Somatic comorbidity of addicts: does hospitalization yield relevant findings?

The aim of this prospective study was to examine the severity and character of somatic comorbidity when addicted patients were admitted to hospital for detoxification. The study was conducted at a university-based psychiatric clinic. Somatic comorbidity was registered by laboratory, radiological and electrocardiographic parameters and by the amount of non-psychiatric consultations. Besides the number of patients with dual diagnosis interpreted as combination of addictive and psychiatric diseases was registered. A total of 111 consecutive patients (32 women) was divided into patients with alcohol dependence and patients with other addictive diseases including polydrug abuse and opiate dependence. Patients with alcohol dependence were characterized by an elevated heart rate and higher values for gamma-glutamyltransferase. No significant differences between groups could be found for the rate corrected QT interval and cardiothoracic ratio. Although viral liver disease was diagnosed in both groups patients with a history of injecting drug use were at greatest risk for hepatitis C. About one-third of all patients required consultant non-psychiatric treatment. Concomitant heart and pulmonary diseases were more pronounced in the alcohol dependence group. The findings emphasize that hospitalization of addicted patients yields relevant somatic morbidity which has an impact on cost and requires medically supervised detoxification programs.

[Combined alcohol dependence and personality disorder and its legal consequences with respect to commitment]. / Die Kombination einer Alkoholabhängigkeit und Persönlichkeitsstörung und ihre betreuungsrechtlichen Auswirkungen.

People frequently consuming an excessive amount of alcohol often show symptoms of personality disorder. Personality disorder and alcohol dependence are frequently connected with each other. However, there are only very few conditions enhancing concomitant dependence and personality disorder to the rank of a mental disease according to German guardianship legislation. If the patient's condition meets the criteria of a psychic disease and endangers his own health and public safety, commitment to a mental hospital or guardianship are justified. The purpose of this clinical analysis was to compare the medical proposal for treatment with legal prerequisites which are indispensable for involuntary admission to a mental hospital. Whereas the Psychiatric Disorders Act intends to avert danger to the public, guardianship legislation aims at individual help. We present a patient who suffered from alcoholism and simultaneously met criteria of a serious personality disorder, which was classified according to ICD-10 (F 60.31). As the aggravation of the symptoms was most likely to entail serious danger to his health the judge ordered immediate involuntary admission. Two other patients had similar comorbidity but had to be released from hospital because of finalisation of detoxification. Neither dependence nor personality disorder were pronounced enough to restrict the rights of the individual. Our analysis shows that the psychiatrist must present with an expert medical report that quantifies the extent of alcoholism and personality disorder and characterises them as psychic disease. Consequently, for the purpose of quantifying the extent of dependence, we recommend to apply the European Addiction Severity Index whose suitability should be assessed.

Electrocardiographic abnormalities during recovery from ultra-short opiate detoxification.

The aim of this study was to detect electrocardiographic abnormalities during recovery from ultra-short opiate detoxification, using a retrospective study design conducted at a university hospital. Twenty-two consecutive patients (mean±SD, age 30.0±6.3 years) receiving daily oral methadone underwent ultrashort opiate detoxification under general anaesthesia. In the post-anaesthetic stages they received oral clonidine and naltrexone, and in some cases trimipramine was dispensed. Heart rate, rate-corrected QT interval (msec) and repolarization abnormalities of 12-lead electrocardiographic recordings before and after detoxification were examined. The serum electrolyte concentrations (mmol/l) including Na⁺, K⁺ and Ca2⁺ were assessed. Eighty-one ECGs were evaluated in total. Compared to the initial values, heart rate was significantly lowered in the first two tracings after detoxification (median values 60.0/min. vs. 52,5/min; p=0.0006). The lowest heart rate measured after detoxification was 44/min. The cQT interval was significantly lengthened (median value 420 msec vs. 453 msec after detoxification). In 16 tracings (20%) taken from 10 patients (45%) cQT rose above 460 msec and in two tracings (2%) it topped 500 msec. Modest hypokalaemia (2.9-3.5 mmol/l) was linked to cQT prolongation (460 msec) in 10 ECG tracings. Spearman's correlation coefficient indicated that prolonged cQT intervals correlated with decreased potassium values. Twelve tracings (15%) taken from 10 patients (45%) after detoxification showed T-wave inversion and in two cases sinus rhythm was turned into a rhythm arising from the atrioventricular node. Serum potassium was significantly lowered (median values 4.3 v.s 3.8 mmol/l, p=0.0001). The Ca2⁺ concentration fell significantly (2.4 vs. 2.2 mmol/l, p=0.0001) but not below the normal range. It was concluded that ultra-short opiate detoxification carries the risk of QT prolongation and bradycardia. These side effects are reversible and can be explained by hypokalaemia and clonidine medication, the effects of which might reinforce each other. To avoid arrhythmic complications, ECG tracings should be carried out regularly during recovery, i.e. at least daily, for a span of 3 days after discharge from the intensive care unit.

[Awakening from anesthesia and recovery of cognitive function after desflurane or isoflurane]. / Aufwachverhalten und kognitive Funktion nach Desfluran oder Isofluran.

UNLABELLED: Desflurane is a new volatile anaesthetic with an extremely low blood/gas partition coefficient of 0.42. This should provide a rapid recovery from anaesthesia. METHODS: We studied 100 adult patients, ASA class I or II, undergoing elective orthopaedic surgery randomly assigned to anaesthesia with desflurane (n = 50) or isoflurane (n = 50) supplemented by nitrous oxide in oxygen. Clorazepat was given for premedication, fentanyl and thiopental for induction of anaesthesia, followed by maintenance with desflurane or isoflurane as clinically appropriate. Emergence from anaesthesia was measured as well as return of cognitive functions (extended Aldrete score, digit symbol substitution test, and visual analogue scales [VAS]). RESULTS: While the demographic characteristics and administrated doses of fentanyl and thiopental were comparable, the recovery profiles in both groups were different. After discontinuation of the volatile anaesthetics, times to extubation and ability to follow simple commands were significantly shorter after desflurane than after isoflurane. Extended Aldrete scores, estimation of the patients' physical condition, results of the digit symbol substitution test, measuring cognitive functions, and rates of drowsiness and weakness on VAS showed better recovery with less impairment of cognitive function in the desflurane group than in isoflurane patients even 120 min after anaesthesia. VAS pain scores and doses of analgesic drugs given within the first 2 postoperative hours, however, showed no significant differences. Desflurane patients were also judged fit for discharge from the recovery room significantly faster. CONCLUSIONS: Our results demonstrate that desflurane anaesthesia, even when supplemented by premedication, intraoperative opioids, and nitrous oxide may offer clinical advantages over isoflurane as far as the post-anaesthetic recovery profile is concerned.

[Severe dextran-induced anaphylactic/anaphylactoid reaction despite preventive hapten administration]. / Schwere dextraninduzierte anaphylaktische/anaphylaktoide Reaktion (DIAR) trotz Haptenprophylaxe.

Dextran-60 is widely used as a colloid volume substitute and for thromboprophylaxis. In order to avoid the most dangerous complication associated with dextran, the dextran-induced anaphylactic/anaphylactoid reaction (DIAR), hapten dextran is infused before starting the first application of dextran. We report of a 60-year-old man with multiple trauma, who received a dextran infusion for thromboprophylaxis because of high risk for thrombosis due to a severe thrombocytosis developing in the late postoperative period. Despite prophylaxis with monovalent hapten dextran, an anaphylactic reaction occurred. Although a serum sample drawn prior to the reaction is lacking, the causal relationship to dextran can be classified as likely, due to the close time relationship to the dextran-60 infusion. In addition, there were high titers of dextran-reactive antibodies in the blood drawn immediately after the reaction occurred. It is concluded that even after correct application of monovalent hapten dextran, dextran infusions carry the risk of severe anaphylactic reactions. They should therefore only be administered if clinical observation of the patient and the possibility of resuscitation are guaranteed.