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Cheese starters (Lactococcus lactis strains 303, 223, 227 and AM2) were subjected to high pressure (HP) in the range 100–400 MPa at 25°C for 20 min either in 0.1 m citrate buffer (pH 5.3), the same buffer containing 4.5% NaCl, or in cheese manufactured using each strain individually as a starter. Inactivation (total viable counts) and cell lysis (release of lactate dehydrogenase, LDH) of each strain were examined post-pressurisation. Starter bacteria were more pressure tolerant in cheese than in buffer. No evidence of release of LDH, and thus autolysis, from the starter cells resulting from HP treatment was observed either in buffer or in cheese. Primary proteolysis, studied by urea-PAGE analysis, increased as a result of the HP treatment. However, while cheeses made with different starter strains varied with respect to levels of pH 4.6 soluble nitrogen expressed as % total N and free amino acids, no further increase in these parameters were observed due to HP treatment. Thus, HP treatment for 20 min inactivated starter bacteria in Cheddar cheese (2–5 log cycle reduction at 400 MPa), but did not induce autolysis.

To the clinician, alcoholism can appear as an amorphous entity that is confusing with respect to diagnosis, treatment prognosis, and the role of the health professional, despite its high incidence and associated morbidities and mortality when unrecognized or untreated. This chapter focuses on the clinical application of current knowledge, with the aim of being useful to the practitioner in working directly with patients for whom alcoholism may or may not be an already identified problem. It briefly reviews large-scale studies and then focuses on diagnosis and prognosis assessment and decision making. Also considered are current controversies in nomenclature and the chapter ends with an economic perspective with respect to healthcare and cost to society. As the introductory chapter, the goal is to provide a context of the scope of alcoholism and attendant problems for the rest of the chapters.

To the clinician, alcoholism can appear as an amorphous entity that is confusing with respect to diagnosis, treatment prognosis, and the role of the health professional, despite its high incidence and associated morbidities and mortality when unrecognized or untreated. This chapter focuses on the clinical application of current knowledge, with the aim of being useful to the practitioner in working directly with patients for whom alcoholism may or may not be an already identified problem. It briefly reviews large-scale studies and then focuses on diagnosis and prognosis assessment and decision making. Also considered are current controversies in nomenclature and the chapter ends with an economic perspective with respect to healthcare and cost to society. As the introductory chapter, the goal is to provide a context of the scope of alcoholism and attendant problems for the rest of the chapters.

Phenotypic and phylogenetic studies were performed on 11 strains of a Microbacterium-like organism isolated from the surface of a smear-ripened cheese. The isolates were Gram-positive, catalase-positive, facultatively anaerobic, oxidase-negative, non-spore-forming, non-motile, small, slender rods and grew in 12% (w/v) NaCl. Chemotaxonomic investigation revealed that all the isolates belonged unambiguously to the genus Microbacterium. They contained type B1 peptidoglycans with L-lysine as the diamino acid and glycolyl acyl types; rhamnose and galactose were the cell wall sugars. The G+C content ranged from 69 to 72 mol%. The major menaquinones were MK-11 and MK-12 and the major fatty acids were anteiso C15:0 and C17:0 and iso C16:0. Phylogenetic analysis of the 16S rRNA sequences of four isolates showed that they represented a new subline in the genus Microbacterium, with Microbacterium barkeri as their nearest phylogenetic neighbour. M. barkeri showed the highest sequence similarity to the isolates; however, DNA-DNA hybridization showed that the isolates had only 38% chromosomal similarity to M. barkeri. Based on the phylogenetic and phenotypic distinctiveness of the isolates, it is proposed that they be classified as a new Microbacterium species, for which the name Microbacterium gubbeenense sp. nov. is suggested. The type strain has been deposited as LMG S-19263T (= NCIMB 30129T). The GenBank accession number for the 16S rDNA sequence of the type strain is AF263563.

At the Editor's request, Dr. Beresford reviews the paper by Martens, with particular reference to the clinical literature on liver transplantation in alcoholism. He concludes that abstract concepts, such as responsibility for one's illness, may have some theoretical value in academic discussions but that no studies support any direct practical usefulness for them in patient selection for solid organ transplantation. Rather, a sizeable body of work delineates a practical clinical approach to the evaluation of alcohol-dependent persons who request liver transplantation. He highlights the relevant aspects of this work briefly.

Ten isolates each of two different bacterial species isolated from the surface of a smear-ripened cheese were found to exhibit many characteristics of the genus Corynebacterium. The isolates were Gram-positive, catalase-positive, non-spore-forming rods that did not undergo a rod/coccus transformation when grown on complex media. Chemotaxonomic investigation revealed that the strains belonged unambiguously to the genus Corynebacterium. Their cell walls contained arabinose, galactose and short-chain mycolic acids (C22 to C36) and their peptidoglycan contained meso-diaminopimelic acid. The G+C content of the DNA was 51-60 mol%. MK-9 (H2) was the principal menaquinone. The 16S rDNA sequences of four isolates of each bacterium were determined and aligned with those of other members of the coryneform group. Phylogenetic analysis showed that the strains represented two new sublines within the genus Corynebacterium; Corynebacterium variabile and Corynebacterium ammoniagenes were their nearest known phylogenetic neighbours. Corynebacterium variabile and Corynebacterium ammoniagenes showed the highest levels of sequence homology with the isolates; however, DNA-DNA hydridization studies indicated that the Corynebacterium strains isolated from the cheese smear did not belong to either Corynebacterium variabile or Corynebacterium ammoniagenes (26 and 46% chromosomal similarity, respectively). On the basis of the phylogenetic and phenotypic distinctiveness of the unknown isolates, it is proposed that the bacteria be classified as two new Corynebacterium species, for which the names Corynebacterium mooreparkense sp. nov. and Corynebacterium casei sp. nov. are proposed. Type strains have been deposited in culture collections as Corynebacterium mooreparkense LMG S-19265T (= NCIMB 30131T) and Corynebacterium casei LMG S-19264T (= NCIMB 30130T).

High pressure (HP) treatment has emerged as a food processing technology primarily due to increasing interest in novel methods for preservation of foods. Applying HP to food products modifies interactions between individual components, influences rates of enzymatic reactions and can inactivate microorganisms. This paper reviews studies of HP induced changes in milk relevant to cheesemaking, including the effects of HP on rennet coagulation time, rate of curd formation and cheese yield. Published studies on the effects of direct HP treatment of cheese and specifically the effects of HP on cheese ripening characteristics, functionality and microbiology, are also reviewed.

The objective of this study was to determine the effect of high pressure (HP) on the inactivation of microbial contaminants in Cheddar cheese ( Escherichia coli K-12, Staphylococcus aureus ATCC 6538, and Penicillium roqueforti IMI 297987). Initially, cheese slurries inoculated with E. coli , S. aureus , and P. roqueforti were used as a convenient means to define the effects of a range of pressures and temperatures on the viability of these microorganisms. Cheese slurries were subjected to pressures of 50 to 800 MPa for 20 min at temperatures of 10, 20, and 30°C. At 400 MPa, the viability of P. roqueforti in cheese slurry decreased by >2-log-unit cycles at 10°C and by 6-log-unit cycles at temperatures of 20 and 30°C. S. aureus and E. coli were not detected after HP treatments in cheese slurry of >600 MPa at 20°C and >400 MPa at 30°C, respectively. In addition to cell death, the presence of sublethally injured cells in HP-treated slurries was demonstrated by differential plating using nonselective agar incorporating salt or glucose. Kinetic experiments of HP inactivation demonstrated that increasing the pressure from 300 to 400 MPa resulted in a higher degree of inactivation than increasing the pressurization time from 0 to 60 min, indicating a greater antimicrobial impact of pressure. Selected conditions were subsequently tested on Cheddar cheese by adding the isolates to cheese milk and pressure treating the resultant cheeses at 100 to 500 MPa for 20 min at 20°C. The relative sensitivities of the isolates to HP in Cheddar cheese were similar to those observed in the cheese slurry, i.e., P. roqueforti was more sensitive than E. coli , which was more sensitive than S. aureus . The organisms were more sensitive to pressure in cheese than slurry, especially with E. coli . On comparison of the sensitivities of the microorganisms in a pH 5.3 phosphate buffer, cheese slurry, and Cheddar cheese, greatest sensitivity to HP was shown in the pH 5.3 phosphate buffer by S. aureus and P. roqueforti while greatest sensitivity to HP by E. coli was exhibited in Cheddar cheese. Therefore, the medium in which the microorganisms are treated is an important determinant of the level of inactivation observed.

The influence of high pressure (HP) on the stability and activity of the milk alkaline pro- teinase plasmin was examined. Assays of enzyme activity following HP treatment of plasmin in phosphate buffer (pH 6.7) indicated that the enzyme was extremely pressure stable, retaining almost all activity even after treatment at 600 MPa for 20 min at 20 °C. Plasmin was also extremely stable when HP treated in buffer containing 25 mg.mL -1 sodium caseinate, and in cheese. However, HP treat- ment in buffer containing 5 mg.mL -1 β-lactoglobulin resulted in enzyme inactivation at pressures > 400 MPa, indicating that the presence of β-lactoglobulin greatly destabilises the enzyme under high pressure, which is analogous to the effect of this protein on the heat stability of plasmin. In separate experiments, hydrolysis of β-casein by plasmin at 20 °C for 30 min at various pressures (300-800 MPa) was studied. Parallel control incubations were performed at atmospheric pressure. Urea-PAGE analysis of digests showed that primary proteolysis of β-casein was decreased at P > 400 MPa. As judged from RP-HPLC analysis, production of 2%-TCA soluble peptides by plas- min appeared unaffected at P < 700 MPa, above which pressure the rates of peptide production decreased. Overall, plasmin is relatively pressure stable in most systems and can hydrolyse its pre- ferred substrate (β-casein) at pressures up to 700 MPa, but is sensitive to destabilisation by denatured β-lactoglobulin. plasmin / high pressure / specificity / stability

The possibility of acceleration of commercial Cheddar cheese ripening by exposure to a high pressure (HP) treatment of 50 MPa for 3 days at 25°C at different stages of ripening was investigated. Proteolysis was examined in the treated and untreated cheeses by measurement of pH 4.6 water soluble nitrogen, expressed as g/100 g total N (pH 4.6 SN/TN), urea-PAGE, reverse phase (RP) HPLC, analysis of molecular mass distribution by gel permeation and measurement of free amino acids (FAA) in the pH 4.6 SN. There was an immediate increase in pH 4.6 SN/TN and FAA in cheese HP-treated at 2 days of age, although this effect decreased with cheese age. Urea-PAGE analysis of cheese samples indicated that HP treatment accelerated degradation of α s1 -casein and accumulation of α s1 -I-casein (f 24-199). RP-HPLC profiles indicated quantitative but not qualitative differences between treated and non-treated samples. Confocal laser scanning microscopy did not indicate any gross structural changes in the cheese matrix as a result of exposure to 50 MPa for 3 days at 25°C. It was concluded that the enhancement of proteolysis observed may be attributed to a combination of the temperature and pressure used in the treatment.

The effects of high pressure (HP) on plasmin activity, β -lactoglobulin denaturation and proteolysis during subsequent storage of HP treated milk, were studied. Fresh raw milk samples were exposed to a range of pressures from 50 to 800 MPa, for times of 1, 10 or 30 min, at 20°C. Residual plasmin activity and whey protein denaturation were measured immediately post HP-treatment. Indices of proteolysis were measured during post-HP storage. Treatment at pressures >300 MPa resulted in extensive β -lactoglobulin denaturation. Plasmin activity decreased in milk treated at pressures ⩾400 MPa; the loss of activity was not well correlated with β -lactoglobulin denaturation. Compared to raw milk, treatment at 50 MPa had little effect on proteolysis during storage of treated milk measured as increases in pH 4.6-soluble N and liberation of proteose peptones, but at pressures of 300–400 MPa, proteolysis was increased relative to raw milk. After pressurisation >500 MPa, proteolysis during storage of milk was less than that observed in raw milk. Overall, HP influenced proteolysis in milk in a way which is different from that produced by heat, in terms of subsequent susceptibility of casein to proteolysis during storage or incubation. In particular, HP treatment at pressures of 300–500 MPa can increase proteolysis in milk, possibly through changes in micelle structure facilitating increased availability of substrate bonds to plasmin, which has implications for products prepared from milk thus treated.

Previous cross-section studies suggested that blood ethanol concentrations (BAC) increase with age. To establish this, and to account for putative gender differences, we studied four cohorts of nonalcoholic subjects.Fifty-seven subjects were studied: 14 men and 14 women in the young (21-40 years) and 14 men and 15 women in the old (or = 60 years) groups. All subjects received ethanol (0.3 g/kg) on three occasions: orally (PO) after an overnight fast; PO after a standard meal; and by intravenous (IV) infusion after a standard meal.In all four cohorts, PO ethanol in the fasted state produced the greatest average areas under the curve (AUC) for ethanol, followed by IV ethanol and PO ethanol, both in the fed state. Pooled by age, blood ethanol AUCs were significantly greater in old subjects given PO ethanol when fasted (p = .001) and IV ethanol when fed (p.004) but not after PO ethanol in the fed state. Pooled by gender, blood ethanol AUCs did not separate men and women in any of the experiments. Corrected for relative volumes of distribution (Vdist) among the four cohorts, only elderly women evidenced AUC values that could not be explained by Vdist alone and only in the fasted state. Both elderly men and women in the fasted state showed higher average peak ethanol levels than gender-matched younger cohorts; this effect was most pronounced in elderly women (47% vs 12%).The data confirm the influence of age, but fail to confirm that of gender, on blood ethanol response after a moderate dose of ethanol. They also show that feeding state can negate differences due to Vdist alone. In the fasted state, Vdist alone explains AUC and peak increases in elderly men but not in elderly women. Neither gastric metabolism nor motility account for age/BAC differences since these were independent of route. These data suggest caution for elderly drinkers or for those prescribing alcoholic beverages to elderly persons as well as for studies of ethanol ingestion that do not account for age and for feeding state.

The early onset of alcohol and tobacco use has been associated with increased risk for later substance abuse and dependence problems. This study investigated genetic and environmental influences on age at onset of alcohol and tobacco use by examining twin resemblance for several retrospectively reported onset milestones including age at first use, age at first alcohol intoxication experience, and age at regular use. In addition, we also examined the latency between age at first use and age at regular use of tobacco and alcohol. The subjects were a volunteer sample of older adult twins 50 to 96 years of age. MZ twin correlations for age at first alcohol use and age at first tobacco use were .57 and .44, respectively, compared to .45 and .37 for DZ same-sex twins. MZ twins correlated .30 and .26 for the latencies between first use and regular use of alcohol and of tobacco, while DZ correlations were −.01 and .05, respectively. Biometrical model-fitting results confirmed that familial resemblance for age at first use for both alcohol and tobacco was largely the result of shared environmental factors, while the latencies between first use and regular patterns of use were more genetically influenced. These findings add to a growing body of literature suggesting that initiation of substance use is influenced primarily by environmental rather than genetic factors.

Little is known about the utility of collateral reports in substantiating self-report for individuals assessed in nonalcoholism treatment contexts. This study examined the concordance of 581 pairs of medical patient and collateral responses to a commonly used alcohol screening instrument, the CAGE Questions, as well as to reports of the patient's drinking consequences and alcohol consumption. Results demonstrated that patient/collateral concordance was marginal, but acceptable, on CAGE cut-off scores and, that similar to reports from alcoholism treatment settings, patients generally reported more drinking consequences than collaterals. Patient and collateral reports of the patient's alcohol consumption did not differ significantly. This pattern of patient and collateral reporting of alcohol consequences and consumption was found for both men and women, as well as for patients with a DSM-III-R diagnosis of alcohol dependence. The findings support the validity of patient self-report on alcoholism screening measures in medical settings. Furthermore, results demonstrated that the addition of collateral reports to information directly obtained from patients only modestly improved the identification of alcohol dependence. The overall findings indicate that alcohol screening can be done effectively and efficiently in medical settings.

The purposes of this study were to determine among a cohort of long-term alcoholic survivors after liver transplantation (1) the incidence of alcohol use, (2) its effect on allograft integrity and extrahepatic health, and (3) the validity of the pretransplant alcohol prognosis screening process. Retrospective clinical cohort study of all alcoholic patients undergoing orthotopic liver transplantation at a single center from February 1987 until January 1991 with follow-up through December 1994, giving a median duration of follow-up of 63 months (range, 6-89 months). Multidisciplinary liver transplantation program at a tertiary-care academic medical center. Fifty alcoholic, long-term liver transplant recipients. The frequency of alcohol relapse, defined as any alcohol use in the period after transplantation, was determined by two questionnaire studies and by clinical follow-up. Allograft integrity was assessed by coded review of serial percutaneous allograft biopsies. Potential systemic effects of alcohol relapse were assessed by chart review. The alcohol prognosis screening process was evaluated by retrospectively comparing pretransplant estimates of putative indicators of alcoholism prognosis in posttransplant alcohol users and abstainers. Thirty-three recipients (66%) consistently denied any alcohol use throughout the duration of posttransplant follow-up, whereas 17 (34%) were identified as having consumed alcohol at least once since the transplant. There were no significant differences at the time of evaluation between abstainers and alcohol users in age, sex distribution, severity of liver dysfunction, median duration of abstinence, or University of Michigan alcoholism prognosis score. The median interval from transplantation to alcohol relapse was 17 months, with a range of 3 to 45 months. Recurrent alcohol use was associated with significant medical complications sufficient to require admission to the hospital in 6 patients. One patient died of graft dysfunction, noncompliance with immunosuppressant medications, and presumed graft rejection while drinking. Mild or progressive hepatitis, which was the most common abnormality in posttransplant liver biopsy findings, was equally distributed between both alcohol users and abstainers and sometimes occurred in the absence of antibody to hepatitis C virus antibodies. There was a similar frequency of biopsy-proven acute cellular rejection in alcohol users and abstainers. Typical histological features of alcoholic liver injury were present in posttransplant biopsies from 1 alcohol user only. Alcohol use by alcoholics is uncommon in the first 5 years after liver transplantation, and alcohol-associated liver injury is unusual. Mild nonspecific hepatitis is common in both alcohol users and nonusers alike. Among a small subset of alcoholic transplant recipients, drinking behavior after liver transplantation is associated with considerable morbidity, requiring hospital admissions and occasionally leading to graft loss and death.

A large and under-recognized sub-set of patients suffer from both traumatic brain injury (TBI) and alcohol abuse/dependence (AA/D). This group appears to use alcohol to self-treat fronto-limbic disinhibition, expressed clinically as affective lability, following TBI. This often results in AA/D and worsens TBI prognosis. The primary study hypothesis states that symptom frequencies of fronto-limbic disinhibition, expressed as affective lability, will decrease significantly in TBI subjects treated with divalproex sodium, a mood stabilizing medication, as compared to placebo. To test the primary hypothesis, we propose an 8 week, double-blind, randomized, controlled trial comparing divalproex sodium to placebo in 50 subjects 25 per group--who suffer from both TBI and AA/D. Subjects will be recruited through the initiating site located at the Department of Veterans Affairs Medical Center, Denver. Final approval from multiple review bodies was granted on September 15, 2009. Active subject recruitment continues. There are no results to report at this time.

High abstinence rates characterize alcohol-dependent liver graft recipients. The immunosuppressants cyclosporine A (CsA) and tacrolimus (TRL) also inhibit calcineurin (CLN) in the brain. Previously, we found that CsA reduces alcohol consumption in C57BL/6J mice. The goals of the present study were: 1) to compare the ethanol preference effects of CsA against TRL, as well as sirolimus (SRL), an immunosuppressant without CLN inhibition and 2) to establish that reduction of alcohol consumption is not caused by caloric reinforcement from these ligands. C57BL/6J mice trained to imbibe ethanol consumed ethanol or sucrose in a modified limited-access drinking-in-the-dark paradigm; test groups received vehicle or doses of CsA (5-50 mg/kg), TRL (0.5-2.5 mg/kg), or SRL (1.0-5.0 mg/kg) for 5 consecutive days, 30 min before each 2-h limited-access session. Brain CsA, TRL, and SRL concentrations were measured. CsA (p < 0.001) and TRL (p < 0.01) each decreased ethanol consumption, whereas SRL showed no significant effects at any dose. Effective doses included CsA at 10 mg/kg and above and TRL at 2.5 mg/kg. CsA (50 mg/kg) did not reduce sucrose consumption. Both CsA and TRL reached significant brain concentrations compared with very low values of SRL. These data suggest that CsA and TRL may reduce alcohol preference through central CLN inhibition rather than by immunosuppression.

Modafinil was tested for efficacy in decreasing use in methamphetamine-dependent participants, compared to placebo.This was a randomized, double-blind, placebo-controlled study, with 12 weeks of treatment and a 4-week follow-up. Eight outpatient substance abuse treatment clinics participated in the study. There were 210 treatment-seekers randomized, who all had a DSM-IV diagnosis of methamphetamine dependence; 68 participants to placebo, 72 to modafinil 200mg, and 70 to modafinil 400mg, taken once daily on awakening. Participants came to the clinic three times per week for assessments, urine drug screens, and group psychotherapy. The primary outcome measure was a methamphetamine non-use week, which required all the week's qualitative urine drug screens to be negative for methamphetamine.Regression analysis showed no significant difference between either modafinil group (200 or 400mg) or placebo in change in weekly percentage having a methamphetamine non-use week over the 12-week treatment period (p=0.53). Similarly, a number of secondary outcomes did not show significant effects of modafinil. However, an ad-hoc analysis of medication compliance, by urinalysis for modafinil and its metabolite, did find a significant difference in maximum duration of abstinence (23 days vs. 10 days, p=0.003), between those having the top quartile of compliance (85% of urines were positive for modafinil, N=36), and the lower three quartiles of modafinil 200 and 400mg groups (N=106).Although these data suggest that modafinil, plus group behavioral therapy, was not effective for decreasing methamphetamine use, the study is probably inconclusive because of inadequate compliance with taking medication.

(1993). Alcoholism in the elderly. International Review of Psychiatry: Vol. 5, No. 4, pp. 477-483.

It has been proposed that evaluation of alcoholic patients for liver transplantation should comprise a multidisciplinary program including medical, surgical, and psychiatric assessment. This article presents the outcome in 99 alcoholic persons evaluated from 1985 through 1989. Alcoholism was defined as alcohol dependence or abuse according to the DSM-III-R. Forty-five patients (43%) were considered suitable candidates and underwent transplantation. Actuarial survival in this group was 78% and 73% at 12 and 24 months, respectively, and did not differ from that observed in nonalcoholic recipients. Return to alcohol use after transplantation has been documented in 5 persons, 2 of whom have had episodes of uncontrolled drinking. Of 54 patients not selected for transplantation, 17 were considered too well and suitable for alternative therapy. Actuarial survival was 93% at 12 and 18 months but declined to 59% at 24 months. Nineteen patients were medically unsuitable and had very poor survival; survival was 35% at 3 months and 0% at 12 months. Seventeen patients were not selected on psychiatric grounds. Actuarial survival in this group (65% at 12 months, 43% at 18 months) was significantly less than that in alcoholics with transplants (P less than 0.05). There were no differences in age, sex ratio, degree of hepatic dysfunction, or duration of abstinence between alcoholics with transplants and those considered psychiatrically unsuitable. It was concluded that liver transplantation is successful in selected patients with alcoholic cirrhosis, that patients who are not selected because they are "too well" need continuing surveillance as a significant decline in survival can occur 18-24 months after initial evaluation and, finally, that patients not selected on psychiatric grounds have a significantly worse survival rate than those with transplants.

Lactobacillus helveticus is a versatile dairy bacterium found to possess heterogeneous genotypes depending on the ecosystem from which it was isolated. The recently published genome sequence showed the remarkable flexibility of its structure, demonstrated by a substantial level of insertion sequence (IS) element expansion in association with massive gene decay. To assess this diversity and examine the level of genome plasticity within the L. helveticus species, an array-based comparative genome hybridization (aCGH) experiment was designed in which 10 strains were analyzed. The aCGH experiment revealed 16 clusters of open reading frames (ORFs) flanked by IS elements. Four of these ORFs are associated with restriction/modification which may have played a role in accelerated evolution of strains in a commercially intensive ecosystem undoubtedly challenged through successive phage attack. Furthermore, analysis of the IS-flanked clusters demonstrated that the most frequently encountered ISs were also those most abundant in the genome (IS 1201 , ISL 2 , ISLhe 1 , ISLhe 2 , ISLhe 65 , and ISLhe 63 ). These findings contribute to the overall viewpoint of the versatile character of IS elements and the role they may play in bacterial genome plasticity.

Background Cocaine dependence is a major public health problem for which there is no FDA-approved pharmacological treatment. Baclofen is a GABA B receptor agonist that in preclinical and early pilot clinical trials has shown promise for the treatment of cocaine dependence. The purpose of this multi-site, double-blind study, was to compare the safety and efficacy of baclofen (60 mg/day) vs placebo in an 8-week treatment of individuals with severe cocaine dependence. The primary outcome measure was subjects’ self-reported cocaine use substantiated by urine benzoylecgonine (BE). Analysis of the data did not show a significant difference between the groups treated with baclofen and placebo. The current results do not support a role for 60 mg baclofen in treating cocaine dependence in the population studied. The contrast of this result to earlier, preclinical and human pilot data with baclofen may reflect the trial's focus on severe cocaine-dependent users, and/or the need for a higher baclofen dose. Baclofen's potential as a relapse prevention agent was not tested by the current design, but may be a useful target for future studies.

The species Lactobacillus helveticus is a commonly used thermophilic starter and/or adjunct culture for Swiss and Cheddar cheese manufacture. Its use is normally associated with flavour improvement which is known to be associated with culture traits such as rapid autolysis and high proteolytic activity. The genome of the commercial strain, DPC4571, was recently sequenced and found to have an abundance of IS sequences in terms of both abundance (213 intact) and diversity (21 types). Given this unique diversity for a lactic acid bacterium, we investigated whether PCR-based IS fingerprinting could be used as a discriminatory tool to distinguish between different strains of Lb. helveticus . A set of ten primers targeting five of the most numerous groups (ISL 1201 , ISLhe 65 , ISLhe 2 , ISLhe 15 and ISL 2 ) of IS elements was designed. Multiplex-PCR with all primers resulted in 1 – 12 discreet amplicons for each strain tested. The resultant fingerprints (in the 0.5 kb – 3 kb range) were found to be strain specific and reproducible. This approach thus provides a valuable method to distinguish between Lb. helveticus strains while giving some indication of the relative abundance of IS sequences in each strain.

A total of 468 lactic acid bacteria (LAB) isolates from the interior of six traditional Pecorino Siciliano cheeses during ripening (1, 30 and 90 days) were characterized genotypically in order to assess the biodiversity within this wild microbial population. Two DNA-based technique, PCR and PFGE were used for genetic typing of isolates. Of the 468 isolates, species-specific PCR analysis showed that 79, 58, 2, 9 and 4 isolates reacted with primers for Lactobacillus paracasei, Lb. plantarum, Lb. pentosus, Lb. rhamnosus and Lb. curvatus, respectively and no isolates reacted with the Lb. casei primers. Genus-specific PCR analysis showed that 59 isolates reacted positively with the lactococcal primers, 221 with the enterococcal primers and 34 with the Leuconostoc primers, 1 with the pediococcal primers and 4 with the streptococcal primers. Enterococci were characterized at species level and twelve of the 221 enterococci isolates showed positive reaction with the E. faecalis species-specific primers, and the remainder 209 isolates positively with the E. faecium species-specific primers. PFGE analysis allowed to identify different strains of the same species of Lb. plantarum and Lb. paracasei. The strains which reacted positively with Lb. curvatus, Lb. pentosus or Lb. rhamnosus primers gave a unique PFGE pattern. PFGE indicated 52 different band patterns for enterococci, 9 for lactococci, 5 for leuconostocs and 1 for streptococci and pediococci. The results suggest that wild bacterial populations should be preserved in order to protect the traditional raw milk cheeses, and to select new specific strains for the dairy industry.

Although depression secondary to medical illness occurs frequently, little is known about its response to conventional antidepressant therapy. In this retrospective study of 50 patients, the authors assessed the charted therapeutic effect of antidepressants and sought to define pretreatment features associated with good outcome. Half (9/18) of the patients with a previous history of depression improved while only 22% (7/32) of the patients without a previous history of depression showed improvement in mood. Those patients meeting DSM-III criteria for major depressive disorder were no more likely to benefit from antidepressants than were patients meeting criteria for adjustment disorder with depressed mood. The authors conclude that previous history of depression should be considered when assessing risks and benefits for antidepressants for medically ill patients with depressive syndromes.

To identify the most effective method of screening for covert alcoholism Ewing's CAGE questionnaire was compared with several computer-assisted laboratory data profiles in a prospectively gathered, random sample of 915 adults admitted to a general hospital. Whether a subject was alcohol dependent (n = 244) or not (n = 671), as defined by DSM-III-R, was determined on the basis of a structured interview. The CAGE questionnaire was highly sensitive (76%) and specific (94%) for recognition of alcohol dependence (positive predictive power 87%). None of the discriminant laboratory functions gave recognition rates greater than chance alone. Until the sensitivities, specificities, and positive predictive powers of computer-assisted methods improve, brief interview alone remains the best screening method for general hospital populations.

Background: Fatty acid ethyl esters (FAEEs) are generated by the nonoxidative metabolism of alcohol and correlate positively with blood alcohol levels (BAL). As FAEEs are produced predominantly in the liver and bind to albumin in plasma, blood FAEE concentrations may be affected by serum albumin levels. The aim of this exploratory study was to define the relationship of FAEE levels with BAL after adjustment for serum albumin concentration. Methods: Fatty acid ethyl ester, BAL, and albumin concentrations were measured from de-identified, ethanol-containing serum samples (N=18). The assay focused on 3 FAEE species ethyl palmitate, ethyl stearate, and ethyl oleate. The relationships of individual and total FAEE concentrations with BAL using albumin as a covariate were analyzed. Values for Pearson's r between the BAL and the natural log-transformed FAEE (ln FAEE) levels were calculated, and then compared with partial correlation coefficients when controlling for albumin. The impact of serum albumin levels on the relationship between ln FAEE and BAL was evaluated by simple linear regression analysis. Results: Concentrations of total FAEE ranged from 632 to 20,166 nM, and BAL ranged from 9 to 375 mg/dL. In the 18 samples, the Pearson correlation coefficient between BAL and total FAEE levels was 0.868, and increased to 0.909 when controlling for albumin (p

Objective: No clear consensus exists regarding the effect of sustained, heavy drinking on hippocampal volume. Our prior work hypothesized significantly lowered total hippocampus volumes in heavy chronically drinking alcohol-dependent (AD) subjects compared with light-drinking nondependent control subjects matched for age and gender. Method: Using a series of applicable exclusion criteria culled from previous published studies, we measured hippocampal volumes from MRI scan data acquired on a 3T scanner and subjected those data to automated volume analysis blind to the drinking history. Results: Comparison with AD test (n 5 8) and non-AD control (n 5 8) subjects found significant lessening in total ( p 5 0.020) and left ( p 5 0.010) hippocampal volumes with a near-significant difference on the right ( p 5 0.051). Linear regression demonstrated that neither total brain volume nor intracranial volume affected the hippocampus measures. Conclusions: These data support the view that heavy drinking exerts a unique and selectively injurious effect on the hippocampus. Further study in larger samples must verify this in a search for possible mechanisms of injury.

The study addressed whether a collaborative model for chronic care, described in part I (this issue), improves outcome for bipolar disorder.The intervention was designed to improve outcome by enhancing patient self-management skills with group psychoeducation; providing clinician decision support with simplified practice guidelines; and improving access to care, continuity of care, and information flow via nurse care coordinators. In an effectiveness design veterans with bipolar disorder at 11 Veterans Affairs hospitals were randomly assigned to three years of care in the intervention or continued usual care. Blinded clinical and functional measures were obtained every eight weeks. Intention-to-treat analysis (N=306) with mixed-effects models addressed the hypothesis that improvements would accrue over three years, consistent with social learning theory.The intervention significantly reduced weeks in affective episode, primarily mania. Broad-based improvements were demonstrated in social role function, mental quality of life, and treatment satisfaction. Reductions in mean manic and depressive symptoms were not significant. The intervention was cost-neutral while achieving a net reduction of 6.2 weeks in affective episode.Collaborative chronic care models can improve some long-term clinical outcomes for bipolar disorder. Functional and quality-of-life benefits also were demonstrated, with most benefits accruing in years 2 and 3.

Psychological treatment studies, uncontrolled for ego defense (adaptive) styles, report conflicting survival results. The authors hypothesized that "immature" adaptive styles and frequent depression symptoms would independently predict lower survival rates. This study followed 86 consecutive, mostly late-stage, cancer outpatients for up to 5 years; their survival data were analyzed in relation to the Beck Depression Inventory and the Defense Style Questionnaire scores at study entry. Cumulative survival probability curves contrasted the extreme cases: the most (N=15) to the least (N=21) depressed, and the "immature" (N=14) to the "mature" (N=16) adaptors. Depression did not separate the groups until 30 months after diagnosis. Ego defense style separated them at 8 months; by 18 months, the "immature" survival probability had dropped to 50%, versus 87% for the "mature." At 36 months, survival probabilities were 19% and 57%, respectively. These data direct clinical attention toward ego defense mechanisms as indicators of distress and lowered survival in cancer patients. They further suggest that the maturity of adaptive mechanisms must be controlled for in behavioral-treatment trials of cancer patients.

Ego defense mechanism (EDM) recognition can offer a powerful and practical tool in clinical psychiatry. However, recognition skill learning can be difficult to assess and may account for the lack of formal EDM recognition training in residency courses.This study hypothesized that mean test scores would increase significantly over 8 weeks in a course on practical EDM recognition. Second-year residents from two successive classes (n = 25) were tested in the first and the last course sessions using a 10-item, multiple-choice test. Correct answer mean scores were compared using Student's t test.Test scores demonstrated an increase in the mean percentage of correct answers between the two time points: 54% versus 82%.These data suggest that clinical EDM recognition can be systematically taught and that learning can be measured appropriately.

Remarkably high rates of abstinence occur among alcohol-dependent persons after a liver transplant. This was thought to be solely due to selection or other nonbiological factors. Observing sustained abstinence for many months to years after a liver transplant, however, we asked whether immunosuppressants might exert a biological effect that supported abstinence from ethanol.We hypothesized that cyclosporine-A-treated mice would drink less ethanol given a choice between water and 10% ethyl alcohol. After a 3-day ethanol conditioning period, C57bl/6j mice (n = 20) medicated with cyclosporine-A (50 mg/kg) and a control group of unmedicated mice (n = 20) injected with saline were given free access to either water or the ethanol solution.The medicated mice drank significantly less ethanol throughout the 11-day choice protocol. This was significant whether measured by mean alcohol consumption per day (p = .003) or by alcohol preference as a percent of total liquid intake per day (p = .03). The two groups did not differ significantly in total daily fluid consumption.These data suggest that cyclosporine-A lowers alcohol preference in mice. Mechanism of action, similar effects by other centrally acting immunosuppressants and translation to humans all remain to be studied. If fruitful, elucidating the actions of cyclosporine and other immunosuppressants that activate central nervous system receptors may illuminate the pathophysiology of alcohol use and addiction.

Patient compliance is essential for optimal therapeutic outcome. However, medical noncompliance remains a significant issue in the treatment of many neurologic disorders. Neurologic patients are particularly vulnerable to poor treatment adherence. The chronic and often relapsing and remitting course of neurologic illness creates challenges in maintaining treatment compliance. In addition, comorbid psychiatric conditions can contribute to noncompliance. Decreasing the complexity of dosing schedules, addressing side effect concerns, recognizing financial impact of treatment, and addressing comorbid psychiatric illness all can help to improve compliance. Potentially, the most effective methods to improve compliance include improving the doctor patient relationship, increasing a patient’s social support system, and maximizing patient education.

Having reported high adherence to court-mandated disulfiram treatment, we hypothesized that other Department of Veterans Affairs (DVA) medical centers would report frequent use of this modality. Telephone interviews with DVA substance abuse clinics in 48 of the 50 states matched the national DVA frequencies. Phone survey responders reported disulfiram prescription as never/rarely 63%, sometimes 32%, and often 5%, while court-ordered disulfiram was used never/rarely 95%, sometimes 3%, and often 2%. Nationally, disulfiram prescriptions covered only 0.07% of all veterans seen. These data suggest a need for a re-evaluation of disulfiram as an underused treatment for alcohol dependence.

Background: Fatty acid ethyl esters (FAEEs) are useful markers of ongoing alcohol use and may be associated with alcohol-induced damage to the liver and pancreas. In this article, we describe a novel method for rapid determination of the three major FAEEs found in human plasma. Methods: Internal standard, ethyl heptadecanoate, was added to plasma samples, and FAEEs were isolated by acetone precipitation, hexane lipid extraction, and amino-propyl silica solid phase extraction. FAEEs were quantitated by gas chromatography-mass spectrometry (GC-MS) using a nonpolar dimethylpolysiloxane column. The accuracy, precision, specificity, and sensitivity of the assay were defined from plasma samples from recently drinking and abstinent persons, with and without the addition of FAEEs. Results: Individual FAEE peaks demonstrated excellent resolution. Instrument time was reduced by more than 60%. The lower limit of detection was 5 to 10 nM, and the lower limit of quantitation for each FAEE was 60 nM (for 22 samples with known concentration 60 nM, × ±SD: 61 ± 5.7, 57 ± 5.7, and 57 ± 5.9 nM, for ethyl palmitate, ethyl oleate, and ethyl stearate, respectively). Instrument precision (coefficient of variance, CV) for these three FAEEs was 0.3%, 0.4%, and 0.7%, respectively. Intra-assay precision (CV) for total FAEEs was less than 7%. FAEEs were absent in 49 samples from abstinent persons. FAEEs were detected in all 76 samples with associated positive blood alcohol levels. Conclusions: Our method of FAEE analysis is rapid and potentially useful in research and clinical studies. FAEE determination using this method is precise, accurate, sensitive, and specific and deserves broader application.

A large and under-recognized sub-set of patients suffer both traumatic brain injury (TBI) and alcohol dependence (ADep). This group appears to use alcohol to self-treat affective and anxiety lability following TBI, resulting in new ADep or worsened prior ADep. This study hypothesized that treatment of such patients with mood-stabilizing medications would relieve post-TBI emotional dysregulation and facilitate reduction in alcohol use.This study reported retrospective medical record data from outpatients in the Substance Abuse Treatment Programme who were treated for labile mood. Medications followed clinical indication and were given in non-blind fashion.Subjects included 18 patients who (1) complained of debilitating affective lability following TBI, (2) described drinking alcohol to ease lability symptoms, (3) met DSM-IV criteria for current ADep and (4) were treated with a mood stabilizing medication.During 6 weeks of treatment, 16 (89%) achieved abstinence from alcohol. All but two (14/16 or 88%) also showed improvement in their affective and anxiety symptoms.These preliminary data are limited by the retrospective collection, clinical impression and non-blinded trial. Nonetheless, the results suggest further investigation of anti-convulsants as potentially useful agents in co-morbid emotional lability and ADep following TBI.

Objectives: The clinical profile of minorities with bipolar disorder has been largely unexplored. We compared the clinical (e.g. psychiatric and substance use comorbidity), psychosocial, and treatment characteristics between white and minority patients with bipolar disorder (minorities were defined as black or other minority, which included Hispanic, Asian-American, or Native-Americans). Methods: We collected demographic, diagnosis, and treatment information using the Structured Clinical Interview for DSM-IV (SCID) from 330 inpatients with a current major affective episode across 11 Veterans Affairs (VA) Medical Centers enrolled in the VA Cooperative Study (Reducing the Efficacy–Effectiveness Gap in Bipolar Disorder). Results: Twenty-four percent (n = 80) were minority; 9% (n = 30) were women, 4% (n = 20) were ≥65 years old; and the majority (87%, n = 286) had bipolar type I. Minorities compared with whites were no more likely to have a current episode of psychosis (30% versus 37%, respectively; p = 0.28). However, minorities were more likely than whites to have a cocaine use disorder (adjusted odd's ratio, OR = 2.2; 95% CI: 1.4–3.5; p

Objective Although abstinence slows liver injury in alcoholic Hepatitis C (HCV) infected patients, few clinicians prescribe disulfiram because of concern over its hepatotoxic effect. Finding no controlled studies on this effect, we investigated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) patterns in seropositive (HCV[+]) and seronegative (HCV[-]) patients who received supervised disulfiram over 12 months. Method We recorded retrospective aminotransferase measurements from medical records of 26 HCV(+) and 20 HCV(-) cases receiving 1500 mg disulfiram weekly in divided doses. Within groups, paired mean AST and ALT levels at 3, 6, 9 and 12 months were compared with baseline; between groups, nonpaired mean comparisons were used. Results There were no statistically or clinically significant elevations for the HCV(+) group at any time point. Between-group means were identical at all time points. Conclusions Although sample size and retrospective design invite replication, the data suggest that disulfiram may be useful for HCV(+) alcohol-dependent patients in slowing hepatic injury by eliminating alcohol use and thereby removing the purported alcohol-HCV hepatotoxic synergy. It may also help to establish the abstinence criteria necessary to qualify for antiviral treatment. If disulfiram is used in HCV treatment, AST and ALT must be monitored closely.

Present knowledge suggests that cocaine is almost always used by snorting, injecting, or smoking. During a recent treatment study, we encountered 2 cases who reported active cocaine use by the sublingual route exclusively. We describe here 1) the method of sublingual use, 2) its attraction for cocaine dependent individuals, especially those who wish to conceal use, and 3) concerns regarding the medical consequences of sublingual cocaine use. Sublingual cocaine use may cause unique medical symptoms and may easily evade detection by medical personnel.

To address the occurrence of deaths in later postoperative years among alcohol-dependent liver graft recipients, the authors developed the Brief Active Focused Follow-Up protocol as an instrument for monitoring alcohol use following liver transplant. In this preliminary study, patient receptiveness to its use was tested and its ability to identify patient drinking was noted. Alcohol-dependent liver transplant recipients (N=24) and alcohol-dependent nontransplant patients (N=25) were asked to rate their receptiveness to the Brief Active Focused Follow-Up in three areas. Subjects used a five-point scale for which 5 indicated the highest positive response. Liver transplant recipients responded positively to the Brief Active Focused Follow-Up, with mean responses of 4.92, 4.08, and 4.63 with regard to clarity, usefulness, and ease of completion, respectively. Nontransplant subjects responded similarly, with mean responses of 4.88, 4.12, and 4.52. The two groups were not significantly different in their receptiveness to the Brief Active Focused Follow-Up interview. The Brief Active Focused Follow-Up identified alcohol use within the last 30 days: 8% (N=2 of 24) in the transplant group, and 56% (N=14 of 25) in the nontransplant group. These results suggest that 1) this manualized, brief monitoring technique is well received by alcohol-dependent liver transplant patients, and 2) the Brief Active Focused Follow-Up's "user friendliness" makes it a potentially appropriate instrument for long-term monitoring of alcohol use among alcohol-dependent liver graft recipients.

Background Recent data indicate high prevalence of both anxiety and substance comorbidity in bipolar disorder. However, few studies have utilized public sector samples, and only one has attempted to separate contributions of each type of comorbidity. Methods 328 inpatient veterans with bipolar disorder across 11 sites were assessed using selected Structured Clinical Interview for DSM-IV modules and self-reports. Results Comorbidity was common (current: 57.3%; lifetime: 78.4%), with multiple current comorbidities in 29.8%. Substance comorbidity rate was comparable to rates typically reported in non-veteran inpatient samples (33.8% current, 72.3% lifetime). Selected anxiety comorbidity rates exceeded those in other inpatient samples and appeared more chronic than episodic/recurrent (38.3% current, 43.3% lifetime). 49% of PTSD was due to non-combat stressors. Major correlates of current substance comorbidity alone were younger age, worse marital status, and higher current employability. Correlates of current anxiety comorbidity alone were early age of onset, greater number of prior-year depressive episodes, higher rates of disability pension receipt, and lower self-reported mental and physical function. Combined comorbidity resembled anxiety comorbidity. Limitations This is a cross-sectional analysis of acutely hospitalized veterans. Conclusions Distinct patterns of substance and anxiety comorbidity are striking, and may be subserved by distinct neurobiologic mechanisms. The prevalence, chronicity and functional impact of anxiety disorders indicate the need for improved recognition and treatment of this other dual diagnosis group is warranted. Clinical and research interventions should recognize these divergent comorbidity patterns and provide individualized treatment built “from the patient out.”

Previously, we observed that the presence of a court-mandate doubled adherence to supervised disulfiram treatment over voluntary supervised disulfiram treatment during the initial twelve weeks. To assess persistence, we conducted a naturalistic followup study of adherence at 15 months in 19 voluntary and 17 court-ordered patients from the original groups. Treatment adherence, measured by the percentage of completed disulfiram clinic visits during the study period, was significantly higher in court-ordered subjects: 61.0% vs. 18.2% in the voluntary group (p.0001). The data suggest that court assistance can exert a significant effect in maintaining adherence. Factors mediating adherence, as well as the effects of adherence on behavior change and abstinence, must be determined through prospective, controlled study.

We hypothesized that court mandate would significantly enhance compliance with supervised disulfiram therapy. We conducted a twelve-week prospective study of outpatient compliance with court-ordered, monitored disulfiram treatment as compared to voluntary, monitored treatment. The court ordered group (n=19) was significantly more compliant than the voluntary group (n=22). Legally mandated subjects attended an average of 87% ( &#45 21%) of scheduled visits, versus 42% ( &#45 35%) for the group without court order. Court mandate roughly doubles the compliance rate of monitored disulfiram therapy, effectively enhancing clinic attendance during the first twelve weeks of treatment. (Am J Addict 2003;12:137-143)