on 07-Jan-2021 (Thu)

VAT is a tax on gross profits i.e. sales minus goods purchased. There is no deduction for wages (usually the largest expense).

the total tax bill of a VAT-able business would not be much different if they increased Employer's NIC to 30% and corporation tax to 37%. Which sounds as shit as it is.

Minor manifestations of alcohol withdrawal include anxiety, agitation, restlessness, insomnia, tremor, diaphoresis, palpitations, headache, and alcohol craving, and often loss of appetite, nausea, and vomiting. Moderate and severe withdrawal syndromes can include hallucinations, seizures, or delirium tremens; the latter two can be life-threatening.

for example, one study showed that an AUDIT-PC score of four or more was 91 percent sensitive and 89.7 percent specific for the development of alcohol withdrawal [5]

Patients who have not had any withdrawal symptoms more than 24 hours after cessation are unlikely to develop such symptoms.

Though alcohol withdrawal is usually mild, an estimated 20 percent of patients experience more advanced manifestations such as hallucinosis, seizures, and delirium tremens [7]. Seizures and delirium tremens, which are sometimes grouped as “severe alcohol withdrawal syndrome,” are a frequent reason for both general inpatient and intensive care unit admissions; for example, alcohol withdrawal syndrome was found to account for more than 10 percent of intensive care unit admissions to a Detroit hospital [8]

Without treatment, symptoms of alcohol withdrawal generally begin within 6 to 24 hours of the last drink or a sudden reduction in chronic alcohol drinking [12]. The onset and duration of withdrawal symptoms vary based on the severity of the syndrome (table 1). Symptoms may emerge before the blood alcohol level has returned to zero.

Mild withdrawal — Symptoms of early or mild alcohol withdrawal include anxiety, minor agitation, restlessness, insomnia, tremor, diaphoresis, palpitations, headache, and alcohol craving. Patients often experience loss of appetite, nausea, and vomiting. Physical signs include sinus tachycardia (heart rates may exceed 120 beats/min), systolic hypertension, hyperactive reflexes, and tremor [7,12]. Symptoms of mild withdrawal resolve within one to two days

Some patients with mild withdrawal will go on to develop additional manifestations of withdrawal, such as alcohol hallucinosis, withdrawal seizures, or withdrawal delirium (delirium tremens). The latter are sometimes considered together as “severe alcohol withdrawal syndrome.” Patients can have withdrawal seizures or hallucinosis without manifesting symptoms of mild withdrawal

Alcohol hallucinosis — Alcohol hallucinosis typically begins within 12 to 24 hours after the last drink and resolves in another 24 to 48 hours. The risk for alcohol hallucinosis may be related to genetic factors [13] and/or decreased thiamine absorption [14].

Alcoholic hallucinosis refers to hallucinations that are usually visual and commonly involve seeing insects or animals in the room; auditory and tactile phenomena may also occur. In contrast to withdrawal delirium, alcoholic hallucinosis is not associated with altered cognition such as disorientation, and vital signs are usually normal

Withdrawal seizures — Alcohol withdrawal-related seizures occur within 6 to 48 hours after drinking either stops or is significantly reduced. Such seizures occur in 10 to 30 percent of patients in alcohol withdrawal [15-17]. Risk factors may include concurrent withdrawal from benzodiazepines or other sedative-hypnotic drugs; other risk factors include relatively low potassium and platelet levels [4]. It has been observed that the risk of seizures increases as patients undergo repeated withdrawals, which has been described as the “kindling effect.” Genetic determinants are under investigation [18]

Withdrawal delirium — Withdrawal delirium (also known as delirium tremens or “DTs”) is a rapid-onset, fluctuating disturbance of attention and cognition, sometimes with hallucinations, in the presence of alcohol withdrawal [21]. In its most severe manifestation, withdrawal delirium is accompanied by agitation and signs of extreme autonomic hyperactivity, including fever, severe tachycardia, hypertension, and drenching sweats.

Withdrawal delirium typically begins between 72 and 96 hours after the patient’s last drink and has been reported to occur in 1 to 4 percent of patients hospitalized for alcohol withdrawal [22]

Laboratory and other testing — Laboratory testing typically includes:

● A complete blood count.

● Serum electrolytes, including potassium, magnesium, and phosphate.

● Glucose.

● Creatinine.

● Liver function tests.

● Amylase and lipase.

● Blood alcohol level.

● Urine drug testing, which should include testing for benzodiazepines, cocaine, and opioids. The opioid test should include not only opiates, which include heroin, codeine and morphine, but also buprenorphine, oxycodone, methadone, and fentanyl, all of which are of increasing importance in the current opioid epidemic.

● Urine human chorionic gonadotropin test for premenopausal women.

An electrocardiogram is suggested for patients over 50 years or if there is a history of cardiac problems.

CIWA-Ar scale — Although several symptom severity scales exist for alcohol withdrawal, the Clinical Institutes Withdrawal Assessment Scale for Alcohol (CIWA-Ar) has been the most studied and is the most widely used (table 3) (calculator 1).

The CIWA scale can help determine the need for medically supervised withdrawal management. Patients with an alcohol use disorder who have not had a drink for five days or more and have a CIWA score of less than 10 will in most cases not need management.

Withdrawal from other sedating substances – Withdrawal from benzodiazepines, opioids, and other sedating substances may resemble mild alcohol withdrawal. Benzodiazepine withdrawal in particular can be virtually indistinguishable from alcohol withdrawal, although tachycardia and hypertension are typically more pronounced in the latter.

Opioid withdrawal may be associated with mild hypertension, tachycardia, tremor, diaphoresis, nausea, and vomiting, but on exam, patients have pronounced mydriasis, piloerection, and rhinorrhea, which are absent in alcohol withdrawal. Most patients with opioid withdrawal are also particularly troubled by muscle and abdominal cramps, which are less pronounced in alcohol withdrawal.