Cerebrospinal Fluid Biomarkers in Patients With Alcohol Use Disorder and Persistent Cognitive Impairment.

BACKGROUND: The prevalence of cognitive impairment is high among alcohol-dependent patients. Although the clinical presentation of alcohol-related cognitive disorder (ARCD) may resemble that of Alzheimer's disease (AD), the prognosis and treatment of the 2 diseases are different. Cerebrospinal fluid (CSF) biomarkers (tau, phosphorylated tau, and amyloid ß) have high diagnostic accuracy in AD and are currently being used to discriminate between psychiatric disorders and AD, but are not used to diagnose ARCD. The aim of this study was to characterize CSF biomarkers in a homogeneous, cognitively impaired alcohol-dependent population. METHODS: This single-center study was conducted in an addiction medicine department of a Parisian Hospital. We selected patients with documented persistent cognitive impairment whose MoCA (Montreal Cognitive Assessment) score was below 24/30 after at least 1 month of documented inpatient abstinence from alcohol. We measured the CSF biomarkers (tau, phosphorylated tau, and amyloid ß 1-42 and 1-40) in 73 highly impaired alcohol-dependent patients (Alcohol Use Disorders Identification Test score over 11 for women and 12 for men) with. RESULTS: Patients' average age was 60 ± 9.1 years and 45 (61.6%) had a normal CSF profile, 8 (11.0%) had a typical CSF AD profile, and 20 (27.4%) had an intermediate CSF profile. CONCLUSIONS: This study revealed a high prevalence of AD in alcohol-dependent patients with persistent cognitive deficits and several anomalies in their CSF profiles. Thus, it is important to consider AD in the differential diagnosis of persistent cognitive deficits in patients with alcohol dependence and to use CSF biomarkers in addition to imaging and neuropsychological testing to evaluate alcohol-related cognitive impairment.

Brain 18FDG-PET pattern in patients with alcohol-related cognitive impairment.

PURPOSE: Brain positron emission tomography using 18F-fluorodeoxyglucose (18FDG-PET) provides a metabolic assessment of brain function that is useful for differential diagnosis among several neurodegenerative diseases manifested by cognitive impairment (CI). The purpose of the study is to describe the pattern of 18FDG-PET abnormalities in patients with CI related to alcohol use disorder. METHODS: Patients admitted to the addiction medicine department of a university hospital in Paris between January 2017 and October 2018 with a confirmed diagnosis of alcohol-related cognitive impairment (ARCI) or Wernicke encephalopathy (WE) were included. Brain 18FDG-PET uptake was measured after at least 1 month of monitored abstinence from alcohol. Standardized uptake values were obtained for 13 regions of interest (ROI) and normalized to the pons. Individual patients' ROI Z-scores were calculated from healthy sex- and age-matched controls provided by Cortex ID software. RESULTS: Twenty-five patients were included in the analysis (20 males and 5 females; mean age 57.6 years (45-76 years old)). The group consisted of 19 ARCI and 6 WE cases. The mean hypometabolism was most severe in the prefrontal medial cortex (PFM) (- 2.80 (± 1.30)), the prefrontal lateral cortex (- 2.20 (± 1.35)), and the anterior cingulate cortex (- 2.24 (± 1.19)). Hypometabolism (Z-score < - 2) was most frequent in the PFM (72.0% of the sample, N = 18). Other regions were also affected (with 5.32/13 hypometabolic ROIs on average (SD = 4.16, range 0-13)). The Z-scores in the 13 ROIs did not differ significantly between the ARCI and WE patients (p ≥ 0.05). CONCLUSIONS: Predominant prefrontal and cingulate cortex hypometabolism was the most frequent brain 18FDG-PET pattern in our sample of patients with ARCI and WE.

Prevalence of benzodiazepine use disorder during hospitalization for alcohol detoxification.

Benzodiazepines (BZDs) are the first-line treatment of alcohol withdrawal. Comorbidity between benzodiazepine use disorder (BUD) and alcohol use disorders (AUD) is common. However, the risk factors are poorly characterized due to the paucity of available BUD screening tools. The present study aimed to rectify this by conducting an observational screening investigation for BUD in patients hospitalized for alcohol detoxification in a specialized unit. During a face-to-face interview, a short BUD screening tool, Echelle Cognitive d'Attachement aux benzodiazépines (ECAB), was administered to record recent patterns of BZD use, thereby allowing categorization of AUD patients as follows: non-BZD users, BZD users without BUD, and BUD (ECAB ≥6). Clinical and sociodemographic risk factors were identified and recorded during clinical assessment and were analyzed using nonparametric bivariate tests and multinomial regression for association with BUD, with p < 0.05 for significance. Of the 150 AUD patients, 23 (15%) had comorbid BUD. Several variables were associated with ECAB score, with their independence being verified using multinomial regression, with lower risk of BUD versus BZD use, when the initial prescriber was an addiction specialist compared with a psychiatrist or a general practitioner [odds ratio (OR) = 0.12, 95% confidence interval (CI) = 0.14-0.75]. A higher risk of BZD use versus no use was evident when comorbid psychiatric disorders were present (OR = 9.2, 95%CI = 1.3-65). Our findings raise clinicians' awareness that in patients hospitalized for alcohol detoxification, BUD is highly prevalent but not specifically related to psychiatric disorders. BUD can be effectively screened by utilization of the ECAB.

Ascorbic Acid Deficiency Prevalence and Associated Cognitive Impairment in Alcohol Detoxification Inpatients: A Pilot Study.

Malnutrition has been reported in alcohol use disorder patients as having a possible influence on cognitive function. The aim of this study was to analyse the prevalence of ascorbic acid (AA) deficiency in inpatients admitted for alcohol detoxification and the associated factors, including cognitive impairment in the early period of abstinence. A retrospective chart review was conducted. The AA level was categorised into three groups: deficiency (AAD) (<2 mg/L), insufficiency (AAI) (2-5 mg/L) and normal level. The cognitive impairment was screened using the Montreal Cognitive Assessment (MoCA). Ninety-six patients were included (74 men; mean age 49.1 years (±11.5)). Twenty-seven AAD (28.1%) and twenty-two AAI (22.9%) were observed. In multivariate analysis, risk factors for AAD versus normal AA level were men (OR 17.8, 95%CI (1.63-194)), compensated cirrhosis (OR 9.35, 95%CI (1.60-54.6)) and street homelessness (OR 5.76, 95%CI (1.24-26.8) versus personal housing). The MoCA score was available for 53 patients (mean MoCA score: 25.7 (±3.3)). In multivariate analysis, the natural logarithm of AA (ß = 1.18, p = 0.037) and sedative use disorder (ß = -2.77, p = 0.046) were associated with the MoCA score. AAD and AAI are frequent in inpatients admitted for alcohol detoxification. A low level of AA was associated with cognitive impairment in the early period of abstinence.

Central venous oxygen saturation is not predictive of early complications in cancer patients presenting to the emergency department.

Central venous oxygen saturation (ScvO2) is easily observable in oncology patients with long-term central venous catheters (CVC), and has been studied as a prognostic factor in patients with sepsis. We sought to investigate the association between ScvO2 and early complications in cancer patients presenting to the ED. We prospectively enrolled adult cancer patients with pre-existing CVC who presented to the ED. ScvO2 was measured on their CVC. The outcome was admission to the intensive care unit (ICU) or mortality by day 7. ScvO2 was first studied as a continuous variable (%) with a ROC analysis and as a categorical variable (cut-off at < 70%) with a multivariate analysis. A total of 210 cancer patients were enrolled. At baseline, ScvO2 showed no significant difference between patients who were admitted to the ICU or died before day 7, and patients who did not (67%; IQR 62-68% vs. 71%; IQR 65-78% respectively, P = 0.3). The ROC analysis showed the absence of discrimination accuracy for ScvO2 to predict the outcome (AUC = 0.56). By multivariate analysis, ScvO2 < 70% was not associated with the outcome (OR 1.67; 95% CI 0.64-4.36). Variables that were associated with ICU admission or death by day 7 included a shock-index (heart rate/systolic blood pressure) > 1 and a performance status > 2 (OR 4.76; 95% CI 1.81-12.52 and OR 6.23, 95% CI 2.40-16.17, respectively). This study does not support the use of ScvO2 to risk stratify cancer patients presenting to the ED.

Monitoring Personalized Learning Curves for Emergency Ultrasound With Risk-adjusted Learning-curve Cumulative Summation Method.

BACKGROUND: Ultrasound (US) has been a regular practice in emergency departments for several decades. Thus, train our students to US is of prime interest. Because US image acquisition ability can be very different from a patient to another (depending on image quality), it seems relevant to adapt US learning curves (LCs) to patient image quality using tools based on cumulative summation (CUSUM) as the risk-adjusted LC CUSUM (RLC). OBJECTIVES: The aim of this study was to monitor LC of medical students for the acquisition of abdominal emergency US views and to adapt these curves to patient image quality using RLC. METHODS: We asked medical students to perform abdominal US examinations with the acquisition of 11 views of interest on emergency patients after a learning session. Emergency physicians reviewed the student examinations for validation. LCs were plotted and the student was said proficient for a specific view if his LC reached a predetermined limit fixed by simulation. RESULTS: Seven students with no previous experience in US were enrolled. They performed 19 to 50 examinations of 11 views each. They achieve proficiency for a median of 9 (6-10) views. Aorta and right pleura views were validated by seven students; inferior vena cava, right kidney, and bladder by six; gallbladder and left kidney by five; portal veins and portal hilum by four; and subxyphoid and left pleura by three. The number of US examinations required to reach proficiency ranged from five to 41 depending on the student and on the type of view. LC showed that students reached proficiency with different learning speeds. CONCLUSIONS: This study suggests that, when monitoring LCs for abdominal emergency US, there is some heterogeneity in the learning process depending on the student skills and the type of view. Therefore, rules based on a predetermined number of examinations to reach proficiency are not satisfactory.