Severe Alcoholics Research Articles

Construction of group norms in a radical acceptanceonline forum for heavy alcohol users: A corpus-based discourse analysis.

Alcohol use is a major source of morbidity and mortality globally. Numerous adverse health outcomes have been linked to alcohol use, including liver disease, road injuries, violence, cancer, cardiovascular disease, suicide, domestic violence and family breakdown. Alcohol use is responsible for approximately three million deaths per year across the globe. Different paradigms have been employed in the treatment of alcohol use disorder, including abstinence-based and harm-reduction models. Radical acceptance, which has been successfully applied elsewhere in mental health treatment, has not gained purchase in the treatment of addictions. We used a set of corpus linguistics techniques to analyze a dataset of approximately 10,000 posts in an online forum for self-identified severe alcoholics. The forum we studied explicitly claims a radical acceptance approach to alcohol use disorder. The forum is "for people who accept their lifestyle choice and don't want to be interrupted . . ." We combined quantitative methods (keyword and collocation analysis) and qualitative methods (concordancing) to conduct a discourse analysis of the linguistic and rhetorical practices employed in the forum. We found that although the forum purports to embrace acceptance and eschew change, in fact, the discursive practices in the forum reveal a highly ambivalent relation with both acceptance and change. We found that acceptance and change are in dialectical tension that mirrors the structure agency dialectic described in critical realism. We suggest there may be merit in considering employing a radical acceptance paradigm in addictions treatment.

Mo1331: FACTORS ASSOCIATED WITH POST HOSPITALIZATION FOLLOW UP IN PATIENTS WITH SEVERE ALCOHOLIC HEPATITIS

Mo1331: FACTORS ASSOCIATED WITH POST HOSPITALIZATION FOLLOW UP IN PATIENTS WITH SEVERE ALCOHOLIC HEPATITIS

“Daddy’s Head Is Broken”: The Treatment of Children of Severe Alcoholics

ABSTRACT The author explicates the complex family relationships of children of severe alcoholics, and internalizations of these relationships, which can be addressed in the treatment of children and in corollary parent work. Children of serious alcoholics (or other substance use disorders) share features with other children whose parents are troubled. However, the author suggests that it is useful to consider what children of severe alcoholics have in common. Children of serious alcoholics can experience the substance of abuse as a mysterious potion, which their alcoholic parent prefers to them. Additionally, alcoholics (along with other substance abusers) expose their children to the specific results of inebriation or withdrawal from alcohol. The author discusses the following common experiences of the children of severe alcoholics: extreme difficulty in understanding parental addiction, particularly for very young children; an unconscious struggle to repair the damaged parent and to try to protect that parent from strain; and guilt at the often-necessary exclusion of the addicted parent from the household unit. Another confusing issue is mourning for a parent who is still alive and in some contact, yet severely impaired. The author describes parent work in these situations (collateral to a child psychoanalysis or psychotherapy), both with the “co dependent” parent and the alcoholic parent.

Rebound of Severe Alcoholic Intoxications in Adolescents and Young Adults After COVID-19 Lockdown

PurposeThe coronavirus lockdown in Italy ended, but the postlockdown phase may be even more challenging than the outbreak itself if the impact on mental health is considered. To date, little evidence is available about the effect of lockdown release in terms of adolescent health from the perspective of an emergency department (ED). MethodsWe reviewed data on ED arrivals of adolescents and young adults (aged 13–24 years) in the weeks immediately before and after the Italian lockdown release in 2020, and in the same periods in 2019, with a focus on cases of severe alcohol abuse, psychomotor agitation, and other mental issues. ResultsThe relative frequency of severe alcohol intoxications increased from .88% during the last part of the lockdown to 11.3% after lockdown release. When comparing these data with the same period in 2019, a highly significant difference emerged, with severe alcohol intoxications accounting for 11.31% of ED visits versus 2.96%, respectively. The relative frequency of ED arrivals related to psychomotor agitation or other mental health issues was not significantly increased after lockdown release. ConclusionsThis report suggests that emergency services should be prepared for a possible peak of alcohol intoxication-related emergencies in adolescents and young adults. The connection between alcohol abuse and mental health should not be overlooked.

Differential Activation of Unconventional T Cells, Including iNKT Cells, in Alcohol-Related Liver Disease.

Liver is enriched in several innate-like unconventional T cells, but their role in alcohol-related liver disease (ALD) is not fully understood. Studies in several acute alcohol feeding models but not in chronic alcoholic steatohepatitis (ASH) model have shown that invariant natural killer T (iNKT) cells play a pathogenic role in ALD. Here, we investigated the activation of iNKT cells in an intragastric (iG) infusion model of chronic ASH as well as the frequency and cytokine phenotype of 3 different unconventional T cells: iNKT, mucosal-associated invariant T (MAIT), and CD8+ CD161hi Vα7.2- cells in peripheral blood of ALD patients. Hepatic iNKT cells were investigated using the iG model of chronic ASH that combines feeding of high-cholesterol/high-fat diet (HCFD) with intragastric feeding of ethanol diet (HCFD+iG Alc). Human iNKT, MAIT, and CD8+ CD161hi Vα7.2- cells were examined by flow cytometry in peripheral blood of patients with severe alcoholic hepatitis (SAH) and chronic alcoholics (ChA) and compared with healthy controls. In the iG model of chronic ASH, IFNγ+ iNKT cells accumulate in their livers compared with pair-fed control mice and activated hepatic iNKT cells show high expression of Fas and FasL. Notably, IFNγ+ iNKT cells are also significantly increased in peripheral blood of ChA patients compared with SAH patients. MAIT cells are significantly reduced in all ALD patients, but CD8+ CD161hi Vα7.2- cells are increased in SAH patients. Although MAIT and CD8+ CD161hi Vα7.2- cells displayed a similar cytokine production profile, the production of IFNγ and TNFα is significantly increased in SAH patients, while significant IL-17A production is found in ChA patients. We found that the 3 unconventional T cells are activated in ALD patients showing interesting differences in their frequency and cytokine production profile between SAH and ChA patients. In the iG murine model of chronic ASH, iNKT cells are also activated secreting proinflammatory cytokines suggesting their involvement in liver disease.

Prognostic Value of Serum Iron, Ferritin, and Transferrin in Chronic Alcoholic Liver Disease.

Ethanol increases iron absorption. Therefore, increased amount of iron reaches the liver, and exerts pro-oxidant effects and stimulates ferritin synthesis and hepatic stellate cell activation, promoting fibrosis and inflammation. These mechanisms would theoretically support a role of ferritin as a marker of the transition to liver cirrhosis, and, consequently, as a prognostic factor, but there is controversy regarding its behavior in alcoholics. We analyzed among 238 severe alcoholics the prognostic value of iron, ferritin, transferrin, transferrin saturation index (TSI) and total iron binding capacity (TIBC), and the relationships of these variables with liver function, proinflammatory markers (C-reactive protein (CRP), interleukin (IL)-6, IL-8, and tumor necrosis factor α), and the presence of cirrhosis. Patients showed higher serum ferritin (Z = 2.50, p = 0.031) but lower transferrin (t(264) = 4.81, p < 0.001), TIBC (t(262) = 4.44, p < 0.001), and iron (Z = 3.19, p = 0.001) values compared with 32 age- and sex-matched controls. Ferritin was related to inflammatory cytokines such as IL-8 (ρ = 0.18, p = 0.012) and to IL-6 (ρ = 0.16, p = 0.016), but not to liver function. On the contrary, cirrhotics showed lower transferrin (t(234) = 4.77, p < 0.001) and TIBC (t(232) = 4.67, p < 0.001), but higher TSI (Z = 3.35, p < 0.001) than non-cirrhotics. Transferrin, TSI, and TIBC were related to liver function impairment (marked differences among the Child's groups regarding transferrin (KW (2) = 22.83, p < 0.001), TSI (KW (2) = 15.81, p < 0.001), and TIBC (KW (2) = 21.38, p < 0.001) but only weakly to inflammation (inverse relationships between IL-6 and total iron (ρ = - 0.16, p = 0.017), TIBC (ρ = - 0.20, p = 0.002), and transferrin (ρ = - 0.20, p = 0.003). In accordance, albumin, IL-6, alcohol quitting, and TSI, in this order, were independently related to mortality, but not ferritin or iron.

Gadolinium Enhancement May Indicate a Condition at Risk of Developing Necrosis in Marchiafava-Bignami Disease: A Case Report and Literature Review.

Marchiafava–Bignami disease (MBD) is a rare condition characterized by demyelination, necrosis and atrophy of the corpus callosum (CC), and mainly associated with alcoholism. MBD may present with various clinical manifestations. Brain magnetic resonance imaging (MRI) scan is important in prompt diagnosis and treatment of MBD. Here we reported a case of MBD and reviewed literature about the usage of gadolinium-enhanced MRI in MBD. Gadolinium enhancement may indicate a condition at risk of developing necrosis. We therefore recommend a contrast-enhanced MRI study in severe alcoholics with suspected diagnosis of MBD.

Study to compare hematological parameters in alcoholic and non-alcoholic individuals

Background: Alcoholism represents one of the most serious worldwide socioeconomic health problems. It is one of the leading causes of preventable mortality, second only to cigarette smoking. Multiple organs can be involved such as hepatobiliary system, cardiovascular system, central nervous system, and hematopoietic system. Impact of alcohol on hematopoietic system divided into direct and indirect effects. Anemia is a predominant feature among chronic alcoholics. Aim and Objective: The study is done to know hematological parameters in alcoholics as compared to non-alcoholic individuals. Materials and Methods: Twenty-five adult patients who are moderate alcoholics, 25 patients who are severe alcoholics, and 25 adult patients who are non-alcoholics were selected. Hematological parameters such as hemoglobin, red blood cell (RBC) count, total white blood cells count, Mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), MCH concentration (MCHC), and platelet (PLT) count were taken for the study. Statistical analysis was done. P < 0.05 was considered as statistically significant. Results: Mean hemoglobin, mean RBC count, mean MCH, and MCHC were normal among the non-alcoholic group and it started decreasing among moderate alcoholics and more so with severe alcoholics, and a similar type of result was also seen with total count and PLT count and the difference was found to be statistically significant. Conclusion: This shows that alcoholic subjects were suffering from anemia. This study will help to create awareness of the diagnosis of anemia by estimating low hemoglobin levels in alcoholic subjects.

Study of Effect of Alcohol on the Microscopic Analysis of Semen

Background: Consumption of alcohol is a major modifiable, rather avoidable lifestyle choice and has shown to affect male fertility. Alcohol has shown to cause various deleterious effects on the male reproductive system. Aims: To compare the effects of alcohol on the sperm count, motility, viability and morphology in alcoholic and non-alcoholic groups. This was a cross sectional study with sample size of 51. There were 25 semen samples of alcoholics (cases) and 26 semen samples of non-alcoholics (controls). Materials and Methods: Adequate history regarding the alcohol consumption was taken and the cases (n=25) were categorized into mild (n=17), moderate (n=8) and severe (n=0) alcoholics as per standard criteria of the CAGE Questionnaire. Semen was examined microscopically and the results were statistically analyzed using ANOVA. Results: Mean sperm count in the non-alcoholics was 58.81 million/ml. It was reduced to 45.44 million/ml and 35.62million/ml in mild and moderate alcoholic groups respectively. (P=0.03). Actively motile sperms in non-alcoholics, mild and moderate alcoholics were found to be 58.08%, 44.41% and 30.62% respectively. (P=0.016). The percentage of sluggishly motile sperms in non-alcoholics, mild and moderate alcoholics were found to be 19.09%, 32.35% and 32.5% respectively. The effect on the percentage of immotile sperms was ambiguous. 15 out of the 26 cases of non-alcoholics showed abnormalities in the morphology. The incidence of abnormal morphology of sperm was higher in the alcoholics. All 25 cases showed abnormal sperm morphology. Alcohol causes a decrease in the sperm vitality. As the grade of alcohol increased, the lowest vitality was in the range of 20-29% and the highest being in the range of 70-79%. Conclusion: The findings reveal that alcohol consumption had significant detrimental effects on the count, morphology and vitality of spermatozoa. It is important to create awareness among people of the adverse effects of alcohol on human health and fertility.

Obesity and Its Correlation With Severe Alcoholic Hepatitis

Introduction: The prevalence of obesity in the United State has been rising in the last two decades. While the association of obesity with alcohol-associated liver disease and cirrhosis is recognized, little is known about possible correlations between severe alcohol hepatitis(AH) and obesity. In contrast to obesity, underweight MBI and its correlation with alcoholic hepatitis is not studied yet. Our aim in this study is to examine whether obesity defined by different body mass index (BMI) groups is associated with the severity of AH and to assess potential correlations between mortality and BMI in those who develop severe AH. Our second aim was to explore correlations between underweight and severe AH. Methods: We performed a single center, retrospective chart review study of patients, between the ages 18 and 80 with AH from January 2008 to January 2018. AH was defined as recent alcohol consumption with elevations in the AST and ALT levels (ratio >1.5), bilirubin level >3 mg/dL and no other causes of liver injury or chronic liver disease. Obesity was classified based on BMI into class I: BMI 30-34.99, class II:35-39.99 and class III: 40 and above. Underweight was defined by BMI < 20. Results: Three hundred and sixty one patients met the criteria of AH, the mean age was 47.6 +/- 10.4 years. Male gender was predominant (65%), while Caucasians represented 92% of the cohort. The mean Maddrey discriminant function(MDF) and MELD scores were 44.4 +/- 42.0 and 22.5 +/- 8.0, respectively. Severe AH, based on MDF ≥32, was found in 198 patients representing 55% of the cohort. Among obese patients, BMI 35-39.9 was associated with severe AH with an odd ratio 2.2 and P-value 0.04. We found an association between BMI and mortality in severe AH. BMI 35-39.9 was associated with higher mortality rate when compared to other BMI groups with an odd ratio of 3.6 and P=Value of 0.004. When compared with moderate AH, (Maddrey Conclusion: Patients with BMI 35-39.9 are more likely to present with severe AH compared to other BMI groups. BMI 35-39.9 correlates with death in severe AH. These data indicate that obesity is a risk factor for severe disease and poor outcome in AH.906 Figure 1 No Caption available.

Time course of microglia activation and brain and blood cytokine/chemokine levels following chronic ethanol exposure and protracted withdrawal in rats.

Alcohol produces complex effects on the immune system. Moderate alcohol use (1-2 drinks per day) has been shown to produce anti-inflammatory responses in human blood monocytes, whereas, the post mortem brains of severe alcoholics show increased immune gene expression and activated microglial markers. The present study was conducted to evaluate the time course of alcohol effects during exposure and after withdrawal, and to determine the relationship between microglial and cytokine responses in brain and blood. Forty-eight adult, male Wistar rats were exposed to chronic ethanol vapors, or air control, for 5 weeks. Following ethanol/air exposure blood and brains were collected at three time points: 1) while intoxicated, following 35 days of air/vapor exposure; 2) following 24h of withdrawal from exposure, and 3) 28 days after withdrawal. One hemisphere of the brain was flash-frozen for cytokine analysis, and the other was fixed for immunohistochemical analysis. The ionized calcium-binding adapter molecule 1 (Iba-1) was used to evaluate microglia activation at the three time points, and rat cytokine/chemokine Magnetic Bead Panels (Millipore) were used to analyze frontal cortex tissue lysate and serum. Ethanol induced a significant increase in Iba-1 that peaked at day 35, remained significant after 1 day of withdrawal, and was elevated at day 28 in frontal cortex, amygdala, and substantia nigra. Ethanol exposure was associated with a transient reduction of the serum level of the major pro- and anti-inflammatory cytokines and chemokines and a transient increase of effectors of sterile inflammation. Little or no changes in these molecules were seen in the frontal cortex except for HMG1 and fractalkine that were reduced and elevated, respectively, at day 28 following withdrawal. These data show that ethanol exposure produces robust microglial activation; however, measures of inflammation in the blood differ from those in the brain over a protracted time course.

Early changes of left atrial function in chronic asymptomatic alcoholics by two-dimensional speckle-tracking echocardiography

Background Chronic excessive alcohol intake has been reported as a possible cause of dilated cardiomyopathy. Two-dimensional speckle-tracking echocardiography (2D-STE) is a novel method for the angle-independent and objective quantification of myocardial deformation. This study sought to assess left atrial function changes among alcoholics related to the duration of heavy drinking by 2D-STE.Methods We classified 92 asymptomatic alcoholics into mild, moderate and severe groups. Thirty age-matched controls were also recruited. We measured left atrial (LA) phasic volumes (max, min and pre-atrial contraction volume) using Simpson’s method in apical four-chamber view. Passive emptying (LAPEF) and active emptying (LAAEF) indices were calculated. Global longitudinal strain rate (SRs) during left ventricular (LV) ejection, early diastolic strain rate (SRe) during LV early diastole and peak negative strain rate (SRa) after the P-wave were also obtained by averaging all atrial segments.Results The alcoholics had larger LA volumes (max, min and pre-atrial contraction volume) since moderate stage (P < 0.01). LAPEF, SRs SRe, and E/A ratio showed progressive decrease according to the grades of alcoholism. The differences between the groups were significant, beginning from the moderate group (P < 0.01). During LAAEF, SRa values increased with the disease severity up to moderate alcoholics and then deteriorated significantly in severe alcoholics (P < 0.01).Conclusions These data suggest that 2D-STE may be considered a promising tool for the early detection of impairment of LA function in alcoholics.

The serum level of NX-DCP-R, but not DCP, is not increased in alcoholic liver disease without hepatocellular carcinoma.

Alcoholic liver disease (ALD) is the most common cause of hepatocellular carcinoma (HCC) worldwide. Des-gamma-carboxy prothrombin (DCP) is elevated in many patients with HCC, but also in severe alcoholics without HCC. We aimed to clarify whether the DCP/NX-DCP ratio (NX-DCP-R) could have a high specificity in ALD patients without HCC. We performed a prospective cohort study on a total of 703 consecutive outpatients of liver diseases including severe alcoholics and healthy volunteers, who underwent blood biochemical examinations at Kobe University Hospital. Serum DCP was measured by electrochemiluminescence immunoassay (ECLIA) using a monoclonal antibody, MU-3. A novel parameter, serum NX-DCP, which represents predominantly DCP caused by reduced vitamin K availability, was also measured by ECLIA using monoclonal antibodies P-16 and P-11. The diagnostic accuracy of DCP and NX-DCP-R in patients with and without excessive alcohol intake was statistically examined. DCP was significantly higher in alcoholics than in non-alcoholics (p= 0.005), whereas the NX-DCP-R did not differ between alcoholics and non-alcoholics (p= 0.375). DCP was significantly increased in the serum of each patient with alcoholic hepatitis and alcoholic cirrhosis (p< 0.05), whereas the NX-DCP-R was not increased (p> 0.05). NX-DCP-R, but not DCP, was not increased in alcoholics without HCC. As for negative screening for HCC, the specificity of the NX-DCP-R in alcoholics without HCC was better than that of DCP in alcoholics without HCC, and so could be a useful negative screening tool for HCC in millions of alcoholics worldwide.

A randomized controlled trial of targeted prefrontal cortex modulation with tDCS in patients with alcohol dependence.

Preliminary small studies have shown that transcranial direct current stimulation (tDCS) reduces craving in alcoholic subjects. It is unclear whether tDCS also leads to changes in clinically meaningful outcomes for alcohol dependence in a properly powered phase II randomized clinical trial. We aimed to investigate whether repetitive tDCS changes the risk of alcohol use relapse in severe alcoholics from outpatient services. Thirty-five subjects were randomized to receive active bilateral [left cathodal/right anodal over the dorsolateral prefrontal cortex (dlPFC)] repetitive (five consecutive days) tDCS (2 mA, 35 cm2, two times daily stimulation for 13 min with a 20-min interval) or sham-tDCS. There were two dropouts before treatment. From 33 alcoholic subjects, 17 (mean age 45.5±8.9 s.d., 16 males) were randomized to sham and 16 (44±7.8 s.d., 16 males) to real tDCS treatment. By the end of the six months of follow-up, two subjects treated with sham (11.8%) and eight treated with real tDCS (50%) were still alcohol-abstinent [p=0.02, Long-rank (Mantel-Cox) Test, HR=0.35 (95% CI, 0.14-0.85)]. No differences with regard to changes on scores of craving, frontal function, global mental status, depressive or anxiety symptoms were observed between groups. However, subjects from the tDCS group improved with regard to their overall perception of quality of life (p=0.02), and increased their scores in the environment domain (p=0.04) after treatment. Bilateral tDCS over dlPFC reduces relapse probability in severe alcoholic subjects and results in improved perception of quality of life.

Gabapentin

Gabapentin

S19 * LIVER TRANSPLANTATION IN PATIENTS WITH ALCOHOLIC LIVER DISEASE

S19 * LIVER TRANSPLANTATION IN PATIENTS WITH ALCOHOLIC LIVER DISEASE

« Hors les lois de la guerre ». À propos du traumatisme psychique chez quatre soldats auteurs de meurtres en situation opérationnelle

ObjectivesFollowing an aggressive situation, can the aggressors, as for the victims, suffer from a traumatic breakdown. As Military Psychiatrists, we have met veteran military murderers. All these patients present with a state of Post-Traumatic Stress Disorder with either severe alcoholism or severe depression (melancholy). We also compared the effects of treatment within the two groups, i.e. murders, and victims. PatientsWe chose four patient observations murderers. Their acts were committed “Except for the laws of war”, that is to say, forbidden by the Geneva Conventions. The alcoholic patients: Guillaume is a 45-year-old veteran from the wars in Indochina and Algeria. He has undergone several unsuccessful detoxification programs. One day, he finally tells the most significant episode of his history. While in Algeria, his lieutenant asked him to execute a prisoner. Since then, he has nightmares where he sees the scene, and calms his anxiety with alcohol. He was hospitalized and commenced psychotherapeutic treatment during which he relived his childhood, adolescence and his military career. Two months later, he is cured from his post-traumatic stress condition and alcoholism. Another veteran from Algeria, who was also a severe alcoholic: whilst there, he was ordered by his chief to execute three prisoners. A few years later, by chance he meets his former boss who tells him that the three victims were brothers. He is very shocked because he comes from a region of “vendettas” where it is said that one does not eliminate a family. These nightmares and his alcoholic career started there. Treatment will prove ineffective. The melancholic patients: Andre is a former veteran of Indochina. There, he participated in the massacre of villagers who had hidden enemies. He returned to France after his time engagement, married, had five children, and resumed his profession as industrial painter. After 5 years, he is assailed by nightmares and cannot stop to tell of the horrors to those around him. His wife eventually threw him out and he became a hobo (tramp) in his small town. Gradually during the night, he has hallucinations: he hears his Vietnamese enemies lurking around him waiting for a day to take revenge. He was hospitalized and fairly gradually, the nightmares disappear and then, slowly, his depressive state. Yanis is a 40-year-old veteran of the French Foreign Legion. He lives in Paris and gradually felt he was the center of a complot by Arab youths in the capital. He became aware of surprised looks and conversations, which indicated that they want to kill him. He took refuge in the Military Hospital, where he recounted the circumstances in which, in Africa, he killed a teenager. This act was the result of a misunderstanding, but he saw himself as a murderer of children. Again, the psychotherapeutic treatment resulted in healing. ResultsIn three of our patients, the disappearance of the syndrome of repetition (repetition syndrome) and the alcohol and the melancholic state was achieved quickly. Probably because the “enjoyment” attached to traumatic images when the patient is a victim, here is outweighed by the horror of an act that the person has committed itself. Thus, the patient is willing much faster than when a victim, to get rid of the repetition syndrome. ConclusionPatient murderers feel themselves as guilty, which turn them to alcohol and ideas of persecution. Despite the severity of the conditions of post-traumatic stress presented by criminal murderers, do not hesitate to commence psychotherapeutic therapy.

Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Requerimientos de macronutrientes y micronutrientes

Energy requirements are altered in critically-ill patients and are influenced by the clinical situation, treatment, and phase of the process. Therefore, the most appropriate method to calculate calorie intake is indirect calorimetry. In the absence of this technique, fixed calorie intake (between 25 and 35kcal/kg/day) or predictive equations such as the Penn State formula can be used to obtain a more accurate evaluation of metabolic rate.Carbohydrate administration should be limited to a maximum of 4g/kg/day and a minimum of 2g/kg/day. Plasma glycemia should be controlled to avoid hyperglycemia. Fat intake should be between 1 and 1.5g/kg/day. The recommended protein intake is 1–1.5g/kg/day but can vary according to the patient's clinical status.Particular attention should be paid to micronutrient intake. Consensus is lacking on micronutrient requirements. Some vitamins (A, B, C, E) are highly important in critically-ill patients, especially those undergoing continuous renal replacement techniques, patients with severe burns and alcoholics, although the specific requirements in each of these types of patient have not yet been established. Energy and protein intake in critically-ill patients is complex, since both clinical factors and the stage of the process must be taken into account. The first step is to calculate each patient's energy requirements and then proceed to distribute calorie intake among its three components: proteins, carbohydrates and fat. Micronutrient requirements must also be considered.

Guidelines for specialized nutritional and metabolic support in the critically-ill patient: update. Consensus SEMICYUC-SENPE: macronutrient and micronutrient requirements.

Energy requirements are altered in critically-ill patients and are influenced by the clinical situation, treatment, and phase of the process. Therefore, the most appropriate method to calculate calorie intake is indirect calorimetry. In the absence of this technique, fixed calorie intake (between 25 and 35 kcal/kg/day) or predictive equations such as the Penn State formula can be used to obtain a more accurate evaluation of metabolic rate. Carbohydrate administration should be limited to a maximum of 4 g/kg/day and a minimum of 2 g/kg/day. Plasma glycemia should be controlled to avoid hyperglycemia. Fat intake should be between 1 and 1.5 g/kg/day. The recommended protein intake is 1-1.5 g/kg/day but can vary according to the patient's clinical status. Particular attention should be paid to micronutrient intake. Consensus is lacking on micronutrient requirements. Some vitamins (A, B, C, E) are highly important in critically-ill patients, especially those undergoing continuous renal replacement techniques, patients with severe burns and alcoholics, although the specific requirements in each of these types of patient have not yet been established. Energy and protein intake in critically-ill patients is complex, since both clinical factors and the stage of the process must be taken into account. The first step is to calculate each patient's energy requirements and then proceed to distribute calorie intake among its three components: proteins, carbohydrates and fat. Micronutrient requirements must also be considered.

Endothelial Dysfunction and High Cardiovascular Risk Profile in Severe Alcoholics Improve Only Partially Following a Medium‐Term Alcohol Withdrawal

Little is known about brachial artery flow-mediated vasodilatation (FMD) in active and medium-term withdrawing heavy alcoholics (HA). FMD and some parameters of cardiovascular (CV) risk were measured in 29 HA (average alcohol intake 135, range 86 to 215 g per day) at baseline and after a 9 ± 7 months withdrawal and in 35 teetotalers. HA showed baseline impaired maximal % FMD (8.5 ± 5.4 SD vs. 14.9 ± 7.4, <0.001 vs. teetotalers), higher systolic (SBP) and diastolic (DBP) blood pressure (+24 mm Hg, <0.001; +15 mm Hg, <0.01), uric acid (5.3 ± 1.1 vs. 4.4 ± 0.8 mg/dl, <0.05), high-sensitivity C-reactive protein (hs-CRP; 2.7 ± 2.0 vs. 1.0 ± 0.9 mg/l, <0.02), endothelin-1 (ET-1, 0.88 ± 0.36 vs. 0.37 ± 0.10 pg/ml,<0.001), asymmetric dimethylarginine (ADMA, 0.50 ± 0.21 vs. 0.41 ± 0.12 μmol/l, p < 0.001), homeostasis model assessment of insulin resistance (HOMA-IR) (2.3 ± 1.1 vs. 1.2 ± 0.4, <0.001), and urinary 8-isoprostane (U8-iso-PGF2α) (237.2 ± 172.4 vs. 168.5 ± 96.6 pg/mg creatinine, <0.05). After withdrawal, SBP fell by 15 mm Hg, DBP by 11 mm Hg (p < 0.001), and hs-CRP by 0.94 mg/l (p < 0.02), all remaining still higher than teetotalers (<0.05, 0.01, 0.05 respectively). ET-1, HOMA-IR, and U8-iso-PGF2α were unchanged (p = NS vs. baseline, <0.05 to 0.001 vs. teetotalers). Maximal % FMD rose (to 10.6 ± 6.2, p < 0.04), but it still remained impaired (<0.04 vs. teetotalers). ADMA increased further to 0.64 ± 0.15 μmol/l (<0.05 vs. baseline, <0.02 vs. teetotalers). HA show marked endothelial dysfunction (ED) and high BP, impaired insulin sensitivity, inflammation, increased oxidative stress, and elevated ET-1 and ADMA, which are unaffected or only partially reversed by a medium-term alcohol withdrawal. ED and related abnormalities persist in detoxified alcoholics, thus contributing to a greater CV morbidity and mortality.