Clinical impact of chronic substance abuse in a Norwegian ICU-population.

BACKGROUND: The clinical impact of chronic substance abuse of alcohol and drugs-referred to as substance use disorders (SUD)-is often overlooked in the intensive care (ICU) setting. The aims of the present study were to identify patients with SUD-regardless of cause of admission-in a mixed Norwegian ICU-population, and to compare patients with and without SUD with regard to clinical characteristics and mortality. METHODS: Cross-sectional prospective study of a mixed medical and surgical ICU-population aged ≥18 years in Oslo, Norway. Data were collected consecutively, using a questionnaire including the AUDIT-C test, medical records and toxicology results. Patients classified with SUD were divided into the subgroups alcohol use disorders (AUD) and drug use disorders (DUD). RESULTS: Overall, 222 (26%) of the 861 patients included were classified with SUD; 137 (16%) with AUD and 85 (10%) with DUD. 130/222 (59%) of the SUD-patients had substance abuse-related cause of ICU-admission. Compared to non-SUD patients, DUD-patients were younger (median age 42 vs 65 years) and had lower SAPS II scores (41 vs 46), while AUD-patients had higher SOFA scores (8.0 vs 7.3). Overall, age-adjusted logistic regression analysis showed similar hospital mortality for SUD-patients and non-SUD patients, but AUD was associated with increased mortality among medical patients and in patients with sepsis (OR 1.7 (95% CI 1.0-2.8), and OR 2.6 (95% CI 1.1-6.2)). CONCLUSION: One in four ICU-patients had SUD regardless of cause of admission. Alcohol use disorder was associated with increased mortality in medical patients and in patients with sepsis.

Concurrent Use of Benzodiazepine by Heroin Users-What Are the Prevalence and the Risks Associated with This Pattern of Use?

INTRODUCTION: Polydrug use involving heroin and benzodiazepines is common. The potential risk of additive pharmacological effects may be associated with poorer outcomes in patients who use benzodiazepines together with heroin. The aim of this study was to determine the clinical picture of patients presenting to the emergency department following acute drug toxicity involving heroin and benzodiazepines. METHODS: Exposure information, clinical data and outcome of acute drug toxicity presentations were collected between 1 October 2013 and 30 September 2014 as part of the European Drug Emergencies Network (Euro-DEN) project. The database was interrogated to identify patients who had taken heroin with or without benzodiazepine(s). RESULTS: A total of 1345 presentations involving acute heroin toxicity were identified: 492 had used one or more non-heroin/benzodiazepine drug and were not further considered in this study; 662 were lone heroin users and 191 had co-used heroin with one or more benzodiazepines. Co-users were more likely than lone heroin users to have reduced respiratory rate at presentation 12.7 ± 4.9 vs 13.6 ± 4.4 (p = 0.02) and require admission to hospital 18.3 vs 9.8% (p < 0.01). There were no differences in critical care admission rates 3.1 vs 3.9% (p = 0.83) or length of stay 4 h 59 min vs 5 h 32 min (p = 0.23). The 3 most common benzodiazepines were clonazepam, diazepam, and alprazolam. No differences were observed for clinical features between the three benzodiazepines. CONCLUSION: This study shows that co-use of heroin and benzodiazepines is common, although the overall outcomes between co-users of heroin and benzodiazepines and heroin-only users were similar.

Presentations to the emergency department with non-medical use of benzodiazepines and Z-drugs: profiling and relation to sales data.

BACKGROUND: Non-medical use of benzodiazepines and Z-drugs is common; however, there is limited information available on the extent of harm related to this in Europe, as well as the relationship between misuse and availability. AIM: To describe presentations to the emergency department in Europe related to the recreational use of benzodiazepines and Z-drugs and compare regional differences in these presentations with legal drug sales of benzodiazepines and Z-drugs within each country. METHODS: Emergency department presentations with recreational misuse of benzodiazepines and Z-drugs were obtained from the Euro-DEN dataset for the period from October 2013 to September 2015; data extracted included demographics, clinical features, reported coused drugs, and outcome data. Sales figures obtained by QuintilesIMS™ (Atlanta, Georgia) were used to compare regional differences in the proportion of benzodiazepines and Z-drugs in the emergency department presentations and legal drug sales across Europe. RESULTS: Over the 2 years, there were 2119 presentations to the Euro-DEN project associated with recreational use of benzodiazepines and/or Z-drugs (19.3% of all Euro-DEN presentations). Presentations with 25 different benzodiazepines and Z-drugs were registered in all countries, most (1809/2340 registered benzodiazepines and Z-drugs, 77.3%) of which were prescription drugs. In 24.9%, the benzodiazepine was not specified. Where the benzodiazepine/Z-drug was known, the most frequently used benzodiazepines and Z-drugs were respectively clonazepam (29.5% of presentations), diazepam (19.9%), alprazolam (11.7%), and zopiclone (9.4%). The proportions of types of benzodiazepines/Z-drugs related to ED-presentations varied between countries. There was a moderate (Spain, UK, Switzerland) to high (France, Ireland, Norway) positive correlation between ED presentations and sales data (Spearman Row's correlation 0.66-0.80, p < 0.005), with higher correlation in countries with higher ED presentation rates. CONCLUSION: Presentations to the emergency department associated with the non-medical use of benzodiazepines and/or Z-drugs are common, with variation in the benzodiazepines and/or Z-drugs between countries. There was a moderate to high correlation with sales data, with higher correlation in countries with higher ED presentation rates. However, this is not the only explanation for the variation in non-medical use and in the harm associated with the non-medical use of benzodiazepines/Z-drugs.

Bronchial wheezing predicts inflammation and respiratory failure in fire smoke victims.

BACKGROUND: Acute fire smoke inhalation injury involves inflammatory mediators whose roles are poorly understood. We carried out a prospective observational study of fire smoke victims to identify clinical and biochemical markers that may predict pulmonary dysfunction and investigated possible correlations between dysfunction and cytokines in bronchoalveolar lavage (BAL) fluid and blood. METHODS: Forty patients with respiratory and/or neurological symptoms following acute fire smoke inhalation had pulmonary function tests and blood gas analyses performed on admission, at discharge, and after 3 months. Cytokines were measured using BioPlex/XMap technology. RESULTS: On admission, 30 (75%) patients had dyspnea. Patients presenting with bronchial wheezing (n = 14) had significantly lower PEF (201 l/min, 82-360) than non-wheezing patients (406 l/min, 100-683) (n = 16, P = 0.03). Bronchial wheezing predicted need for ICU treatment with OR = 93.3 at 95% CI (P < 0.001) and was associated with gas exchange impairment, with mean pa O2 /FiO2 ratio 34.4 (11.8-49.8) kPa on admission and 21.3 (8.3-44.5) kPa 48 h later. Blood HbCO also predicted ICU treatment, with OR = 1.58 at 95% CI (P < 0.001). Serum CRP, IL-6, IL-8, and MCP-1 were significantly higher in wheezing patients after 12-24 h compared with non-wheezing patients and study controls. Cytokine levels were still elevated after 3 months. BAL fluid had significantly higher levels of IL-8, MCP-1, IL-1ß, and G-CSF compared with healthy controls. CONCLUSION: In victims of fire smoke inhalation, pulmonary wheezing predicts inflammation, pulmonary dysfunction, respiratory failure, and need for intensive care.

Clinical assessment compared to laboratory screening in acutely poisoned patients.

Acute poisonings may require identification of the toxic agents. It is impossible for routine laboratories to provide a full spectrum of toxicological analyses, and clinicians should know the reliability of the clinical diagnoses of toxic agents. We performed a 1-year study of hospitalized acute poisonings to determine the agreement between the clinical assessment on admission and serum laboratory tests for eight common toxic agents. Blood samples were drawn in 665 (70%) of the 947 admissions. The total number of laboratory found agents (967) exceeded the clinically suspected (871) by 11%. The agreement between the clinical assessment and laboratory analyses was good for ethanol and paracetamol (kappa = 0.70 for both), whereas only moderate or fair for other agents (kappa 0.22-0.51). Sensitivities of the clinical assessments compared to the laboratory results were better for common than rare agents, and better for higher than lower serum concentrations. The four most common agents (ethanol, benzodiazepines, paracetamol, and opiates) had overall sensitivity of 82% for higher-than-median serum concentrations, whereas the other agents had sensitivities ranging from 14% to 71% for higher-than-median concentrations. The reliability of the clinical diagnoses varied to such an extent that agents, which are important to recognize for specific treatment, should be tested for.

[Myelomatosis and low level of vitamin B12]. / Myelomatose og lavt serum-vitamin B12-nivå.

Many patients with multiple myeloma tend to have low serum cobalamin. The cause of this remains unclear. The important issue is whether cobalamin therapy should be used or not. We describe one case of megaloblastic erythropoiesis and multiple myeloma, and refer to some of the few studies describing the subject. Most of the patients with multiple myeloma are elderly, and the frequency of hypo- and achlorhydria is therefore increased. It has been demonstrated that cobalamin uptake and consumption is higher in myeloma cells than in normal bone marrow cells, and that cobalamin may be required for paraprotein synthesis. These facts may suggest that patients with multiple myeloma are more vulnerable to developing megaloblastic anemia than others. Our patient received cobalamin therapy in addition to cytostatic therapy for multiple myeloma without complications. However, we cannot exclude that cobalamin therapy may accelerate multiple myeloma; this should be considered when such therapy is given. However, accurate guidelines require more studies.