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1 Management of Alcohol Withdrawal Delirium An Evidence-Based Practice Guideline ORIGINAL INVESTIGATION Michael F. Mayo-Smith, MD, MPH; Lee H. Beecher, MD; Timothy L. Fischer, DO; David A. Gorelick, MD, PhD; Jeanette L. Guillaume, MA; Arnold Hill, MD; Gail Jara, BA; Chris Kasser, MD; John Melbourne, MD; for the Working Group on the Management of Alcohol Withdrawal Delirium, Practice Guidelines Committee, American Society of Addiction Medicine Background: Alcohol withdrawal delirium is the most serious manifestation of alcohol withdrawal. Evidence suggests that appropriate care improves mortality, but systematic reviews are unavailable. Methods: Articles with original data on management of alcohol withdrawal delirium underwent structured review and meta-analysis. Results: Meta-analysis of 9 prospective controlled trials demonstrated that sedative-hypnotic agents are more effective than neuroleptic agents in reducing duration of delirium and mortality, with a relative risk of death when using neuroleptic agents of 6.6. Statistically significant differences among various benzodiazepines and barbiturates were not found. No deaths were reported in 217 patients from trials using benzodiazepines or barbiturates. Conclusions: Control of agitation should be achieved using parenteral rapid-acting sedative-hypnotic agents that are cross-tolerant with alcohol. Adequate doses should be used to maintain light somnolence for the duration of delirium. Coupled with comprehensive supportive medical care, this approach is highly effective in preventing morbidity and mortality. Arch Intern Med. 2004;164: From the Primary Care Service, Veterans Administration Medical Center, Manchester, NH (Dr Mayo-Smith); the Tri County Commission on Alcohol and Drug Abuse, Orangebury, SC (Dr Fischer); the Intramural Research Program, National Institute on Drug Abuse, Baltimore, Md (Dr Gorelick); the American Society of Addiction Medicine, Chevy Chase, Md (Mss Guillaume and Jara); Marlboro Medical Center, Marlborough, Mass (Dr Hill); Kasser & Associates, Cordova, Tenn (Dr Kasser); and Conifer Park Rehabilitation Center, Scotia, NY (Dr Melbourne). Dr Beecher is in private practice in St Louis Park, Minn. The authors listed in the byline constitute the Working Group on the Management of Alcohol Withdrawal Delirium. The authors have no relevant financial interest in this article. ALCOHOL DEPENDENCE IS commonly encountered by physicians, and it occurs in 15% to 20% of hospitalized patients in some settings. 1-3 Alcohol withdrawal is among the many medical problems associated with alcohol dependence. Withdrawal signs and symptoms are usually minor, but they can be considerable and even fatal. Alcohol withdrawal delirium (AWD), commonly known as delirium tremens or DTs, is the most serious manifestation of alcohol withdrawal syndrome. Current diagnostic criteria for AWD include disturbance of consciousness, change in cognition or perceptual disturbance developing in a short period, and the emergence of symptoms during or shortly after withdrawal from heavy alcohol intake (Table 1). 4 The classic clinical presentation of AWD also includes hyperpyrexia, tachycardia, hypertension, and diaphoresis. The incidence of AWD averages 5% in placebo-treated alcoholdependent patients entered into clinical trials of inpatient drug treatment for alcohol withdrawal. 5 Clinical features of alcohol withdrawal syndrome can appear within hours of the last drink, but delirium typically does not develop until 2 to 3 days after cessation of drinking. Alcohol withdrawal delirium usually lasts 48 to 72 hours, but there have been case reports 6-8 of much longer duration. Initial studies found mortality to be as high as 15%, 8 but with advances in treatment, mortality rates have fallen, with more recent studies 9 indicating mortality of 0% to 1%. Given the seriousness of AWD and the apparent value of appropriate treatment in preventing morbidity and mortality, the development of an evidencebased guideline would have widespread utility. The purpose of this guideline, therefore, is to assist physicians and other health care professionals in providing appropriate treatment for all patients with AWD. This guideline does not address the management of uncomplicated alcohol withdrawal syndrome or the prevention of AWD as these topics are covered in a previously published guideline. 5 METHODS Management of AWD was a topic identified for guideline development by the American Society of Addiction Medicine Committee on Practice Guidelines. A working group was appointed that included individuals with training 1405
2 Table 1. DSM-IV Diagnostic Criteria for Alcohol Withdrawal and Alcohol Withdrawal Delirium* Alcohol Withdrawal A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged. B. Two (or more) of the following, developing within several hours to a few days after criterion A: (1) Autonomic hyperactivity (eg, sweating or pulse rate 100/min) (2) Increased hand tremor (3) Insomnia (4) Nausea or vomiting (5) Transient visual, tactile, or auditory hallucinations or illusions (6) Psychomotor agitation (7) Anxiety (8) Grand mal seizures C. The symptoms in criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. Specify whether with perceptual disturbances. Alcohol Withdrawal Delirium A. Disturbance of consciousness (ie, reduced clarity of awareness of the environment), with reduced ability to focus, sustain, or shift attention. B. A change in cognition (such as memory deficit, disorientation, or language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. C. The disturbance develops in a short period (usually hours to days) and tends to fluctuate during the day. D. There is evidence from the history, physical examination, or laboratory findings that the symptoms in criteria A and B developed during, or shortly after, a withdrawal syndrome. *Data from the American Psychiatric Association. 4 This diagnosis should be made instead of a diagnosis of substance withdrawal only when the cognitive symptoms are in excess of those usually associated with the withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention. in internal medicine, family practice, psychiatry, and pharmacology and individuals involved in primary care medicine, addiction medicine, and research on alcohol withdrawal. The primary outcomes considered by the working group included (1) mortality rate, (2) duration of delirium, (3) time required for control of agitation, (4) adequate control of delirium, (5) treatment complications, and (6) costs. Acquisition costs were determined by averaging wholesale prices listed in the 2001 Red Book. 10 The options considered for managing AWD included pharmacologic and nonpharmacologic strategies. Any pharmacologic agent that has been studied in the management of AWD was considered. Nonpharmacologic strategies included the choice of the setting for treatment, evaluation, monitoring, and supportive and psychosocial care. REVIEW OF THE EVIDENCE Table 2. Methods of Grading Levels of Evidence and Recommendations 12 Level I studies Level II studies Level III studies Level IV studies Level V studies Grade A Grade B Grade C Definition Levels of Evidence Randomized trials with low false-positive and low false-negative errors Randomized trials with high false-positive or high false-negative errors Nonrandomized, concurrent cohort comparisons Nonrandomized, historical cohort comparisons Case series without controls Recommendations Supported by level I studies or by a meta-analysis in which the lower limit of the confidence interval for the effect of treatment exceeds the minimally clinically significant benefit Supported by level II studies or by a meta-analysis in which the estimate of treatment effect exceeds the minimal clinically significant benefit but the lower limit of the confidence interval does not Supported by data other than prospective controlled trials, including secondary analyses of level I or II studies Searches of the English-language medical literature were conducted through MEDLINE using the key words substance withdrawal syndrome and alcohol, alcohol withdrawal delirium, and delirium tremens from the initial entries in MEDLINE (January 1, 1966, through September 30, 2001). Articles were selected if they involved human subjects and included new clinical data on the management of AWD (ranging from a single case report to a prospective randomized trial). References from the selected articles, including those from before 1966, from review articles, and from textbooks were also examined and included when appropriate. Members of the working group, using a structured data collection form, abstracted all articles meeting the initial inclusion criteria. Articles identified as prospective controlled trials with patients meeting explicit inclusion criteria, including the basic elements of the DSM-IV criteria for AWD, underwent further independent review by a second member, with abstraction of data for metaanalysis. Any differences of interpretation were resolved by consensus. Meta-analysis was performed when possible using the logit method. 11 RECOMMENDATIONS Recommendations based on the evidence were drafted and graded according to a published system (Table 2). 12 In several areas, it was recognized that a single recommendation could not be formulated to guide the treatment of all patients but that the decisions should be guided by a series of clinical considerations. In such areas, the level of evidence supporting these considerations was identified. In formulating recommendations, greater weight was given to studies with higher grades of evidence, as defined in Table 2. When no evidence from controlled studies was available, expert opinion was considered. Among outcomes, greatest value was given to patient safety, followed by patient comfort, and then cost. Given the seriousness of the outcomes involved, it was believed that there would be little or no variation in patient preference for treatment and that patients would prefer improved medical outcomes (decreased mortality, shorter duration of delirium, etc). GUIDELINE REVIEW The draft guideline was sent for review to first authors of articles from the past 10 years that met the inclusion criteria and to representatives of organizations of medical interest (drawn from the list published by the American Medical Association) for whom this guideline may have been of interest. The American Society of Addiction Medicine Board of Directors approved the final version in October 2002, with review and re- 1406
3 vision scheduled for November 2007, unless new information warrants revision before then. RESULTS Forty-three articles were identified as having original data, including 9 prospective controlled trials. In the following subsections, data are reviewed according to the specific intervention studied. BENZODIAZEPINES AND OTHER SEDATIVE-HYPNOTIC AGENTS Mortality No controlled trials comparing sedative-hypnotic agents with placebo in treating AWD were identified. However, 5 controlled trials compared sedative-hypnotic agents and neuroleptic drugs in reducing mortality with AWD (Table 3). Meta-analysis indicated that sedativehypnotic use is more effective than neuroleptic use in reducing mortality from AWD, with a summary relative risk of mortality with neuroleptic treatment compared with sedative-hypnotic treatment of 6.6 (95% confidence interval, ). The effectiveness of different sedative-hypnotic agents (diazepam, chlordiazepoxide, pentobarbital, paraldehyde, and barbital) in reducing mortality with AWD was evaluated in 5 controlled trials (Table 3). 15,17-20 Two deaths were reported (both patients were treated with paraldehyde); thus, overall, these trials do not demonstrate statistically significant differences among them. The small number of deaths in these trials, however, limits the power to detect differences in this outcome. Duration of Delirium Table 4 summarizes the results of prospective trials evaluating different agents in reducing the duration of AWD. Three of 4 trials 13,14,17 comparing sedative-hypnotic agents with neuroleptic agents demonstrated that the former are superior to the latter in reducing the duration of AWD. (In the fourth trial, 16 there was insufficient data in the original article to calculate P values.) Differences among sedative-hypnotic agents in reducing duration of AWD were not demonstrated. Time Required to Control Agitation Only 2 studies were identified that considered the time required to control agitation. In a study 19 comparing rectal paraldehyde use with intravenous (IV) diazepam use, the time to achieve adequate sedation, defined as the patient being quiet but awake, was significantly shorter with diazepam (1.1 vs 3.0 hours; P=.02). In contrast, in a study 20 comparing intramuscular diazepam use and oral barbital therapy, there was no significant difference in the mean number of hours to achieve adequate sedation, defined as a light sleep from which the patient could easily be aroused (11 hours for diazepam vs 8 hours for barbital; P.05). General pharmacokinetic studies have shown that oral diazepam has slightly shorter times to onset and to Table 3. Prospective Controlled Trials Reporting Mortality as an Outcome* Route of Administration peak action than other benzodiazepines. 21 The onset of action of all benzodiazepines injected IV is rapid, ranging from 15 seconds to a few minutes. Peak action of IV benzodiazepines is 5 to 15 minutes. 21 Intramuscular injection of chlordiazepoxide and diazepam is associated with erratic absorption, which can lead to difficulty in rapid control of symptoms. 22,23 An exception is lorazepam, which has good intramuscular and sublingual absorption. 24 Continuous infusion of shorter-acting agents, such as midazolam and lorazepam, has also been used, 25 with the hypothesis that this may facilitate rapid titration of the dose. However, continuous infusion has not been directly compared with intermittent dosing in any study. Adequate Control of Delirium Deaths, No./ Patients, Total No. Source Intervention Friedhoff and Chlorpromazine IM/PO 0/15 Zitrin, Paraldehyde IM/PO 0/16 Thomas and Promazine PO 6/17 Freedman, 14 Paraldehyde PO 1/ Chambers and Promazine plus PO 0/34 Schultz, 15 chloral hydrate 1965 Diazepam PO 0/35 Chlordiazepoxide PO 0/34 Golbert et al, 16 Promazine IM/PO 2/ Paraldehyde and IM/PO 0/12 chloral hydrate Kaim and Klett, Brown et al, Thompson et al, Kramp and Rafaelsen, Perphenazine IM/PO 0/46 Chlordiazepoxide IM/PO 0/46 Pentobarbital IM/PO 0/41 Paraldehyde IM/PO 0/55 Diazepam IV 0/7 Chlordiazepoxide IV 0/7 Diazepam IV 0/17 Paraldehyde Rectal 2/17 Diazepam IM 0/13 Barbital PO 0/17 Present Neuroleptics vs meta-analysis sedative-hypnotics Abbreviations: IM, intramuscular; IV, intravenous; PO, oral. *Neuroleptic agents are shown in italic. P.05. The summary relative risk of neuroleptics vs sedative-hypnotics of the 2 studies with mortality is 6.6 (95% confidence interval, ). In the study 19 comparing rectal paraldehyde use and IV diazepam administration, satisfactory control of agitation was achieved in all 17 patients in the diazepam arm but in only 12 of 17 in the paraldehyde arm. In a large, multicenter Veterans Affairs study, 17 there were no significant differences in achieving adequate control of delirium, but the rate of failure was low. Two of 46 patients taking perphenazine and 1 of 41 taking pentobarbital were unresponsive to treatment with their assigned medication. Studies have demonstrated that the 1407
4 Table 4. Prospective Controlled Trials Reporting Duration of Delirium* Source Intervention Route of Administration Patients, No. Duration, h P Value Friedhoff and Zitrin, Chlorpromazine IM/PO Paraldehyde Thomas and Freedman, Promazine PO Paraldehyde PO Golbert et al, Promazine PO Paraldehyde/chloral hydrate Kaim and Klett, Perphenazine IM/PO Pentobarbital IM/PO Paraldehyde IM/PO Chlordiazepoxide IM/PO Thompson et al, Paraldehyde Rectal Diazepam IV Abbreviations: IM, intramuscular; IV, intravenous; PO, oral. *Neuroleptic agents are shown in italic. Fisher exact test, 2-tailed. Insufficient data provided in the original article to calculate P value. required dose of medication can vary substantially among patients and within the same patient over time. In one study, 19 the doses for initial calming ranged from 15 to 215 mg of diazepam. Cumulative doses of more than 2000 mg of diazepam in 2 days, 26 more than 2000 mg of diazepam in 4 days, and more than mg of oxazepam in 9 days 27 have been required for the management of AWD. In one published case, 28 the patient required 2850 mg of midazolam in a 50-day period. Another patient required mg of diazepam, 121 mg of lorazepam, 3050 mg of chlordiazepoxide, and 2025 mg of midazolam in 8 weeks. 29 Although studies have shown no difference in overall rates of achieving control of delirium among different sedative-hypnotic agents, case series describe patients whose agitation was refractory to even massive doses of benzodiazepines but then responded to pentobarbital 30 or IV infusions of propofol. 31 The authors hypothesized that the benzodiazepine receptors that mediate -aminobutyric acid A activity became saturated with high doses of benzodiazepines and that further increases thus had little effect on control of delirium. Barbiturates and propofol act via a different set of receptors, and, thus, their addition could yield beneficial results. Furthermore, propofol has additional effects on N-methyl- D-aspartate and glutamate receptors that also are believed to play a role in alcohol withdrawal symptoms. Thus, propofol may be able to modify withdrawal symptoms by a different pathway than benzodiazepines. Treatment Complications In the study 19 comparing rectal paraldehyde use and IV diazepam use, 2 of 17 patients in the paraldehyde group developed respiratory arrest requiring resuscitation. In another study, 17 1 patient treated with pentobarbital developed lethargy progressing to coma. In the remainder of the studies, significant complications related to treatment were not observed. It has also been demonstrated in patients undergoing alcohol withdrawal, but not in those with AWD, that shorter-acting agents have a higher incidence of rebound symptoms 32 and may be associated with the occurrence of withdrawal seizures if discontinued too rapidly. 30,33 Several case series have reported on the use of other sedative-hypnotic agents in managing AWD, including chlormethiazole, lorazepam, 38,39 flunitrazepam, 40 pentobarbital, 41 propofol, 31,42-45 and midazolam. 29 Chlormethiazole and flunitrazepam are not available in the United States. The shorter-acting agents propofol, pentobarbital, lorazepam, and midazolam were thought to be advantageous owing to ease of titration and lower risk of excess sedation. However, there are no controlled trials comparing short- and longer-acting agents in AWD. Costs Costs can vary greatly depending on the selected drug and the route of administration. For example, the average wholesale cost of different agents in oral form at approximately equivalent dosages are as follows: chlordiazepoxide, 25 mg, $0.07; diazepam, 5 mg, $0.10; and lorazepam, 1 mg, $ ,29 Intravenous medication, which is usually needed for adequate control of AWD, is often more than 3 times as expensive as oral medication. For example, the average wholesale cost of these agents in equivalent dosages are as follows: diazepam, 10 mg, $2.40; lorazepam, 2 mg, $2.74; pentobarbital, 350 mg, $4.90; and midazolam, 5 mg, $5.60. (Midazolam would need continuous infusion, with published doses at 0.75 to 10.0 µg/kg per minute, or $3.36 to $47.04 per hour for a 70-kg person, although prices are expected to decrease as the generic form becomes available.) Some practitioners 28,29,46 have described the use of continuous infusion of short-acting benzodiazepines, such as lorazepam or midazolam. Such infusions can require very large amounts of medication over several hours or days. Direct drug costs (excluding costs of preparation, administration, and monitoring) of $50335 for a 25-hour infusion of midazolam were reported for 1 patient, 29 and a hospital stay costing $26045 was reported for another patient. 46 Furthermore, there are no trials reporting comparative risks and benefits of intermittent vs continuous IV administra- 1408
5 tions, and no evidence could be identified documenting an advantage for continuous infusion. 46 NEUROLEPTIC AGENTS No placebo-controlled trials of neuroleptic agents in AWD were identified. The trials reviewed earlier demonstrated that neuroleptic drug therapy is inferior to sedativehypnotic drug use in reducing mortality and duration. Nevertheless, neuroleptic agents, especially haloperidol, are commonly used with sedative-hypnotic drugs to calm patients with AWD However, neuroleptic agents have the potential to cause a variety of serious adverse effects, particularly when used in very high doses, which may be required to control severe agitation. Chlorpromazine, promazine, and other low-potency typical antipsychotic agents have been reported 51 to have the greatest effect on lowering seizure threshold. Chlorpromazine and thioridazine are the most common offenders for causing hypotension, and thioridazine may also prolong the QTc interval, increasing risk for torsade de pointes and sudden death. 52 All neuroleptic agents are thought to have the potential for causing neuroleptic malignant syndrome, 53 and cases have been reported in patients with AWD who have received neuroleptic drugs. No studies were identified describing the use of newer atypical antipsychotic agents, such as risperidone, olanzapine, and quetiapine, for AWD. These agents are at least as efficacious as typical antipsychotic agents for other indications and have a preferable adverse effect profile. -ADRENERGIC ANTAGONISTS The effect of -adrenergic antagonists in patients with AWD has not been studied. However, delirium is a known adverse effect of -adrenergic blocker therapy, 54 and in at least 1 controlled study 55 of propranolol in alcohol withdrawal syndrome, there was an increased incidence of delirium. MAGNESIUM Low serum magnesium levels have repeatedly been reported in patients with AWD. It has been suggested that magnesium administration reduces neuromuscular activity. However, its use has not been evaluated in controlled trials in AWD. ETHYL ALCOHOL Although there have been small case series describing administration of alcohol for the prevention and treatment of withdrawal symptoms, there are no controlled trials evaluating its use in the prevention or treatment of AWD. Ethyl alcohol is known to have the potential for several adverse effects, including hepatic, gastrointestinal, hematologic, and neurologic toxic effects. THIAMINE Patients with alcohol dependence are often thiamine deficient, and it has been reported 57,59 that patients with AWD have even more substantial deficiencies. Thiamine deficiency is associated with Wernicke encephalopathy and Wernicke-Korsakoff syndrome. Thiamine administration has a low risk of adverse effects and can prevent the development of these conditions. In particular, thiamine should be given before administration of IV fluids containing glucose, as the IV administration of glucose may precipitate acute thiamine deficiency. 60 OTHER AGENTS Several articles describe the use of various other agents in managing AWD, including carbamazepine, 61 dexamethasone, 62 physostigmine, 63 5-hydroxytrytophan, 64 and bromperidol. 65 However, these case series have been small and uncontrolled. In addition, although studies of other agents (antiepileptic agents, clonidine, etc) in managing alcohol withdrawal without delirium have been published, no evidence regarding their effectiveness in AWD has been identified. 5 SUPPORTIVE CARE No controlled studies of nonpharmacologic interventions were identified in the literature search. However, the literature includes recommendations from clinical experts on general management of AWD. A comprehensive history, physical examination, and thorough diagnostic evaluation are always recommended in view of the known morbidity and mortality of AWD and the frequent occurrence of associated medical illnesses. 47,48,50,66-68 Patients usually need the standard diagnostic tests to evaluate new-onset delirium, including neuroimaging to rule out subdural hemorrhaging or other intracranial lesions. Lumbar punctures have been recommended in febrile patients when there are no contraindications. 67,68 Further diagnostic evaluation can be undertaken for any indication of commonly coexisting conditions, such as gastrointestinal hemorrhage, pancreatitis, and infectious diseases. 47,50,67,68 Most experts have recommended general supportive care that includes a quiet, well-lit room, reassurance and reorientation, frequent monitoring of vital signs, and restraints as needed. 47,49,50,67,68 Dehydration and metabolic abnormalities, such as magnesium and phosphorus deficiency, are common with AWD, and it is generally recommended that fluid status and electrolyte levels be monitored carefully and any abnormalities be corrected ,67,68 RECOMMENDATIONS CHOICE OF PHARMACOLOGIC AGENT The initial therapeutic goal in patients with AWD is control of agitation, the symptom that should trigger use of the medication regimens described in this guideline. Rapid and adequate control of agitation reduces the incidence of clinically important adverse events. Sedativehypnotic drugs are recommended as the primary agents for managing AWD (grade A recommendation). These drugs reduce mortality, reduce the duration of symptoms, and are associated with fewer complications compared with neuroleptic agents in controlled trials. 1409
6 Examples of Medication Regimens Several different benzodiazepines and dosing regimens have been used and recommended. The following are examples of medications and dosing regimens. Benzodiazepines Diazepam, 5 mg intravenously (2.5 mg/min). If the initial dose is not effective, repeat the dose in 5 to 10 minutes. If the second dose of 5 mg is not satisfactory, use 10 mg for the third and fourth doses every 5 to 10 minutes. If not effective, use 20 mg for the fifth and subsequent doses until sedation is achieved. Use 5 to 20 mg every hour as needed to maintain light somnolence. Lorazepam, 1 to 4 mg intravenously every 5 to 15 minutes, or lorazepam, 1 to 40 mg intramuscularly every 30 to 60 minutes, until calm, then every hour as needed to maintain light somnolence. Neuroleptics Haloperidol, 0.5 to 5 mg intravenously/intramuscularly every 30 to 60 minutes as needed for severe agitation. (Only to be used as adjunctive therapy with sedativehypnotic agents.) Haloperidol, 0.5 to 5 mg orally every 4 hours as needed for agitation not controlled by sedative-hypnotic agents alone. Current evidence does not clearly indicate that a specific sedative-hypnotic agent is superior to others or that switching from one to another is helpful. Benzodiazepines are most commonly used and recommended by addiction specialists because of a favorable therapeutic/ toxic effect index. Examples of commonly used regimens are shown in the Box. However, reported clinical experience indicates that barbiturates may be considered an option. Owing to difficulties in administration and titration of dose, paraldehyde is not recommended (grade A recommendation). Choice among benzodiazepines may be guided by the following considerations: (1) agents with rapid onset control agitation more quickly, for example, oral or IV diazepam has a more rapid onset than other agents (level II evidence); (2) agents with long duration of action (eg, diazepam) provide a smooth treatment course with less breakthrough symptoms; (3) agents with shorter duration of activity (eg, lorazepam) may have lower risk when there is concern about prolonged sedation, such as in patients who are elderly or who have substantial liver disease or other serious concomitant medical illness (level III evidence); and (4) the cost of different benzodiazepines can vary considerably. If a patient demonstrates agitation that is not controlled with extremely large doses of benzodiazepines, use of pentobarbital or propofol can be considered (grade C recommendation). DETERMINATION OF DOSE AND ROUTE OF ADMINISTRATION It is recommended that the dose be determined specifically for each individual patient and that medications be given in doses sufficient to achieve and maintain light somnolence as the recommended therapeutic end point (grade C recommendation). Light somnolence is characterized by a state in which the patient is awake but tends to fall asleep unless stimulated or is sleeping but easily aroused. The amount of medication required for adequate sedation varies greatly from patient to patient and over time in the same patient. Sedative-hypnotic drug doses needed to suppress AWD are commonly much higher than doses used to treat severe anxiety or to sedate patients presurgically. Tolerance, age, severity of signs and symptoms, and medical comorbidity affect the quantity of medication needed for adequate control. When using shorter-acting agents, medication should be tapered carefully even after AWD resolves to prevent the development of breakthrough symptoms or the occurrence of withdrawal seizures. The medication should be administered by a route that supports achievement of rapid control of agitation and maintenance of appropriate sedation (light somnolence). Intravenous administration has the quickest onset compared with other routes. Intramuscular injection of most benzodiazepines is not recommended owing to erratic absorption (grade C). Lorazepam, however, is an option in patients with stable cardiovascular status, as it has good intramuscular absorption. Intermittent IV administrations of long-acting medications and continuous IV infusion of short-acting medications seem effective and thus are acceptable. However, continuous IV infusion is considerably more expensive, and there is no existing evidence of therapeutic superiority. OTHER AGENTS Neuroleptic agents are not recommended as the sole pharmacologic agents in the treatment of AWD because they are associated with higher mortality, longer duration of delirium, and more complications compared with sedative-hypnotic agents in controlled trials (grade A recommendation). Neuroleptic agents may be considered for use in conjunction with benzodiazepines when agitation, perceptual disturbances, or disturbed thinking are not adequately controlled by benzodiazepine therapy (grade C recommendation). -Adrenergic antagonists may be considered for use in conjunction with benzodiazepines in selected patients for control of persistent hypertension or tachycardia (grade C recommendation). They are not recommended for routine use in all patients with AWD, however, as there is no evidence that they improve outcomes in AWD, and -adrenergic antagonists, particularly propranolol, may worsen delirium (level V evidence). Ethyl alcohol is not recommended because there are no controlled trials and there are well-known adverse effects (grade C recommendation). There is no evidence that magnesium therapy specifically benefits the delirium in alcohol withdrawal. However, magnesium deficiency is common in patients with AWD. Magnesium should be provided for demonstrated hypomagnesemia, and it is also safe and reasonable to include it in IV fluids given for volume repletion provided renal function is normal and levels are monitored (grade C recommendation). 1410
7 Parenteral administration of thiamine (100 mg daily for at least 3 days, IV or intramuscularly) is recommended to prevent or treat Wernicke-Korsakoff syndrome (grade C recommendation). SETTING AND SERVICES The following recommendations are based on the clinical experience of recognized experts; they have not been the subject of controlled studies (grade C recommendations). EVALUATION On admission or transfer of a patient from one setting to another, a thorough medical evaluation is needed to determine appropriate diagnostic tests, monitoring, and medication. Elderly patients and those with concurrent medical conditions, acute and chronic, are at higher risk of complications. Concurrent medical conditions are common and may include dehydration, unrecognized head trauma, electrolyte abnormalities, infections (including meningitis), gastrointestinal hemorrhage, pancreatitis, liver disease, and myocardial infarction. These conditions may not be obvious or self-reported in delirious patients. MONITORING Close monitoring by nursing personnel is critical in providing protection for the patient and for maintaining accurate information to guide ongoing medical management. In many cases, continuous, one-to-one observation and monitoring may be required to ensure safe and adequate management of agitated and disoriented patients. Vital signs should be monitored regularly in all patients. The appropriate frequency of monitoring depends on the frequency of medication administration, concurrent medical conditions, and the degree of abnormality of the vital signs. When high doses of benzodiazepines are needed, or when continuous infusions of medication are used, or when patients have significant concurrent medical conditions, cardiac monitoring and oximetry should be in place and resuscitative equipment should be readily available. MANAGEMENT A quiet room with good lighting and environmental cues (eg, a clock and a calendar) may help reduce confusion. Physical restraints may be needed temporarily to protect agitated patients from injuring themselves and to protect staff. Guidelines have been formulated on the appropriate use of restraints to ensure patient safety. 69,70 If patients cannot take oral medications or maintain adequate oral intake, or if more rapid sedation is needed, IV fluids and medications are recommended. Fluid and electrolyte balance should be maintained, and monitoring of fluid input and output and laboratory variables may be required. Occasionally, endotracheal intubation and ventilatory support may be required. Accepted for publication September 4, This study was supported by the American Society of Addiction Medicine and the Stepping Stones Foundation, Bedford Hills, NY. We thank Emily Williams for assistance with manuscript preparation. This guideline is not a substitute for the experience and judgment of a physician. It has been developed to enhance the physician s ability to practice evidence-based medicine. Presented authors opinions are not necessarily representative of the agencies for which they work. Correspondence: Michael F. Mayo-Smith, MD, MPH, Veterans Administration Medical Center, 718 Smyth Rd, Manchester, NH REFERENCES 1. Buschbaum DG, Buchanan RG, Poses RM, Schnoll SH, Lawton MJ. Physician detection of drinking problems in patients attending a general medical practice. J Gen Intern Med. 1992;7: Graham AW. Screening for alcoholism by life-style risk assessment in a community hospital. Arch Intern Med. 1991;151: Moore RD, Bone LR, Geller G, Mamon JA, Stokes EJ, Levine DM. Prevalence, detection and treatment of alcoholism in hospitalized patients. JAMA. 1989;261: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; Mayo-Smith MF. Pharmacological management of alcohol withdrawal. JAMA. 1997;278: Stendig-Lindberg G, Rudy N. Stepwise regression analysis of an intensive 1-year study of delirium tremens. Acta Psychiatr Scand. 1980;62: Cutshall B. The Saunders-Sutton syndrome: an analysis of delirium tremens. Q J Stud Alcohol. 1965;26: Victor M, Adams RD. The effect of alcohol on the nervous system. Res Publ Assoc Res Nerv Ment Dis. 1953;32: Ferguson JA, Suelzer CJ, Eckert GJ, Zhou XH, Dittus RS. Risk factors for delirium tremens development. J Gen Intern Med. 1996;11: Red Book. Montvale, NJ: Medical Economics Data Inc; Hedges LV, Olkin I. The Logit Method: Statistical Methods for Meta-analysis. Orlando, Fla: Harcourt Brace Jovanovich; 1985: Cook DJ, Guyatt GH, Laupacis A, Sackett DL. Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest. 1992;102:305S-311S. 13. Friedhoff AJ, Zitrin A. A comparison of the effects of paraldehyde and chlorpromazine in delirium tremens. N Y State J Med. 1959;59: Thomas DW, Freedman DX. Treatment of the alcohol withdrawal syndrome: comparison of promazine and paraldehyde. JAMA. 1964;188: Chambers JF, Schultz JD. Double-blind study of three drugs in the treatment of acute alcoholic states. Q J Stud Alcohol. 1965;26: Golbert TM, Sanz CJ, Rose HD, Leitschuh TH. Comparative evaluation of treatments of alcohol withdrawal syndromes. JAMA. 1967;201: Kaim SC, Klett CJ. Treatment of delirium tremens: a comparative evaluation of four drugs. Q J Stud Alcohol. 1972;33: Brown JH, Moggey DE, Shane FH. Delirium tremens: a comparison of intravenous treatment with diazepam and chlordiazepoxide. Scot Med J. 1972;17: Thompson WL, Johnson AD, Maddrey WL. Diazepam and paraldehyde for treatment of severe delirium tremens: a controlled trial. Ann Intern Med. 1975;82: Kramp P, Rafaelsen OJ. Delirium tremens: a double-blind comparison of diazepam and barbital treatment. Acta Psychiatr Scand. 1978;58: Greenblatt DJ, Shader RI, Abernethy DR. Drug therapy: current status of benzodiazepines. N Engl J Med. 1983;309: Kanto J. Plasma concentrations of diazepam and its metabolites after peroral, intramuscular, and rectal administration: correlation between plasma concentration and sedatory effect of diazepam. Int J Clin Pharmacol Biopharm. 1975; 12: Greenblatt DJ, Shader RI, MacLeod SM, Sellers EM. Clinical pharmacokinetics of chlordiazepoxide. Clin Pharmacokinet. 1978;3: Greenblatt DJ, Shader RI, Franke K, et al. Pharmacokinetics and bioavailability of intravenous, intramuscular, and oral lorazepam in humans. J Pharm Sci. 1979; 68:
8 25. Favazza AR, Martin P. Chemotherapy of delirium tremens: a survey of physicians preferences. Am J Psychiatry. 1974;131: Nolop KB, Natow A. Unprecedented sedative requirements during delirium tremens. Crit Care Med. 1985;13: Woo E, Greenblatt DJ. Massive benzodiazepine requirements during acute alcohol withdrawal. Am J Psychiatry. 1979;136: Lineaweaver WC, Anderson K, Hing DN. Massive doses of midazolam infusion for delirium tremens without respiratory depression. Crit Care Med. 1988;16: Wolf KM, Shaughnessy AF, Middleton DB. Prolonged delirium tremens requiring massive doses of medication. J Am Board Fam Pract. 1993;6: Hill A, Williams D. Hazards associated with the use of benzodiazepines in alcohol detoxification. J Subst Abuse Treat. 1993;10: Coomes TR, Smith SW. Successful use of propofol in refractory delirium tremens. Ann Emerg Med. 1997;30: Ritson B, Chick J. Comparison of two benzodiazepines in the treatment of alcohol withdrawal: effects on symptoms and cognitive recovery. Drug Alcohol Depend. 1986;18: Mayo-Smith MF, Bernard D. Late-onset seizures in alcohol withdrawal. Alcohol Clin Exp Res. 1995;19: Athen D. Comparative investigation of chlormethiazole and neuroleptic agents in the treatment of alcoholic delirium. Acta Psychiatr Scand. 1986;73: Schied HW, Kimmerle K, Braunschweiger M. A retrospective comparison of delirium tremens cases before and after the availability of chlormethiazole. Acta Psychiatr Scand. 1986;73: Schied HW, Braunschweiger M, Schupmann A. Treatment of delirium tremens in German psychiatric hospitals: results of a recent survey. Acta Psychiatr Scand. 1986;73: Feuerlein W, Reiser E. Parameters affecting the course and results of delirium tremens treatment. Acta Psychiatr Scand Suppl. 1986;329: Spencer J. Use of injectable lorazepam in alcohol withdrawal. Med J Aust. 1980; 2: Hosein IN, de Freitas R, Beaubrun MH. Intramuscular/oral lorazepam in acute alcohol withdrawal and incipient delirium tremens. West Indian Med J. 1979;28: Pycha R, Miller C, Barnas C, et al. Intravenous flunitrazepam in the treatment of alcohol withdrawal delirium. Alcohol Clin Exp Res. 1993;17: Hillbom ME, Hjelm-Jaeger M. Should alcohol withdrawal seizures be treated with anti-epileptic drugs? Acta Neurol Scand. 1984;69: Stiebel VG, Crippen D, Ermakov S. Treatment of delirium tremens with continuous propofol infusion [abstract]. Psychosomatics. 1994;35: Crippen D, Ermakov S. Titrated treatment of delirium tremens using continuous propofol infusion, clonidine, esmolol and cerebral function monitoring [abstract]. Intensive Care Med. 1994;20: Crippen DW. Strategies for managing delirium tremens in the ICU. J Crit Illn. 1997; 12: Ermakov S, Crippen DW. Continuous propofol infusion for sedation in delirium tremens [abstract]. Crit Care Med. 1994;20(suppl):S Hoey LL, Nahum A, Vance-Bryan K. A retrospective review and assessment of benzodiazepines in the treatment of alcohol withdrawal in hospitalized patients. Pharmacotherapy. 1994;14: Lewis DC, Femino J. Management of alcohol withdrawal. Ration Drug Ther. 1982; 16: Rosenbloom A. Emerging treatment options in the alcohol withdrawal syndrome. J Clin Psychiatry. 1988;49: Mayo-Smith MF. Management of alcohol intoxication and withdrawal. In: Graham AW, Schultz TK, eds. Principles of Addiction Medicine. Chevy Chase, Md: American Society of Addiction Medicine; Adinoff B, Bone GHA, Linnoila M. Acute ethanol poisoning and the ethanol withdrawal syndrome. Med Toxicol. 1988;3: Hyman SE, Arana GW, Rosebaum JF. Handbook of Psychiatric Drug Therapy. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; Glassman AH, Bigger JT Jr. Antipsychotic drugs: prolonged QTc interval, torsade de pointes, and sudden death. Am J Psychiatry. 2001;158: Francis A, Chandragiri S, Petrides G. Risk factors for neuroleptic malignant syndrome. Am J Psychiatry. 1998;155: Zechnich RJ. Beta blockers can obscure diagnosis of delirium tremens. Lancet. 1982;1: Zilm DH, Jacob MS, MacLeod SM, Sellers EM, Ti TY. Propranolol and chlordiazepoxide effects on cardiac arrhythmias during alcohol withdrawal. Alcohol Clin Exp Res. 1980;4: Kramp P, Ronsted P, Hansen T. Barbital and diazepam plasma levels during treatment of delirium tremens. Acta Psychiatr Scand. 1979;59: Hoes M. Plasma concentrations of vitamin B-1 in alcoholism and delirium tremens: pathogenic and prognostic implications. Acta Psychiatr Belg. 1981;81: Sullivan JF, Lankford HG, Swartz MJ, Farrell C. Magnesium metabolism in alcoholism. Am J Clin Nutr. 1963;13: Hoes MJ. The significance of the serum levels of vitamin B-1 and magnesium in delirium tremens and alcoholism. J Clin Psychiatry. 1979;40: Marcus R, Coulston AM. Water soluable vitamins. In: Hardman JG, Limbird LE, Gilman AG, eds. Goodman and Gilman s The Pharmacological Basis of Therapeutics. 10th ed. New York, NY: McGraw-Hill Co; 2001: Brune F, Busch H. Anticonvulsive-sedative treatment of delirium alcoholicum. Q J Stud Alcohol. 1971;32: Fischer DK, Simpson RK, Smith FA, Mattox KL. Efficacy of dexamethasone in benzodiazepine-resistant delirium tremens [letter]. Lancet. 1988;1: Powers JS, Decoskey D, Kahrilas PJ. Physostigmine for treatment of delirium tremens. J Clin Pharmacol. 1981;21: Campioni A, Russo Perez G. Treatment of delirium tremens with 5-hydroxytryptophan. Ital J Neurol Sci. 1981;2: Schmatolla E. Interim report: high dosage bromperidol therapy of delirium tremens. Acta Psychiatr Belg. 1978;78: Romach MK, Sellers EM. Management of the alcohol withdrawal syndrome. Annu Rev Med. 1991;42: Turner RC, Lichstein PR, Peden JG, Busher JT, Waivers LE. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation and treatment. JGen Intern Med. 1989;4: Thompson WL. Management of alcohol withdrawal syndromes. Arch Intern Med. 1978;138: American Psychiatric Association. Seclusion and Restraint: The Psychiatric Uses. Washington, DC: American Psychiatric Association; Task Force report Allen MH, Currier GW, Hughes DH, Reyes-Harde M, Docherty JP, Expert Consensus Panel for Behavioral Emergencies. The Expert Consensus Guideline Series: treatment of behavioral emergencies. Postgrad Med. 2001;May:
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Self-Catering in Buxton
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BRZ Buyers Surprise Subaru
Sales of Subaru's multi-award winning BRZ sports coupe have revealed some departures from the brand's traditional sales trends, according to figures released today.
Victoria, Western Australia and South Australia are proving exceptionally strong markets for BRZ, selling well above the usual Subaru ratios.
Victoria accounts for 17 per cent of BRZ sales, compared to the average Subaru figure of 12 per cent across all other models.
WA is also a strong BRZ performer, with 13 per cent, versus eight per cent on the rest of the Subaru range.
SA represents nine per cent of BRZ sales, against six per cent for the balance of the range.
However, the figure is starkly reversed in Tasmania, which only accounts for one per cent of BRZ sales, compared to three percent for the range.
Nick Senior, Managing Director, Subaru Australia, said: "It goes to show that Tasmania prefers their All-Wheel Drive Subarus!"
He added: "The over-representation of BRZ sales in Melbourne and Perth is not a surprise. "Historically, performance WRX and WRX STI sales have also been significantly stronger in these regions.
"Indeed, the surge in WRX sales, which began in 1997, was first noted in Perth, then Melbourne."
BRZ continues to be sold exclusively online in Australia at www.buybrzonline.subaru.com.au


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Why the Hightop Has One Foot in the Grave
Nash, Bryant Lead The Lowcut Trend; 'Better Mobility'
This season's Western Conference Finals matchup between the Phoenix Suns and Los Angeles Lakers is a meeting of the two most talented guards of this era—Steve Nash and Kobe Bryant.
Between them, these two balletic floor leaders have collected a combined 17 all-star nominations and 19 playoff trips in the past 10 years alone.
But there's another,...


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Apple cider vinegar is the best vinegar to use when treating gout, according to Natural News. The liquid helps to coat the stomach and protect it from an over abundance of acid.
Drinking 1 to 2 tablespoons of apple cider vinegar in a glass of water can relieve or lessen the symptoms of gout. It can also reduce muscle spasms and arthritis. Baking soda is also shown to decrease the symptoms. A half tablespoon in 8 ounces of water can stop the pain almost immediately. If that does not work, add in the juice of a lemon and drink after it has stopped fizzing. A doctor should be seen before trying any home remedy for gout.


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Why Study Classical Fencing?
Art Or Sport?
IFV Classical Fencing Method
Maître d'Armes
Salle d'Armes du Lion
The Romance of Duelling in all Times & Countries
Andrew Steinmetz (1868)
In this short excerpt, Steinmetz reviews the common protocols of the duel. The similarities between them and the protocols of the fencing match are obvious. Indeed, the principal distinction between the two is the difference between blunt and sharp.
It is evident from all these details that the fancy of duellists must have run mad in devising such a multiplicity of methods of fighting, --many of them calculated to place a man in an extremely ridiculous situation, veritably making the affair a monstrous tragicomedy. Such, however, were the various modes of duelling sanctioned for the vindication of injured honour, and we have now to inquire into the nature of the offences entailing such tremendous retribution.
According to the French code of honour there are three sorts of offences;
With regard to the first, if in the course of a discussion an offence is offered, the person who has been offended is the injured party.
If this injury is followed by a blow, of course the party struck is the injured one.
To return one blow with another of a more serious natureseverely wounding, for instance, after a slap in the facedoes not constitute the person who received the second blow, however severe it may be, the party originally insulted.
If in the course of a discussion, during which the rules of politeness have not been transgressed, but in consequence of which expressions have been used which induce one of the party to consider himself offended, the man who demands satisfaction cannot be considered the aggressor, or the person who gives it the offended; the case must be submitted to the trial of chance.
But if a man sends a message without a sufficient cause, he becomes the aggressor; and the seconds, before they allow a meeting to take place, must insist upon a sufficient reason being manifestly shown.
All these are insisted on because the selection of the weapons and the kind of duel rests with the offended party.
A son may espouse the cause of his father if he is too aged to resent an insult, or if the age of the aggressor is of great disparity; but the son cannot espouse the quarrel of his father if he has been the aggressor. As Dr. Millingen observes, this is a very judicious rule. Some of your old men are particular crusty and inconsiderate, and if this rule were not enforced any old gentleman might grievously offend another, screening himself by his age and infirmities, and sending some vigorous, active, and practised "big boy" to do the brave for him. Consequently he should be made personally responsible for his conduct, and obliged to make a most humble apology, if he cannot give personal satisfaction. Besides, the rule prevents the sacrifice of life to which filial affection might expose a generous youth, who in his conscience may condemn his fathers conduct.
If the offence has been attended by acts of violence, the offended party has the right to name, not only his duel, his arms, the distance, but may also insist upon the aggressor not using his own arms, to which he may have become accustomed by practice; but in this case the offended party must also use weapons with which he has not practised.
Honour can never be compromised by the offending party admitting that he was in the wrong. If the apology of the offending party is deemed sufficient by the seconds of the offended, if the seconds express their satisfaction and are ready to affirm this opinion in writing, or if the offender has tendered a written apology considered of a satisfactory nature, --in such a case the party that offers to apologize ceases to be the offender, and if his adversary persists the arms must be decided by lot.
However, no apology can be received after a blow. Such an offence has often led to a mortal combat.
If the seconds of the offending party come to the ground with an apology instead of bringing forward their principal, it is only to them that blame can be attached, as the honour of their principal was placed in their hands.
No challenge can be sent by collective parties. If any body or society of men have received an insult, they can only send an individual belonging to it to demand satisfaction. A message collectively sent may be refused, but the challenged party may select an antagonist from the collection, or leave the nomination to chance.
All duels should take place during the forty-eight hours that succeed the offence unless it is otherwise stipulated by the seconds. As Dr. Millingen remarks, this rule is of importance; forty-eight hours may be considered a fair time to reflect upon the painful necessity of a hostile meeting, and there is in general reason to suppose that a challenge sent long after a provocation has been the result of the interference of busy friends.
It is the duty of the seconds to decide upon the necessity of the duel and to state their opinions to their principals. After having consulted with them in such a manner as not to allow any chance of avoiding a duel to escape, they must again meet, and exert their best endeavours to settle the business amicably.
The seconds of a young man shall not allow him to fight an adversary above sixty years of age, unless this adversary had struck him, and in this case his challenge must be accepted in writing. His refusal to comply with this rule is tantamount to giving satisfaction, and the young mans honour is thereby satisfied.
If any unfair occurrence takes place in a duel, it is the duty of the seconds to commit the circumstance to paper, and follow it up before the competent tribunals, when they are bound to give evidence.
Such are the chief rules and regulations of the French code of honour. These new pandects were authorized and signed by eleven peers, twenty-five general officers, and fifty superior officers. Nearly all the maires and prefets gave in their adhesion, and even the minister of war, being restrained by a pardonable delicacy and the awkwardness of official position from attaching his signature, took the trouble of writing a formal letter, signifying his approval of the entire arrangement.
Many of the regulations however, are transparently borrowed from the Irish constitutions before mentioned. The important axiom of a blow admitting of no verbal apology whatever, and the almost casuistical theories as to what constitutes "the insulted party," are common to both.
Strange as may appear such exalted sanction according by the leading men of France to the practice of duelling, we must not forget the very wise remark of Bentham:
Of all the accounts of duels, ordinary and extraordinary, this is certainly one of my favorites. If you know and love dogs as I do, it will not surprise you in the least. Perhaps this is why dogs enjoy such liberty in France. In any case, its a tale with the wag of truth in it. This account is taken from The Romance of Duelling in All Times and Countries, Vol. 1, by Andrew Steinmetz, 1868. Republished by The Richmond Publishing Co., Ltd., Surrey, 1971.
At the close of the thirteenth century, Philip the Fair, having justly entertained at that early period a refined sense of the evil attending the judicial combat, used his best means to put a restraint on its practice. But the state of the times militated so much against his good intention that all he was able to effect was the publication of an edict of regulation, whereby nothing was to be brought to that bloody issue which could be determined by any other means. In consequence of this was adopted that singular ordeal, for want of other evidence, which took place in the Isle of Notre Dame, in the reign of Charles V. of France.
The Chevalier Maquer, in the sight of all Paris, entered the lists, with a dog, in mortal combat. The spot which was the scene of this singular encounter is still shown. The following are the circumstances that gave rise to it.
Aubry Mondidier, whilst taking a solitary walk in the neighbourhood of Paris, was murdered and buried under a tree. His dog, which he had left at home, went out at night to search for his master, whom at length he traced to the forest, and discovered his grave. Having remained some days on the spot, till hunger compelled him to return to the city, he hastened to the Chevalier Ardilliers, a friend of the deceased, and by his melancholy howling gave him to understand that their common friend was no longer in existence.
Ardilliers offered the dog some food, and endeavoured to quiet him by caresses; but the distressed animal continued to howl pitiably, and, laying hold of his coat, led him significantly towards the door.
Ardilliers at length complied with the dogs apparent request, and was led by the sagacious and affectionate animal from street to street, and conducted from the city to a large oak in the forest, where he began to howl louder, and to scratch the earth with his feet. Aubrys friend could not help surveying the sport with melancholy foreboding, and desired the servant who accompanied him, to fetch a spade and dig up the earth, --when, in a short time, he discovered the body of his murdered friend.
Some time after, the dog accidentally met the murderer of his master, barked, rushed upon him, and attacked him with such ferocity that the spectators could not, without great difficulty, extricate him. The same circumstance occurred several times. The faithful animal, which was in general as quiet as a lamb, became like a raging tiger every time he saw the person who had murdered his master.
This circumstance excited great astonishment; and strong suspicions having arisen, it was remembered that Maquer, on several occasions, had betrayed symptoms of enmity against Aubry; and various other circumstances being combined, brought the matter almost to a certainty.
The King, hearing of this affair, was desirous of being convinced with his own eyes whether or not the dog was in the right. The parties were brought before him; the dog fawned upon everybody else, but attacked Maquer with the utmost violence as soon as he saw him enter. The King, considering this to be a fair occasion for the ordeal, --which was at the time customary upon less important occasions, --ordered the fate of Maquer to be determined by single combat with the dog. Charles instantly appointed the time and place.
Maquer entered the list armed with his lance; the dog was let loose upon him, and a most dreadful contest ensued. Maquer made a thrust, but the dog, springing aside, seized him by throat, and threw him down. Thereupon the villain confessed his crime, and Charles, in order that the remembrance of the faithful animal might be handed down to posterity, caused to be erected to him, in the forest where the murder was committed, a marble monument, with a suitable inscription.
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The Naked Truth | If I Had a Hammer
The Sabre's Edge | Swordfight at the OK Corral
How to Defend a Monopoly | A Propos d'un Accident
The Dubious Quick Kill part 1 | The Dubious Quick Kill part 2
Review and Commentary | Duels with the Sword | Starting with Foil
Liancour's Tercentenary | The Manuel d'escrime of 1877 | The Military Masters Fencing Program
Analysis of the Patton Fencing Manual | The Red Court Fencing's Royal Connection
| The Practical Saviolo part 1 | Saddle, Lance and Stirrup
Demystification of the Spanish School 1 | Demystification of the Spanish School 2
Demystification of the Spanish School 3
| A Brief Look at Joseph Swetnam
| Ithacan Retains Title | Third Time's a Charm
Cross-Training Not Cross-Purposes | Riposte Direct | Use of the Word "Sparring"
Chivalry Makes a Come-back | Teachings of Marozzo |
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Game Masha and the Bear have always been very interesting. Masha unusual girl, and she always has to be right.
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I guess my story isn't that romantic compared to others.In fact I could have written this a lot shorter but I had to add the little details because its special to me. It led up to something great in my personal opinion.
So it was the summer after my first year of college. I had decided to work in a café for the time being till school started again.I would spend most of the week working and not much else. On my time off, I'd just scroll through the Internet to kill the boredom since there wasn't much else to do. It was eventually I came across a website called 'Meet Me'. For those who are not aware of the site, it is a very shitty social media site that tried to double up as a dating site. I wasn't really looking for a relationship at the time, but I enjoyed reading the comments everyone would post. Because they were usually the douchest things I have ever seen in my whole life. Like, " Who wants a piece of this ?!? Willing to hookup with some hotties tonight but if you're a fugly GTFO!#gotswag#yolo" Just shit like that had me thinking that even if I wanted to date someone, it wouldn't be from here.
So one night, I was scrolling and reading things from people that somehow breath the same air as me. I suddenly get a friend request out of the blue from a girl. At first I thought about ignoring it, I had no real reason to except it. But I glanced at the profile anyways, seeing she only lived about half an hour away and was just a few months younger than I was. I put a little bit of thought into and decided, " Why the hell not?" So I added her, guessing she wasn't probably going to talk to me anyways like everyone else who I had added on there. But a few days later she had sent message which had taken me off guard. I decided to be kind, I start to write back. Most of out conversations where small to start. Though I could see she was just a nice and innocent girl who somehow managed to get on the dumb site. Eventually we exchanged cell numbers. We began conversing through text and calls when we both weren't busy from work. About three or four weeks, I could tell she liked me. I'd normally say something goofy and apparently charming to her. She would reply back with something like, " You make me smile a lot. Lol" and I would same something in the same goofy charm," Oh I try my best. XD " I was realizing I was starting to like her back
Finally one night, while I was just sitting at home. She texted me on her work break, asking me if I wanted to come meet her after work to hang out for a bit. Despite that she got off work at 11 pm, it was the only real time that whole week we could meet because our schedules were so different. Never the less, I agreed to meet her in the parking lot at her work. The 30 minute drive up there, I started to feel anxious and nervous since I had no clue how things would go. Once I arrived, I waited outside of my car, slightly kicking at the ground to calm my nerves. She eventually came out, looking as shy and nervous as I was. But after we started to talk a bit, the tension started to lift a little. We didn't get to talk much since how late it was and she had to get home. We started saying our goodbyes and saying that we should try to find time to go on some sort of a date. Before we left, a brave feeling sorta popped up. I decided to be a little bold which normally wasn't me. But inside voice was like, " DAMN IT DEREK,STOP BEING SUCH A WUSS! Show her that you like her the way she must like you !" I gave her a light hug and small peck on the lips.I instantly felt more anxiety over my actions but I knew things were good. We said our goodbyes again and both drove our separate ways home. That's the story of how we met and started to date.


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Opened in September 2008 the GC Europe Campus is a world-class meeting & education centre where dental professionals of Europe, and of the rest of the world exchange knowledge and experience.
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The GC Europe Campus offers different dental training modules for all GC's major technologies and products.
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Recenze - Navigátor
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Commodore 264 Series
Commodore C16 / C116
At the 1983 (or was it 84?) C.E.S., Commodore showed off a new line of computers to follow up the Commodore 64. They sported a new wonder chip-- the TED (Text Editing Device). The C116 would be the low end of this spectrum, having about 12K of memory. The C264 and V364 would have built in software, 64k of memory, and the V364 would have speech synthesis built in. Of these machines, only the C116 was released in Europe, though it was also morphed into the C16 for American consumers. The C264 became the Plus/4, while the V364 was never released.
There has been much speculation as to the reason Commodore released these machines. They lack compatibility with the C64, an immensely popular machine. They lack the sound and video capabilities of the C64. They *do* have a faster processor and a larger color pallette, and the Plus/4 has built-in software, but this was not quite enough.
The low end members of the 264 series are the Commodore 16 and the Commodore 116. Of all the machines showcased at the C.E.S., the C116 was the only model to make it to store shelves as originally designed; though it was only in Europe, and in very small numbers. The picture to the left here is of the Commodore 116, with a spoon in front of it to show just how tiny it really is.
Now, the Commodore 16, shown above, was meant to be a replacement for the VIC-20, which had been discontinued a few months before. Compared to the VIC, it is indeed an impressive upgrade. 16K to the VICs 3.5K, better video graphics, and full compatibility with VIC peripherals. As mentioned above, however, consumers at this time were not looking to make such a small step when so many other great machines were available. Commodore tried to market the C16 as an educational computer. This marketing ploy was not successful however. Perhaps because there is only so much you can learn from a 16k breadbox that pales before its peers.
Statistics, features, and C16/C116 resources:
Personal Note: The Commodore 16 came from an eBay auction, while the C116 came from a German computer shop. The 116's keyboard is extremely hard to type on, making it my least favorite "tinkering" machine. However, I also have a 116 with 64k of memory, which was perfect for a little PAL "demo" viewing spree I went on shortly after receiving it.
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