Correspondence

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Intravenous crystalloid fluid for Acute alcoholic intoxication prolongs emergency department length of stay

To the Editor,

I read with great interest the article entitled “Intravenous crystalloid fluid for acute alcoholic intoxication prolongs emergency department length of stay” by Homma et al. [1]. The authors investi- gated the association between intravenous crystalloid infusion (IVF) and the length of stay in the emergency department (ED) among patients with acute alcohol intoxication. They concluded that IVF for the treatment of acute alcohol intoxication prolongs the length of stay in the ED. Despite the lack of evidence, alcohol-Intoxicated patients are still routinely treated with IVF [2]. Therefore, this study added important treatment information in this area. Nonetheless, I think there are several issues in this study that should be confirmed.

First, what is the proportion of patients who received a Bolus infusion of crystalloid fluid (e.g., a 1-L bolus of crystalloid fluid) in the IVF group? This article lacks important information regarding how much crystalloid fluid the patients received and how rapidly the patients were infused with crystalloid fluid in the IVF group. Without this information, it is difficult to discriminate the effectiveness of a bolus infusion of crystalloid fluid from the effect of the placement of venous access. Second, was there a difference between the two groups regarding blood pressure and heart rate at admission in the ED? Because dehydration is an important indication for IVF [3], patients with tachycardia and hypotension are more likely to be treated with IVF. Thus, the difference between the two groups in the proportion of dehydration might confound the outcome. Third, did the authors evaluate the Recovery time utilizing the full score of the Glasgow coma scale (GCS)? If the GCS score was monitored in their routine care, this assessment could be performed. Evaluation of other outcomes, such as gait and GCS score, would augment the authors’ conclusion that IVF for the treatment of acute alcohol intoxication was not useful if the recovery time to the full score of the GCS did not differ between the IVF and no IVF groups. Given that many factors such as ED crowding, testing, and consultation affect the ED length of stay [4,5], an additional evaluation of other related outcomes is important in the Observational study design.

As the authors noted, it is unclear why IVF significantly prolonged

the length of stay in the ED by approximately 60 min. Given that this study is not a randomized controlled design but a retrospective observa- tional design, the authors should minimize the confounding factors af- fecting the outcome as much as possible and interpret their findings cautiously.

Junpei Komagamine MD Department of Internal Medicine, National Hospital Organization Tochigi Medical Center, 1-10-37, Nakatomatsuri, Utsunomiya, Tochigi 3208580,

Japan E-mail address: [email protected].

1 February 2018

https://doi.org/10.1016/j.ajem.2018.03.019

References

1. Homma Y, Takashi S, Hoshina Y, Numata K, Mizobe M, Nakashima Y, et al. Intravenous crystalloid fluid for acute alcoholic intoxication prolongs emergency department length of stay. Am J Emerg Med 2017. https://doi.org/10.1016/j.ajem.2017.12.054.
2. Perez SR, Keijzers G, Steele M, Byrnes J, Scuffham PA. Intravenous 0.9% sodium chlo- ride therapy does not reduce length of stay alcohol-intoxicated patients in the emer- gency department: a randomised controlled trial. Emerg Med Australas 2013;25: 527-34. https://doi.org/10.1111/1742-6723.12151.
3. Vonghia L, Leggio L, Ferrulli A, Bertini M, Gasbarrini G, Addolorate G, et al. Acute alco-

   hol intoxication. Eur J Intern Med 2008;19:561-7 (doi: 10.1016/j.ejim.2007.06.033).

   McCarthy ML, Zeger SL, Ding R, Levin SR, Desmond JS, Lee J, et al. Crowding delays treatment and lengthens emergency department length of stay, even among high- acuity patients. Ann Emerg Med 2009;54:492-503. https://doi.org/10.1016/j. annemergmed.2009.03.006.

4. Casalino E, Wargon, Peroziello A, Choquet C, Leroy C, Beaune S, et al. Predictive factors for longer length of stay in an emergency department: a prospective multicentre study evaluating the impact age, patient’s clinical acuity and complexity, and Care pathways. Emerg Med J 2014;31:361-8. https://doi.org/10.1136/emermed-2012- 202155.

   Effect of high-carbohydrate meals on the rate of Ethanol metabolism on emergency department patients

   Over 4% of all emergency department visits are secondary to acute or chronic alcohol intoxication [1]. Clinicians may observe these patients for extended periods of time in the emergency department (ED). Often they are admitted for observation because they have no caregiver available. There are many influences as to the rate of detoxification of patients, one of which is the consumption of food. It has been shown that consumption of alcoholic beverages along with or just after eating diminishes the intensity and duration of intoxication. It has also been noted that a faster rate of ethanol elimination was seen when its pas- sage through the liver was slower and more prolonged, which is the case when alcohol is consumed during or after a meal [2]. The objective of this study was to determine if simply feeding intoxicated ED patients a meal might increase the metabolism of ethanol, allowing for faster hospital disposition.

   We conducted a prospective clinical study using a convenience sam- ple of patients admitted to the ED with acute alcohol intoxication. The study took place at a single urban U.S. academic medical center over a

   0735-6757/(C) 2018

   6-month study period. To estimate the blood alcohol, we used the Alco- Sensor IV (Intoximeters Inc., St Louis, MO), an automated handheld breath alcohol instrument approved by the Department of Transporta- tion. The instrument was calibrated daily according to manufacturer’s instructions [3]. All patients presenting to the ED with apparent acute alcohol intoxication, alcohol abuse, or a history of chronic use of alcohol were eligible for inclusion in the study. Exclusion criteria included patients presenting with a social or medical problem that was not alcohol-related, such as other substance abuse, or an acute medical condition such as trauma which required emergent interven- tion. Patients who were unable to cooperate with the automated hand- held breath alcohol instrument also were considered ineligible or dropped from study. Demographic data was collected to determine pa- tient characteristics, and diagnostic testing, interventions, and time spent in the ED were also recorded. The ED protocol for intoxicated patients recommends a meal (sandwich, fruit, and cookie) when the patient was able to eat. We obtained a minimum of three hourly alcohol readings before and after eating. Ethanol elimination from the blood per hour was determined from these measurements. The amount eaten by each patient was also recorded and an approximate calorie count was calculated. Descriptive statistics (mean, SD) and frequency tables were used to describe the key quantitative and qualitative variables.

   Twenty-six subjects completed the study and 25 (96%) were male. The mean age was 48 +- 9.3 years and mean weight was 85.9 +-

   11.9 kg. Mean breath alcohol concentration on arrival was 326 mg/dL (or 0.326% measured by volume). Subjects were given a meal as soon as they were able to feed themselves. Between 75%-100% of the meal was consumed for an average of 609 cal (range 394-700). The mean al- cohol elimination rates before eating was 21.3 +- 6.9 mg/dL/h. In com- parison, one hour after eating, the elimination rate increased to 34.0

   +- 9.1 mg/dL/h. This represents a net increase of 12.7 mg/dL/h (62.6%). However, within three hours after eating, the alcohol elimination rate had decreased to 21.6 +- 7.4 mg/dL/h. The mean length of stay in the ED was 9.0 h.

   Despite the small sample size, we found that the intake of food tem- porarily increased the clearance of ethanol by approximately 63%. Previ- ously, mechanisms such as enhanced activity of alcohol metabolizing enzymes and increased blood flow through the liver have been de- scribed as contributing to the increased clearance of ethanol [4]. It also has been noted that presence of food in the stomach after ingesting al- cohol may elicit a hormonal response which may increase the rate of ethanol metabolism and/or hepatic blood flow [5]. Jones has also shown that composition of the meal, whether high-fat, high-protein, or high-carbohydrate, had no significant influence on the clearance of alcohol but all decreased the systemic availability of ethanol [5]. Future studies should examine the metabolic differences between acute and chronic alcoholics, gender and age differences, and further delve into whether or not the composition of meals has an effect on alcohol clearance.

   Lindsey Ouellette MSU College of Human Medicine, Department of Emergency Medicine, 15 Michigan St NE 736, Grand Rapids, MI 49503, United States

   Joseph Boss Alexander Brown Rachel Hagert Shaun O’Toole Joe Postma Alonso Del Camp Eric VanDePol

   Spectrum Health - Michigan State University Emergency Medicine Residency Program, 15 Michigan St NE Suite 701, Grand Rapids, MI 49503,

   United States

   Jeffrey Jones MSU College of Human Medicine, Department of Emergency Medicine, 15 Michigan St NE 736, Grand Rapids, MI 49503, United States

   Spectrum Health - Michigan State University Emergency Medicine Resi- dency Program, 15 Michigan St NE Suite 701, Grand Rapids, MI 49503,

   United States

   Corresponding author at: 15 Michigan St NE Suite 701, Grand Rapids, MI

   49503, United States.

   E-mail address: [email protected].

   7 March 2018

   https://doi.org/10.1016/j.ajem.2018.03.021

   References

   White AM, Slater ME, Ng G, Breslow R. Trends in alcohol-related emergency depart- ment visits in the United States: results from the Nationwide emergency department sample, 2006 to 2014. Alcohol Clin Exp Res 2018;42(2):352-9.

5. Han RG, Norber A, Gabrielsson J, et al. Eating a meal increases the clearance of ethanol given by intravenous infusion. Alcohol Alcohol 1994;29(6):673-7.
6. Intoximeters. Alco-Sensor IV calibration procedure. Retrieved from http://www.

   intox.com/t-calibration_asiv_p1.aspx. (Copyright 2009-2018).

   Svensson CK, Mauriello DJ, Barde PM, et al. Effect of food on hepatic blood flow: im- plications in the “food effect” phenomenon. Clin Pharmacol Ther 1983;34:316-23.

7. Jones AW, Jonsson KA, Kechagias S. Effect of high-fat, high-protein, and high- carbohydrate meals on the pharmacokinetics of a small dose of ethanol. J Clin Pharmacol 1997;44:521-6.

   Doubts on the meta-analysis of serum procalcitonin levels as a diagnostic marker for Septic arthritis

   To the Editor:

   We read the enchanting article [1] by Zhao et al., which is a meta- analysis about serum procalcitonin levels as a diagnostic marker for septic arthritis . We have some questions and different views after reading the article.

   First of all, there are some mistakes in the meta-analysis, as Fig. 1 in the commented paper [1] shows, there are 68 records after searching the 3 databases (Pubmed, Embase and Cochrane Library), then 15 re- cords are removed due to duplication, therefore it should be 53 (68-15) records left, however, Fig. 1 shows that only 14 records are left for next step. Even though the number of 14 is correct, according to Fig. 1, there should be 8 studies included in the quantitative analysis after 4 records of reviews or letter and 2 uncorrelated reports are re- moved, but as a matter of fact, there are 10 studies included in the final analysis, How to explain it?

   Secondly, the authors also make mistakes in extracting the charac- teristics of the included studies. The population of the study of Butbul- Aviel et al. [2] should be children rather than adults, similarly, the pop- ulation in the study of Maharajan et al. [3] should be all age groups rather than adults. The PCT test method of the study of Wang C et al.

   [4] should be PCT-ELFA rather than PCT-LUMItest. What’s more, different PCT test methods may affect the values of PCT. Thus we think it’s better to carry out a subgroup analysis based on the methods of PCT-test in order to make the meta-analysis more convincing. Otherwise, the specificity should be 98.61% rather than 72.0% in the study of Wang C et al. [4]. These mistakes could lead to a wrong final result.

   Thirdly, Septic arthritis (SA) refers to infection in a joint due to a bac- terial, mycobacterial, or fungal cause [5]. Obviously, SA is different from osteomyelitis in many aspects. Nevertheless, the studies carried by Butbul-Aviel et al. [2] and Maharajan et al. [3] comprised population of