim was to examine the outcomes of alcohol withdrawal syndrome (AWS) and DT in patients with ACS. METHODS: We used the Nationwide Inpatient Sample (2000-2009) for our study. A multivariable logistic regression model was used to examine the independent association of AWS on inhospital mortality and a multivariable linear regression was used to examine the effect of AWS on inpatient length of stay (LOS). RESULTS: An estimated 2,465,852 admissions with a primary diagnosis of ACS were analyzed. Of these, 4,499 patients had AWS and 3,460 patients had DT. Adjusting for age, gender, race, insurance, hospital characteristics, Charlson's comorbidity index, stent placement and year, the inhospital mortality was significant only for DT (OR 1.56; 95% CI 1.21-2.04). Inpatient LOS was 1.64 (95% CI 1.58-1.73) times higher in those with AWS and 2.33 (95% CI 2.22-2.43) times higher in DT when compared to nonalcoholics. Total hospital charges were higher for patients with AWS and DT when compared to nonalcoholics. CONCLUSIONS: Coexisting DT in ACS admissions is associated with increased mortality along with longer inpatient LOS and higher hospital costs.

The effect of alcohol abuse and alcohol withdrawal on short-term outcomes and cost of care after head and neck cancer surgery.

OBJECTIVES/HYPOTHESIS: Alcohol abuse is associated with an increased incidence of postoperative complications in surgical patients and is a significant risk factor for the development of head and neck cancer (HNCA). We sought to determine the relationship between alcohol abuse and in-hospital mortality, postoperative complications, length of stay, and costs in HNCA surgery. STUDY DESIGN: Retrospective cross-sectional study. METHODS: Discharge data from the Nationwide Inpatient Sample for 92,312 patients aged 18 years and older who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm in 2003 to 2008, were analyzed using cross-tabulations and multivariate regression modeling. RESULTS: Patients who abused alcohol were more likely to have advanced comorbidity, undergo major surgical procedures, and require medical care at another facility or home healthcare after discharge. The development of alcohol withdrawal symptoms (AWS) was associated with an increased incidence of acute medical complications (odds ratio [OR]: 5.6, P < .001) and surgical complications (OR: 2.3, P < .001). After controlling for all other variables, there was no significant association of alcohol abuse or AWS with in-hospital mortality; however, alcohol abuse and AWS were associated with significantly increased length of hospitalization and hospital-related costs, with AWS having the single largest impact on length of stay and costs. CONCLUSIONS: Alcohol withdrawal is associated with an increase in postoperative medical and surgical complications, length of hospitalization, and hospital-related costs in HNCA surgical patients. Aggressive measures to prevent the development of AWS in patients who abuse alcohol are warranted.

Analysis of the factors determining survival of alcoholic withdrawal syndrome patients in a general hospital.

AIM: To investigate the clinical variables associated with the risk of dying and the causes of death during the course of alcoholic withdrawal syndrome (AWS) in a general hospital. METHODS: Cohort study of AWS patients admitted to Xeral Hospital in Lugo, Spain between 1987 and 2003. The characteristics of patients who died were contrasted with those who survived. The different clinical, epidemiological and biochemical variables reflective of alcohol consumption habits, basal health status and presentation features of the syndrome and its complications were all recorded. RESULTS: There were 539 episodes of hospitalization for AWS in 436 patients (mean age 45.0, SD 12.0, 91.3% males), 71.1% of whom presented with delirium tremens. A total of 29 patients died, yielding a 6.6% mortality rate (95% confidence interval, CI: 4.2-9.1%). Eighteen patients (62%) died after being admitted to the intensive care unit (ICU). The following independent variables were associated with the risk of dying in a multivariate logistic regression model: cirrhosis [odds ratio (OR) 4.8 (95% CI 1.5-14.6), P = 0.006]; presenting with delirium tremens at diagnosis [OR 3.5 (95% CI 1.3-8.9), P = 0.008]; the existence of an underlying chronic pathology other than liver disease [OR 2.5 (95% CI 1-6.1), P = 0.01]; and the need for orotracheal intubation [OR 2.9 (95% CI 1.1-7.9), P = 0.03], especially if pneumonia requiring ICU is added [OR 8 (95% CI 3-21.3), P < 0.001]. Receiver operating characteristic analysis revealed an area under the curve of 0.818 (95% CI 0.742-0.894). CONCLUSIONS: The factors determining survival after admission to a general hospital for alcoholic withdrawal syndrome depend on the intensity of clinical manifestations (delirium tremens, ICU, orotracheal intubation) and the presence of associated comorbidity.

Predictors of mortality in patients with delirium tremens.

OBJECTIVES: The objectives were to identify factors that may help predict mortality for patients with delirium tremens (DT). METHODS: The authors conducted a 1:1 gender- and age-matched case-control study of patients hospitalized for DT. Using McNemar chi-square tests and conditional logistic regression (CLR), risk factors for death, including demographics, location of diagnosis, vital sign derangements, treatment methods, and comorbid conditions, were evaluated. Crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) are reported. RESULTS: Thirty-five patients with DT died between January 2000 and June 2006. The majority (31; 88.6%) were male with a mean (+/-standard deviation [SD]) age of 51.7 (+/-7.6) years. Hyperthermia in the first 24 hours of DT diagnosis (OR = 10.0, 95% CI = 2.3 to 42.7), persistent tachycardia (OR = 24.0, 95% CI = 3.3 to 177.4), and use of restraints (OR = 7.50, 95% CI = 1.7 to 32.8) were associated with increased mortality by univariate analysis, while an emergency department (ED) diagnosis of DT (OR = 0.18, 95% CI = 0.05 to 0.6) and use of clonidine (OR = 0.10, 95% CI = 0.01 to 0.78) were associated with decreased mortality. In the CLR model, restraint use and hyperthermia were the only variables that remained significant (OR = 5.8, 95% CI = 1.0 to 32.2; and OR = 6.1, 95% CI = 1.2 to 30.4, respectively). CONCLUSIONS: The use of restraints and hyperthermia is associated with increased odds of death for patients with DT. This study highlights the need for further research into modifiable factors influencing mortality from DT.

Mortalidad en el síndrome de abstinencia alcohólica / Mortality in alcoholic withdrawal syndrome

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Life-threatening brain failure and agitation in the intensive care unit.

The modern intensive care unit (ICU) has evolved into an area where mortality and morbidity can be reduced by identification of unexpected hemodynamic and ventilatory decompensations before long-term problems result. Because intensive care physicians are caring for an increasingly heterogeneous population of patients, the indications for aggressive monitoring and close titration of care have expanded. Agitated patients are proving difficult to deal with in nonmonitored environments because of the unpredictable consequences of the agitated state on organ systems. The severe agitation state that is associated with ethanol withdrawal and delirium tremens (DT) is examined as a model for evaluating the efficacy of the ICU environment to ensure consistent stabilization of potentially life-threatening agitation and delirium.

Delirium tremens.

BACKGROUND: The hyperadrenergic syndrome, delirium tremens, as contrasted with tile milder alcohol withdrawal syndromes, is a medical emergency. The clinical features of delirium tremens were carefully described almost 200 years ago. Since then, many therapies have been suggested as superior to preceding therapeutic approaches. Unfortunately, morbidity and mortality remain relatively unchanged for the last 100 years. METHODS: Using a literature review, we review the history of delirium tremens, including the suggested therapeutic approaches. RESULTS/CONCLUSIONS: We recommend a rational approach to management and therapy, based on present knowledge.

[Fatal post-traumatic alcohol delirium--compensation responsibility in private accident insurance?]. / Letale posttraumatische Alkoholdelirien--Entschädigungspflicht in der privaten Unfallversicherung?

While several case reports about fatal posttraumatic alcohol withdrawal deliriums after minor traumas and compensation by legal insurance have been published this problem has been hardly addressed regarding private accidance insurance. Based on the very comprehensive definition of an accident in the private insurance law posttraumatic deaths by alcohol withdrawal deliriums can be causally related even to minor traumas and compensations by private insurance are justified. However according to section 8 AUB 88 the contribution of preexisting alcoholism and alcohol related organ damage to the lethal outcome must be subtracted.

Assessing gender interactions in the prediction of mortality in alcoholic men and women: a 20-year follow-up study.

This study investigates the predictors of mortality in 259 male and female alcoholics who were psychiatrically hospitalized between 1967 and 1968 and followed for > 20 years. The findings showed that, in addition to age, marital status, medical complications, and non-antisocial personality comorbidity were important independent predictors of time to death. Data pointed to gender interactions, in that marital disruption tended to be a stronger predictor of mortality in men, and delirium tremens tended to be a stronger predictor of mortality in women. Knowing and understanding that certain events and processes may differentially affect the survival of male and female alcoholics will allow for the development of more individualized and gender-specific therapeutic interventions.

[Alcoholic withdrawal delirium]. / Majaczenie alkoholowe.

The actual progress of medical studies, reach to 1% in comparison with former data 20% a number of death in delirium tremens. The aim of this study is the presentation the symptoms of alcohol psychosis, as well as of various methods of it's cure. To choose of right therapy is sometimes very difficult for the physician. In this work one tries to explain pathogenesis of delirium tremens. Author's doctors of first contact in achieving right diagnosis and therapy.

Predictors of mortality in alcoholic women: a 20-year follow-up study.

Very little is known about the factors that predict mortality in female alcoholics. This study investigates these predictors in 103 female alcoholics who were psychiatrically hospitalized between 1967 and 1968 and followed for over 20 years. The findings showed that age, benders, and/or delirium tremens, comorbidity, and 3-year posttreatment drinking status were associated with time to death. That older alcoholics and those with pathological drinking within 3 years after treatment had a significantly shorter time to death was not surprising. However, the association of benders with mortality indicated that women may be very sensitive to short periods of high concentrations of alcohol. Comorbidity also had an intriguing effect in that women with a history of depression were more likely to survive. The predictors of mortality in these female alcoholics differed from those of the male alcoholics in this sample. These differences will be discussed in future publications.

[Alcoholic delirium--a potentially life-threatening condition]. / Das Alkoholdelir--ein potentiell lebensbedrohlicher Zustand.

Full-blown alcoholic delirium is characterised by the symptoms of an exogenous psychosis and signs of vegetative dysregulation. Organic brain disease may initiate its development. The pathogenesis of the condition remains hypothetical. Therapeutic drugs of first choice have long been clomethiazole and benzodiazepines. Basic sedative treatment may be usefully supplemented by highly potent neuroleptic agents. This, together with improvements in intensive medical care, has reduced the mortality rate to 3 to 8%. Concomitant organic diseases may complicate and prolong the condition. A defective state is a possible outcome.

Outcome in subjects with alcohol-provoked seizures.

The outcome in 165 subjects with either an unknown (n = 93) or an alcohol-related (n = 72) seizure etiology, admitted to the emergency room of a general hospital in 1977-1978, was assessed after 10 years on the basis of subsequent hospital records and death-certificate-based mortality data. Alcohol and/or drug poisoning was the most frequent cause of death in the group with alcohol-related seizures. Sixty-four percent of the deaths in this group were directly related to alcohol abuse. The crude mortality was 45.8 (expected 8.6)/100 persons/10 years in the group with alcohol-related seizures and 15.1 (expected 6.0)/100 persons/10 years in the other group, the odds ratio between the groups being 4.8. Twenty percent of those with an unknown seizure etiology were found to show alcohol-related seizures, while the seizure etiology remained unknown in 59%, and a specific etiology other than alcohol abuse was revealed in 21% during the follow-up period. We conclude that alcohol abuse is an important, though often undetected, seizure etiology carrying a poor prognosis. The difference in mortality between the groups was due more to alcoholism than to seizures. There was no difference in mortality between those with a first alcohol-related seizure and those with previous alcohol-related seizures.

[Alcohol delirium--pathogenesis and therapy]. / Das Alkoholdelir--Pathogenese und Therapie.

Alcohol-induced delirium tremens (DT) is a well-known disease with an unpredictable, either favorable or fatal, spontaneous course. The cardinal symptoms are disorientation, hallucinations and autonomic lability. The pathogenesis of DT is still unknown, and the numerous hypothesis have spawned as many therapeutic approaches. Drugs with a cross-tolerance to alcohol have so far proved best. Benzodiazepines and clomethiazole have been considered the drugs of first choice for the past 20 years and more. Improvements in intensive care has helped lower the mortality rate to 3 to 8%. Major tranquilizers with a strong antipsychotic effect and anti-epileptic agents can effectively expand the sedative management of DT. Cerebral convulsions at the beginning of DT appear to dispose the patient to a prolonged course, and preexisting or concomitant disease affecting other organs (complicated DT) clearly prolongs the duration of delirium. The risks and contraindications of clomethiazole are emphasized. The course and outcome of DT is unpredictable--in our patients we found a mortality rate of 3.7% and 12.3% end up in a defective state.