Neuromuscular mechanisms of weakness in a mouse model of chronic alcoholic myopathy.

BACKGROUND: Weakness is a common clinical symptom reported in individuals with chronic alcohol use disorder. However, it remains unclear whether low strength in these individuals is directly related to excessive ethanol intake, other deleterious factors (lifestyle, environment, genetics, etc.), or a combination of both. Therefore, we examined whether (and how) ethanol reduces the muscle's force-producing capacity using a controlled in vivo preclinical mouse model of excessive ethanol intake. METHODS: To establish whether chronic ethanol consumption causes weakness, C57BL/6 female mice consumed 20% ethanol for 40 weeks (following a 2-week ethanol ramping period), and various measures of muscular force were quantified. Functional measures included all-limb grip strength and in vivo contractility of the left ankle dorsiflexors and plantarflexors. Once confirmed that mice consuming ethanol were weaker than age-matched controls, we sought to determine the potential neuromuscular mechanisms of muscle dysfunction by assessing neuromuscular excitation, muscle quantity, and muscle quality. RESULTS: Mice consuming chronic ethanol were 13 to 16% weaker (p ≤ 0.016) than controls (i.e., mice consuming 100% water) with the negative impact of ethanol on voluntary grip strength (ƞ2  = 0.603) being slightly larger than that of electrically stimulated muscle contractility (ƞ2  = 0.482). Relative to controls, lean mass and muscle wet masses were 9 to 16% lower in ethanol-consuming mice (p ≤ 0.048, ƞ2  ≥ 0.268). No significant changes were observed between groups for indices of neuromuscular excitation at the level of the motor unit, neuromuscular junction, or plasmalemma (p ≥ 0.259, ƞ2  ≤ 0.097), nor was muscle quality altered after 40 weeks of 20% ethanol consumption (p ≥ 0.695, ƞ2  ≤ 0.012). CONCLUSIONS: Together, these findings establish that chronic ethanol consumption in mice induces a substantial weakness in vivo that we interpret to be primarily due to muscle atrophy (i.e., reduced muscle quantity) and possibly, to a lesser degree, loss of central neural drive.

Guía de práctica clínica consumo perjudicial y dependencia de alcohol y otras drogas en personas menores de 20 años / Clinical practice guide harmful consumption and dependence on alcohol and other drugs in people under 20 years of age

Generar recomendaciones basadas en la mejor evidencia disponible acerca del manejo clínico del consumo perjudicial y dependencia de alcohol y otras drogas en personas menores de 20 años.

Environmental factors and awareness of colorectal cancer in people at familial risk. / Fatores ambientais e conscientização sobre o câncer colorretal em pessoas com risco familiar.

OBJECTIVE: to identify the association between environmental risk factors and awareness of colorectal cancer in people at familial risk. METHOD: cross-sectional correlational study, with a sample consisted of people who met at least one of the Revised Bethesda criteria, and 80 participants were included in this study. A sociodemographic data record, the AUDIT Test for alcohol use, the Fagerström Test for tobacco smoking, the Estimation and Frequency of Food Intake scale, and the Cancer Awareness Measure questionnaire to assess the colorectal cancer awareness were used. Body mass index was calculated, and descriptive statistics and the Pearson's Correlation Coefficient were used to estimate the association. RESULTS: female sex predominated, with an average age of 37.8 years, almost half of the participants were overweight, 45% showed symptoms of alcohol dependence, half of the sample showed an association between hereditary factors and the development of colorectal cancer, and less than half of them were aware of cancer prevention programs. CONCLUSION: there is little information on the main environmental risk factors, signs and symptoms of colorectal cancer, and no significant association was found between these and colorectal cancer awareness.

Consumo de alcohol, relación con el trauma y su severidad / Relationship between alcohol consumption and trauma. Severity of traumatic injury / Consumo de álcool, relação com o trauma e sua gravidade

Introducción: Uruguay no cuenta con estudios que reporten resultados de alcoholemias en traumatizados y menos aún su asociación con la severidad del trauma. Desde el año 2016 nuestro país cuenta con la llamada ley de tolerancia cero en base al supuesto de que la alcoholemia positiva representa un factor de riesgo para la severidad del trauma. Objetivos: describir el perfil epidemiológico de los traumatizados y estudiar la asociación existente entre el consumo de alcohol y la severidad del trauma. Material y método: estudio transversal; se incluyeron todos los pacientes que presentaron un evento traumático y fueron asistidos en el Departamento de Emergencia del Hospital de Clínicas durante el período 1 de marzo al 31 de agosto de 2017. Los datos se recopilaron prospectivamente y se extrajo muestra de alcoholemia a cada uno de los pacientes. Se consideraron diversas variables relacionadas con los pacientes y la severidad del traumatismo Se analizó la asociación entre las alcoholemias positivas y la severidad del trauma. Resultados: se incluyeron 121 pacientes, 28% presentaron alcoholemia positiva y 27% presentaron trauma severo. La alcoholemia positiva se asoció con la severidad del trauma (p < 0,0001). No se encontró asociación entre el nivel de alcoholemia y la severidad del trauma (p = 0,323). Conclusiones: el consumo de alcohol se asocia significativamente con la severidad del trauma. Nuestro estudio muestra que los traumatismos son severos solo por el hecho de presentar alcoholemias positivas independientemente de su nivel, apoyando la implementación de la ley de tolerancia cero.

Introduction: our country has not conducted studies to report results on blood alcohol levels in traumatized patients or on its association with the severity of the traumatic injury. Objective: to describe the epidemiological profile of trauma patients and to study the relationship between alcohol consumption and the severity of the traumatic injury. Method: transversal study including all patients who suffered a traumatic event and were assisted at the Emergency Department of the Clínicas Hospital between March 1, 2017 and August 31, 2017. Data was prospectively collected and a blood alcohol level sample was taken from each one of the patients. Several patient related variables were considered, as well as the severity of the traumatic injury. Results: 121 patients were included in the study, 28% showed positive blood alcohol levels and 27% presented severe traumatic injuries. Positive blood alcohol levels were associated to severity of the traumatic injury (p < 0.0001). No association was found between blood alcohol levels and the severity of the traumatic injury (p = 0.323). Conclusions: alcohol consumption is significantly associated to the severity of trauma. Our study shows that traumas are severe simply because blood alcohol levels are positive, regardless of the alcohol level, what supports the Zero Tolerance Law.

Introdução: no Uruguai não existem estudos que mostrem não somente os resultados de alcoolemia em traumatizados como também sua associação com a gravidade do trauma. Desde 2016 conta com a Lei de Tolerância 0 baseada no princípio de que a alcoolemia positiva é um fator de risco para a gravidade do trauma. Objetivos: descrever o perfil epidemiológico dos traumatizados e estudar a associação existente entre o consumo de álcool e a gravidade do trauma. Materiais e métodos: estudo transversal que incluiu todos os pacientes que apresentaram um evento traumático e foram atendidos no Departamento de Emergência do Hospital de Clínicas no período 1 de março - 31 de agosto de 2017. Os dados foram levantados prospectivamente e uma amostra de alcoolemia foi coletada a todos os pacientes. Foram incluídas variáveis relacionadas aos pacientes e à gravidade do traumatismo. A associação entre as alcoolemias positivas e a gravidade do trauma foi analisada. Resultados: foram incluídos 121 pacientes; 28% apresentaram alcoolemia positiva e 27% apresentaram trauma severo. As alcoolemias positivas estavam associadas com a gravidade do trauma (p < 0,0001). Os resultados não mostraram associação entre o nível de alcoolemia e a gravidade do trauma (p = 0,323). Conclusões: o consumo de álcool está significativamente associado com a gravidade do trauma. Nosso estudo mostra que os traumatismos são graves somente pela presença de alcoolemias positivas independentemente de seu nível o que respalda a implementação da Lei de Tolerância 0.

At-Risk Drinking Is Independently Associated With Acute Kidney Injury in Critically Ill Patients.

OBJECTIVES: Unhealthy use of alcohol and acute kidney injury are major public health problems, but little is known about the impact of excessive alcohol consumption on kidney function in critically ill patients. We aimed to determine whether at-risk drinking is independently associated with acute kidney injury in the ICU and at ICU discharge. DESIGN: Prospective observational cohort study. SETTING: A 21-bed polyvalent ICU in a university hospital. PATIENTS: A total of 1,107 adult patients admitted over a 30-month period who had an ICU stay of greater than or equal to 3 days and in whom alcohol consumption could be assessed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We assessed Kidney Disease Improving Global Outcomes stages 2-3 acute kidney injury in 320 at-risk drinkers (29%) and 787 non-at-risk drinkers (71%) at admission to the ICU, within 4 days after admission and at ICU discharge. The proportion of patients with stages 2-3 acute kidney injury at admission to the ICU (42.5% vs 18%; p < 0.0001) was significantly higher in at-risk drinkers than in non-at-risk drinkers. Within 4 days and after adjustment on susceptible and predisposing factors for acute kidney injury was performed, at-risk drinking was significantly associated with acute kidney injury for the entire population (odds ratio, 2.15; 1.60-2.89; p < 0.0001) in the subgroup of 832 patients without stages 2-3 acute kidney injury at admission to the ICU (odds ratio, 1.44; 1.02-2.02; p = 0.04) and in the subgroup of 971 patients without known chronic kidney disease (odds ratio, 1.92; 1.41-2.61; p < 0.0001). Among survivors, 22% of at-risk drinkers and 9% of non-at-risk drinkers were discharged with stages 2-3 acute kidney injury (p < 0.001). CONCLUSIONS: Our results suggest that chronic and current alcohol misuse in critically ill patients is associated with kidney dysfunction. The systematic and accurate identification of patients with alcohol misuse may allow for the prevention of acute kidney injury.

Do Associations Between Alcohol Use and Alcohol Use Disorder Vary by Weight Status? Results From the National Epidemiologic Survey on Alcohol and Related Conditions-III.

BACKGROUND: Understanding whether the associations between alcohol use and alcohol use disorder (AUD) differ by weight status may be useful in screening for AUD in populations where obesity is common. We aimed to determine whether the associations between alcohol use and AUD differ by weight status. METHODS: A total of 24,869 adult participants of the National Epidemiologic Survey on Alcohol and Related Conditions-III with a body mass index ≥18.5 kg/m2 who reported past-year alcohol use were included. The AUD and Associated Disabilities Interview Schedule-5 were administered to identify past-year AUD. Logistic regression was used to test the associations between weight status and levels and patterns of alcohol use with AUD; interactions between weight status and alcohol use variables in relation to AUD were examined. Analyses were stratified by gender. RESULTS: For males and females, the odds of AUD were higher with greater frequency of any alcohol use and heavy drinking, higher average quantity of drinks per drinking day, and past-year high-risk drinking. Among males, at the same average quantity of drinks per drinking day, frequency of heavy drinking, or presence of high-risk drinking, those with class 3 obesity had higher odds of AUD versus lower classes or no obesity (p for all interactions <0.01). Among females, at the same frequency of any alcohol use, those with healthy weight had the highest odds of AUD, while females with class 3 obesity had the lowest odds of AUD (p for interaction <0.001); interactions between weight status and other alcohol use variables were not significant (p ≥ 0.05). CONCLUSIONS: The associations between some measures of alcohol use and AUD differed by weight status, with inconsistent results between males and females. Alcohol use thresholds typically used in AUD screening may be too high in males with class 3 obesity.

Alcohol withdrawal syndrome management: Is there anything new?

Patients with alcohol use disorder experience frequently alcohol withdrawal syndrome (AWS), which is a potentially life-threatening condition mainly caused by glutamate overactivity. The aim of therapeutic alcohol withdrawal is the entry into a process of complete and lasting abstinence. Therefore preparing withdrawal is crucial to optimize compliance and efficacy of aftercare. Indeed, performing repeated withdrawal per se without any project of subsequent abstinence may be deleterious, at least because of repeated exposure to glutamate neurotoxicity. Managing AWS mainly consists in anticipating severe withdrawal, decreasing the risk of complications, making this experience as comfortable as possible, preventing from long-term benzodiazepine use, and enhancing motivation to aftercare and long-term abstinence. In particular, there are specific guidelines to choose which benzodiazepine administration approach to adopt (i.e. symptom-triggered, fixed schedule or loading dosage) and which other drugs to deliver (e.g. thiamine, folate, magnesium). Specific precautions should be taken in the elderly.

O álcool dentro dos agravos em urgências e emergências: um estudo de representações sociais / The aggravations in health services of urgencies and emergencies having alcohol as the leading cause: a study of social representations / El alcohol dentro de trastornos en urgencies y de emergencia. un estudio de representación social

Objetivo: Compreender as representações sociais dos usuários de álcool e suas complicações para os agravos dentro das urgências e emergências. Métodos: Estudo do tipo descritivo, com abordagem qualitativa, utilizando o aporte das Representações Sociais de Moscovici para compreender as representações acerca das urgências e emergências traumáticas relacionadas ao uso abusivo do álcool. Resultados: Foram identificados três núcleos direcionadores: impressões e experiências quanto ao uso do álcool, representações quanto as consequências e/ou agravos do acidente e representações quanto a visão da família. Conclusão: As falas dos participantes revelam um grande sofrimento das famílias e usuários devido ao consumo e ao abuso de bebida alcoólica, aonde este estudo visou contribuir para o conhecimento frente ao comportamento das pessoas que fazem o uso do álcool com frequência, auxiliando no seu enfrentamento e na prevenção de agravos

Objetivo: Comprender las representaciones sociales de los usuarios de alcohol y sus complicaciones a las quejas dentro de las urgencias y emergencias. Métodos: Estudio descriptivo, con enfoque cualitativo, mediante la aportación de las representaciones sociales de Moscovici comprender las representaciones sobre las emergencias de emergencia y traumáticos relacionados con el abuso de alcohol. Resultados: Se identificaron tres conductores principales: impresiones y experiencias en relación con el uso del alcohol, las representaciones sobre las consecuencias y / o lesiones del accidente y representaciones como la visualización de la familia. Conclusión: Los discursos de los participantes revelan un gran sufrimiento de las familias y los usuarios debido al consumo y abuso de alcohol, donde tuvo el propósito de contribuir al conocimiento contra el comportamiento de las personas que consumen alcohol con frecuencia, ayudando en su superación y la prevención de enfermedades

Objective: The study's purpose has been to gain further understanding with regards to the social representations of alcohol users, and also to assess its complications within the health services of urgencies and emergencies. Methods: This is a descriptive study with a qualitative approach, which used the Moscovici's Social Representations in order to understand the representations about urgencies and traumatic emergencies related to alcohol abuse. Results: Based on the findings, the following three support meaning centers were identified: impressions and experiences with regards to alcohol intake; representations related to either the consequences or aggravations of the accident; and, representations by considering the family viewpoint. Conclusions: The participants' statements reveal a pronounced suffering of both the families and users due to the consumption and the abuse of alcoholic beverages. This study aimed to contribute towards improving the scientific knowledge about people's behavior, particularly, those who use alcohol regularly. Therefore, through this research, the health professionals may find a solid scientific support to helping them to stand against this issue, as well as preventing people's health aggravations

A quantification of the alcohol use-consequences association in college student and clinical populations: A large, multi-sample study.

BACKGROUND: The present study sought to quantify the relationship between alcohol use and alcohol-related consequences in both college student and clinical samples. METHODS: We gathered 33 college student datasets comprising of 15,618 participants and nine clinical sample datasets comprising of 4,527 participants to determine the effect size of the relationship between alcohol use and alcohol-related consequences. We used random-effects meta-analytic techniques, separately in college and clinical samples, to account for a distribution of true effects and to assess for heterogeneity in effect sizes. RESULTS: Results demonstrated that the clear majority of the variability in alcohol-related consequences is not explained by alcohol use (ie, >77% in college samples; >86% in clinical samples), and that there was significant heterogeneity in all effect sizes. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Experiencing alcohol-related consequences results from factors that extend beyond frequency and quantity of alcohol consumed suggesting a need to examine other predictors of alcohol-related consequences beyond alcohol use. (Am J Addict 2018;27:116-123).

Chronic Pancreatitis.

Chronic pancreatitis is a debilitating condition often associated with severe abdominal pain and exocrine and endocrine dysfunction. The underlying cause is multifactorial and involves complex interaction of environmental, genetic, and/or other risk factors. The pathology is dependent on the underlying pathogenesis of the disease. This review describes the clinical, gross, and microscopic findings of the main subtypes of chronic pancreatitis: alcoholic chronic pancreatitis, obstructive chronic pancreatitis, paraduodenal ("groove") pancreatitis, pancreatic divisum, autoimmune pancreatitis, and genetic factors associated with chronic pancreatitis. As pancreatic ductal adenocarcinoma may be confused with chronic pancreatitis, the main distinguishing features between these 2 diseases are discussed.

Environmental enrichment may protect against neural and behavioural damage caused by withdrawal from chronic alcohol intake.

Exposure to stress and prolonged exposure to alcohol leads to neuronal damages in several brain regions, being the medial prefrontal cortex (mPFC) one of the most affected. These changes presumably reduce the ability of the organism to cope with these stimuli and may underlie a series of maladaptive behaviours among which include drug addiction and withdrawal. Drug-addicted individuals show a pattern of behavior similar to patients with lesions of the mPFC. This impairment in the decision-making could be one of the mechanisms responsible for the transition from the casual to compulsive drug use. The environmental enrichment (EE) has a protective effect on the neural and cognitive impairments induced by psychoactive drugs, including ethyl alcohol. The present study aims to determine the influence of withdrawal from intermittent long-term alcohol exposure on alcohol preference, emotional reactivity and neural aspects of early isolated or grouped reared rats kept under standard or complex environments and the influence of social isolation on these measures, as well. Our results point out new insights on this matter showing that the EE can attenuate the adverse effects of withdrawal and social isolation on rat's behavior. This effect is probably due to its protective action on the mPFC integrity, including the cingulate area 1 (Cg1), and the prelimbic (PrL) and infralimbic cortex (IL), what could account for the absence of changes in the emotional reactivity in EE alcohol withdrawal rats. We argue that morphological changes at these cortical levels can afford the emotional, cognitive and behavioural dysregulations verified following withdrawal from chronic alcohol intake.

Association of testosterone and BDNF serum levels with craving during alcohol withdrawal.

Preclinical and clinical studies show associations between testosterone and brain-derived neurotrophic growth factor (BDNF) serum levels. BDNF and testosterone have been independently reported to influence alcohol consumption. Therefore, we aimed to investigate a possible interplay of testosterone and BDNF contributing to alcohol dependence. Regarding possible interplay of testosterone and BDNF and the activity of the hypothalamic pituitary axis (HPA), we included cortisol serum levels in our research. We investigated testosterone and BDNF serum levels in a sample of 99 male alcohol-dependent patients during alcohol withdrawal (day 1, 7, and 14) and compared them to a healthy male control group (n = 17). The testosterone serum levels were significantly (p < 0.001) higher in the patients' group than in the control group and decreased significantly during alcohol withdrawal (p < 0.001). The decrease of testosterone serum levels during alcohol withdrawal (days 1-7) was significantly associated with the BDNF serum levels (day 1: p = 0.008). In a subgroup of patients showing high cortisol serum levels (putatively mirroring high HPA activity), we found a significant association of BDNF and testosterone as well as with alcohol craving measured by the Obsessive and Compulsive Drinking Scale (OCDS). Our data suggest a possible association of BDNF and testosterone serum levels, which may be relevant for the symptomatology of alcohol dependence. Further studies are needed to clarify our results.

Unpeeling the Evidence for the Banana Bag: Evidence-Based Recommendations for the Management of Alcohol-Associated Vitamin and Electrolyte Deficiencies in the ICU.

OBJECTIVE: Patients with a chronic alcohol use disorder presenting to the ICU may be deficient in important vitamins and electrolytes and are often prescribed a "banana bag" as a reflexive standard of therapy. The difficulty of diagnosing Wernicke's encephalopathy in the critical care setting is reviewed. Furthermore, whether the contents and doses of micronutrients and electrolytes in standard banana bags meet the needs of critically ill patients with an alcohol use disorder is assessed based on available evidence. DATA SOURCE: MEDLINE/PubMed (1966 to June 2015) database search, the Cochrane Database of Systematic Reviews, and manual selection of bibliographies from selected articles. STUDY SELECTION AND DATA EXTRACTION: Articles relevant to Wernicke's encephalopathy, vitamin and electrolyte deficiencies in patients with alcohol use disorders, and alcoholic ketoacidosis were selected. Articles were narratively synthesized for this review. DATA SYNTHESIS: Of these deficiencies, thiamine is the most important for the practicing clinician to assess and prescribe replacement in a timely manner. Based on a pharmacokinetic assessment of thiamine, the banana bag approach likely fails to optimize delivery of thiamine to the central nervous system. Folic acid and magnesium may also merit supplementation although the available data do not allow for as strong a recommendation as for prescribing thiamine in this setting. There is no available evidence supporting the prescription of a multivitamin. CONCLUSIONS: Based on the published literature, for patients with a chronic alcohol use disorder admitted to the ICU with symptoms that may mimic or mask Wernicke's encephalopathy, we suggest abandoning the banana bag and utilizing the following formula for routine supplementation during the first day of admission: 200-500 mg IV thiamine every 8 hours, 64 mg/kg magnesium sulfate (approximately 4-5 g for most adult patients), and 400-1,000 µg IV folate. If alcoholic ketoacidosis is suspected, dextrose-containing fluids are recommended over normal saline.

The Association Between Alcohol Consumption and Lung Carcinoma by Histological Subtype.

Alcohol is a carcinogen suspected of increasing lung cancer risk. Therefore, we prospectively evaluated the relationship between alcohol consumption and lung carcinoma in 492,902 persons from the National Institutes of Health-AARP Diet and Health Study. We used Cox models to calculate hazard ratios and 95% confidence intervals, adjusting for tobacco smoking and other potential confounders. Between 1995/1996 and December 31, 2006, there were 10,227 incident cases of lung carcinoma, classified as adenocarcinoma (n = 4,036), squamous cell carcinoma (n = 1,998), small cell carcinoma (n = 1,524), undifferentiated carcinoma (n = 559), and other (n = 2,110). Compared with nondrinking, alcohol consumption was associated with a modest nonlinear reduction in total lung carcinoma risk at lower levels of consumption (for 0.5-<1 drink/day, HR = 0.89, 95% confidence interval: 0.82, 0.96) but a modest increase in risk in the highest category (for ≥7 drinks/day, HR = 1.11, 95% confidence interval: 1.00, 1.24). Regarding histological type, alcohol was associated with a nonlinear reduction in squamous cell carcinoma that became attenuated as consumption increased and a modest increase in adenocarcinoma among heavier drinkers. Cubic spline models confirmed these findings. Our data suggest that the relationship between alcohol consumption and lung carcinoma differs by histological subtype.

[THE ROLE OF BIOLOGICAL MEMBRANES IN DIFFERENTIAL DIAGNOSTICS OF SALMONELLA AND ACUTE ALCOHOL GASTROENTERITIS].

We evaluated the influence of Salmonella infection and alcohol on biological membranes from the content of serum phospholipid fraction known to be a component ofenterocyte membranes. Any change of membrane phospholipid content leads to a change of their blood level. The study included 50 patients with acute alcohol gastroenteritis, 50 ones with salmonella gastroenteritis, and 50 healthy subjects. Both salmonellosis and alcohol caused differently directed changes in biological membranes. The mechanism of diarrhea in patients with salmonella and acute alcohol gastroenteritis is different. Diarrhea associated with alcohol gastroenteritis is due to enhanced viscosity of biomembranes that decreases in salmonella gastroenteritis. It suggests different approaches to the treatment of these conditions. The membrane destruction coefficient below 2 is an additional proof of alcoholic etiology of gastroenteritis whereas its value above 3 confirms the involvement of salmonellosis in pathogenesis of gastroenteritis.

[One case of epistaxis and alcohol withdrawal syndrome].

UNLABELLED: The patient with long history of alcohol was admitted because of intermittent right nasal bleeding for two days,and treated by nasal packing. After 3 days,the patient exhibited auditory hallucinations and immediately showed rage, mania, sweating and fever. CT examination showed calcification in the right frontal lobe, brain atrophy and sinusitis. DIAGNOSIS: epistaxis and alcohol withdrawal syndrome, deviated septum, sinusitis.

The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome.

BACKGROUND: To date, no screening tools for alcohol withdrawal syndromes (AWS) have been validated in the medically ill. Although several tools quantify the severity of AWS (e.g., Clinical Institute Withdrawal Assessment for Alcohol [CIWA]), none identify subjects at risk of AWS, thus missing the opportunity for timely prophylaxis. Moreover, there are no validated tools for the prediction of complicated (i.e., moderate to severe) AWS in the medically ill. OBJECTIVES: Our goals were (1) to conduct a systematic review of the published literature on AWS to identify clinical factors associated with the development of AWS, (2) to use the identified factors to develop a tool for the prediction of alcohol withdrawal among patients at risk, and (3) to conduct a pilot study to assess the validity of the tool. METHODS: For the creation of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), we conducted a systematic literature search using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for clinical factors associated with the development of AWS, using PubMed, PsychInfo, MEDLINE, and Cochrane Databases. Eligibility criteria included: (i) manuscripts dealing with human subjects, age 18 years or older, (ii) manuscripts directly addressing descriptions of AWS or its predisposing factors, including case reports, naturalistic case descriptions, and all types of clinical trials (e.g., randomized, single-blind, or open label studies), (iii) manuscripts describing characteristics of alcohol use disorder (AUD), and (iv) manuscripts dealing with animal data (which were considered only if they directly dealt with variables described in humans). Obtained data were used to develop the Prediction of Alcohol Withdrawal Severity Scale, in order to assist in the identification of patients at risk for complicated AWS. A pilot study was conducted to assess the new tool's psychometric qualities on patients admitted to a general inpatient medicine unit over a 2-week period, who agreed to participate in the study. Blind to PAWSS results, a separate group of researchers retrospectively examined the medical records for evidence of AWS. RESULTS: The search produced 2802 articles describing factors potentially associated with increased risk for AWS, increased severity of withdrawal symptoms, and potential characteristics differentiating subjects with various forms of AWS. Of these, 446 articles met inclusion criteria and underwent further scrutiny, yielding a total of 233 unique articles describing factors predictive of AWS. A total of 10 items were identified as correlated with complicated AWS (i.e., withdrawal hallucinosis, withdrawal-related seizures, and delirium tremens) and used to construct the PAWSS. During the pilot study, a total of 68 subjects underwent evaluation with PAWSS. In this pilot sample the sensitivity, specificity, and positive and negative predictive values of PAWSS were 100%, using the threshold score of 4. DISCUSSION: The results of the literature search identified 10 items which may be correlated with risk for complicated AWS. These items were assembled into a tool to assist in the identification of patients at risk: PAWSS. The results of this pilot study suggest that PAWSS may be useful in identifying risk of complicated AWS in medically ill, hospitalized individuals. PAWSS is the first validated tool for the prediction of severe AWS in the medically ill and its use may aid in the early identification of patients at risk for complicated AWS, allowing for prophylaxis against AWS before severe alcohol withdrawal syndromes develop.

Effects of the minimum legal drinking age on alcohol-related health service use in hospital settings in Ontario: a regression-discontinuity approach.

OBJECTIVES: We assessed the impact of the minimum legal drinking age (MLDA) on hospital-based treatment for alcohol-related conditions or events in Ontario, Canada. METHODS: We conducted regression-discontinuity analyses to examine MLDA effects with respect to diagnosed alcohol-related conditions. Data were derived from administrative records detailing inpatient and emergency department events in Ontario from April 2002 to March 2007. RESULTS: Relative to youths slightly younger than the MLDA, youths just older than the MLDA exhibited increases in inpatient and emergency department events associated with alcohol-use disorders (10.8%; P = .048), assaults (7.9%; P < .001), and suicides related to alcohol (51.8%; P = .01). Among young men who had recently crossed the MLDA threshold, there was a 2.0% increase (P = .01) in hospitalizations for injuries. CONCLUSIONS: Young adults gaining legal access to alcohol incur increases in hospital-based care for a range of serious alcohol-related conditions. Our regression-discontinuity approach can be used in future studies to assess the effects of the MLDA across different settings, and our estimates can be used to inform cost-benefit analyses across MLDA scenarios.