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The excessive and chronic use of alcohol is associated with a variety of neurocognitive changes in a substantial number of detoxified alcoholics. These deficits extend across a wide variety of neuropsychological domains and can be observed over a period of months following detoxification. Furthermore, they are seen in both male and female alcoholics, despite the fact that female alcoholics often have shorter drinking histories. Although these deficits are widely observed, there is considerable heterogeneity both within and across studies. Currently, the sources of this variability are only poorly understood. In this article, we review these neurocognitive and neurophysiological deficits, their pattern of recovery, potential contributing or confounding factors, and some of the clinical implications of these findings.

This study was conducted to determine whether alcoholics' memory difficulties are due, in part, to access (retrieval) or to availability (retention) deficits. Forty-four alcoholics (n = 20 females) and 44 controls (n = 22 females) learned a paired associate list consisting of 12 adjective-CCC trigram pairs. Half of the subjects in each group learned the list to a low degree of learning (DOL; 4/12 pairs); the remainder to a high DOL (8/12 pairs). Two distinct environmental contexts (providing implicit cues) were used during acquisition. Subjects then completed a cued recall (an explicit cue) test in either the same or a different room. Alcoholics were significantly inferior in the acquisition phase on trials required to reach criterion, regardless of DOL required [F(1,68) = 10.92, p = 0.002]. The main effect for implicit cuing was not significant; similarly, there were no significant interactions. In contrast, the explicit cue manipulation produced a significant group x DOL interaction on the number of trigrams correctly recalled [F = (1,77) = 6.38, p = 0.01]; alcoholics' recall did not benefit from the higher DOL in contrast to a significant improvement in recall by controls. The failure of alcoholics to demonstrate improvement with higher levels of learning is consistent with a deficit in the availability of information. The results confirm previous reports of recovering alcoholics' verbal learning and memory dysfunction, and suggest that these deficits may be attributed, in part, to a deficit in the availability of information (retention).

Four measures of anger were investigated in sober male and female alcoholics and nonalcoholic peers. The relationships among anger variables, past drinking behavior, and substance abuse consequences in alcoholics were explored. Additionally, the interrelationships among anger, depression, and anxiety in the groups were examined, and the relationships between an overall dysphoria index and drinking behavior and substance abuse consequences were determined. 104 alcoholics (sober 21 to 45 days) and 70 community controls, aged 21 to 56, were given the Spielberger Anger Expression Inventory, the Beck Depression Inventory, and the Spielberger State Anxiety Inventory. Alcoholics scored higher than controls on Trait Anger, Anger-In, and Anger-Out, but not on State Anger. There were no main effects of sex. Anger-In was significantly negatively correlated with the Quantity-Frequency Index in alcoholic males. Anger-In was significantly positively correlated with depression in male and female alcoholics and with substance abuse consequences in the latter group. The depression measure was significantly correlated with consequences in female, but not in male alcoholics. These data have treatment implications, especially for female alcoholics.

Mental health and medical administrators responded to the Oklahoma City bombing with cooperative and overlapping efforts to meet community needs in the wake of terrorism. The major agencies assisted in the immediate rescue response, organized crisis hotlines, prepared mental health professionals to counsel bereaved families and victims, organized debriefing of rescuers, assessed mental health needs of local school children, planned for longer term treatment, and coordinated research efforts to learn from the disaster. Implications to mental health administrators responding to significant acts of terrorism are discussed.

Background Postoperative death following large bowel surgery is relatively infrequent and no large study has analysed the cause of all deaths comprehensively and critically. Methods In-hospital deaths following large bowel surgery in South-East Scotland were reviewed by independent assessors. The audit was confidential but not anonymous. Independent assessors' reports were returned to consultants. Results The audit documented 187 deaths. The independent assessors noted an adverse event in 78 patients (42 per cent). Twenty-six deaths (14 per cent) occurred following an anastomotic leak. A further 43 deaths (23 per cent) occurred because surgery was delayed (17) or there was undue delay in making the initial diagnosis (12) or recognizing a developing complication (14). Consultants operated on only half the patients classed as American Society of Anesthesiologists grade IV or V, or undergoing a second or subsequent operation. Conclusion Half the patients dying in this study had identifiable deficiencies in their management. There is a clear need for greater consultant input with critically ill patients.

In the days and weeks following the Oklahoma City bombing on April 19,1995, Oklahoma state authorities, university faculty and staff, and leading experts from across the nation formed a coalition to address issues of clinical service delivery, educational intervention, and research. This article focuses on the centralized approach applied to the administration of research endeavors. This centralization was designed to minimize revictimization of both survivors and affected families, enhance the quality of data collected, and facilitate cooperation between participating investigators. The resultant set of projects includes a variety of research methodologies and study populations and will serve to significantly enhance understanding of the mental health sequelae of such disasters.

The relation between childhood behavior disorders (CBD), attentional difficulties (ADD), and antisocial personality disorder (ASP) was examined in a clinical population of alcoholics and polysubstance abusers. Polysubstance abusers reported increased CBD symptomatology, increased attentional problems, a higher rate of ASP, and a greater number of both current and lifetime ASP symptoms relative to alcoholics without polysubstance abuse. An examination of gender effects revealed significant differences on self-reported adult attentional problems, with females endorsing a greater number of items. As a group, females exhibited the highest rate of ASP. Males showed a significant correlation between current ASP symptoms and both attention and conduct problems in early childhood.

Alcohol is the most commonly used substance across the life span, with alcohol use typically initiated during adolescence, escalating and peaking during early adulthood, and abating through later life (National Epidemiologic Survey on Alcohol and Related Conditions, 2010). Over this same period of time, the brain undergoes significant structural and functional changes, with substantial neurodevelopment occurring between adolescence and the third decade of life, followed by neural restructuring and atrophy beginning in older age (Simpkins and Simpkins, 2013). For the purpose of this review, human adolescence is defined as 12 to 18 years, which corresponds to an animal age of postnatal 28 to 42 days; adulthood refers to human ages 25 to 54 years, which corresponds to an animal age of 70 days to 15 months; and aged adults refers to humans 55+ years, which corresponds to an animal age of 18+ months (Spear, 2000). Not surprisingly, the effects of alcohol on brain functioning differ based on the developmental period when alcohol use was initiated, as well as the ages over which drinking persists. This mini-review expands on existing studies (Welch et al., 2013) by incorporating the most current research examining alcohol's differential effects on adolescents, adults, and aged populations in both animal and clinical models. While prenatal alcohol exposure is an important developmental concern (Riley et al., 2011), this review focuses on alcohol exposure between the ages when alcohol is most commonly used (i.e., adolescence to older adulthood). The overall goal is to present areas of similarity regardless of experimental system and highlight areas of needed research. The first section of the review focuses on recent adolescent clinical findings. Studies suggest aberrations that exist in human adolescent brain structure and function before initiating heavy substance use are predictive of future substance use, while subsequent alcohol use is related to worsening brain function. The second section reviews the adolescent animal literature, suggesting behavioral and preexisting neurobiological factors might explain heavy alcohol use in adolescents. The third section reviews neurocognitive and neuroimaging findings from human older adults, which suggest that acute alcohol use in aged populations is related to worse cognitive functioning and aberrations in neural response patterns that differ from younger adults. Finally, the last section describes recent findings in aged rats that provide the beginnings of an animal model to study impaired cognitive processing produced by alcohol in the aged population. The effects of alcohol are complex. However, if these effects are to ever be understood, research must integrate age with clinical and preclinical research into a unified framework. We hope this mini-review is a step in that direction.

Gender, family history, comorbid psychiatric and substance use disorders, and age all influence a person’s risk for alcoholism. In addition, these factors interact with alcoholism to influence neurocognitive functioning following detoxification. This article examines these factors and considers how they interact with each other. This complexity reinforces the need for both animal and human studies and suggests multiple factors that may be sensitive to differential prevention, intervention, and treatment efforts. Thus, it is imperative that hypothesis-driven research designs be directed to identifying the relative potency of these factors and their interactions.

Neurocognitive functions were compared in alcoholic, schizophrenic, and dually diagnosed (schizophrenic and alcoholic) patients and community control volunteers. Participants (N = 52, n = 13 in each group) completed a brief battery including two measures of neuropsychological function and two affective measures. The neuropsychological tests included the Trail-Making Test Forms A and B and a face-recognition test. The affective measures included assessment of anxiety and depression. The major objective was to compare the patterns of neurocognitive performance among the four groups. The groups did not differ in mean age (35.37) or years of education (12.46). Compared with the community control and alcoholic groups, the schizophrenic groups reported higher mean depression (12.92 vs. 5.54) and mean state anxiety scores (60.73 vs. 46.04). Control subjects were generally, although not always significantly, superior to the other groups. Contrary to expectations, alcoholic patients were not consistently better than the schizophrenic groups, and dually diagnosed participants were not more impaired than schizophrenic patients without substance abuse histories. Thus, the interaction of schizophrenia and substance abuse did not have an additive effect on neurocognitive performance assessed in this study. More research using this complete four-group design and a larger neurocognitive battery is needed.

Cloninger's Type 1/Type 2 classification scheme was examined in 82 male alcoholics. Only 16% were classified by presence/absence of Type 1/Type 2 symptoms. When age of symptom onset was considered, 75.6% were classified into early (ESO) and late symptom onset (LSO) groups. Relatively few group differences were found: ESOs were younger, had lower SES, began drinking earlier, reported greater frequency of maternal alcoholism and more severe paternal alcoholism, and reported more antisocial behaviors. ESO/LSOs did not differ on neuropsychological performance, although both performed poorer then controls. Differences between these findings and those found with female ESO/LSO alcoholics are discussed and clinical implications considered.

Using a component processes model, the current study examined the cognitive processes of alcoholic and community control subjects engaged in the acquisition of new context-bound (e.g., episodic) information. Of particular interest was whether alcoholics were inferior to controls in the efficiency with which information was acquired and whether there was a gender x group interaction in cognitive efficiency. Alcoholic (n = 16 females ; n = 22 males) and community control (n = 21 females ; n = 21 males) subjects participated in a serial learning task that consisted of three 12-item word lists. Standard administration protocols for serial learning tasks were used. On efficiency measures, there were significant differences between groups [F(1,75) = 8.51, p = 0.005] and sexes [F(1,75) = 4.05, p = 0.048]. There was also a group x sex interaction [F(1,75) = 7.73, p = 0.007]. Duncan multiple-range comparisons revealed alcoholic females to be significantly inferior to control females, but equivalent to male controls and alcoholics. These data are consistent with other studies revealing the sensitivity of cognitive efficiency to alcohol-related effects and extend previous findings to tasks involving episodic learning tasks.

Background Nearly 40% of adults aged 65 and older in the United States consume alcohol. Research in older adults has largely examined potential health effects of a moderate drinking lifestyle. Examination of acute effects in this population is generally lacking. To investigate alcohol-induced alteration of electrophysiological correlates of attention in this population, we employed a covert attentional task. We hypothesized that moderate alcohol administration as well as older age would reduce P3 amplitude and increase latency. We anticipated an interaction such that, relative to their age-matched controls, older adults receiving alcohol would be more affected than their younger counterparts. Methods Participants included healthy older (aged 50 to 67; n = 20; 9 men) and younger (aged 25 to 35; n = 12; 5 men) moderate drinkers. Participants received either a moderate dose of alcohol (breath alcohol concentration ∼50 mg/dl) or a placebo beverage. Following absorption, the task was administered and neurophysiological measures were obtained. P3 amplitude and latency were separately subjected to ANOVA across cue conditions using age and dose as independent variables. Results As predicted, P3 amplitude in older adults was significantly lower than in younger adults across cue conditions. An age by alcohol interaction was detected, revealing that older adults receiving alcohol showed lower P3 amplitudes than any other group. An age effect for P3 latency was found, with older adults having longer latencies than their younger counterparts. A significant age by alcohol interaction for P3 latency was detected, revealing that older adults receiving alcohol displayed delayed P3 latencies relative to older adults receiving placebo. In contrast, younger adults receiving alcohol had reduced latency compared to those receiving placebo, although this effect did not reach significance. Conclusions Results suggest that older adults demonstrated alcohol-related shifts in P3 characteristics during an intentional attention task, whereas younger adults failed to demonstrate this pattern.

This study was conducted to examine the role of childhood behavioral disorders (CBDs) and residual attention deficit disorder (ADDRT) in alcohol-related cognitive dysfunction in male and female subjects. Alcoholic (n = 44 females, 56 males) and control (n = 40 females, 40 males) subjects completed assessments that included measures of CBDs, ADDRT, and cognitive and psychosocial functioning. Cognitive tests were specifically designed to assess efficiency in function. As expected, alcoholics were inferior to controls in their cognitive efficiency [F(1,171) = 10.43, p = 0.0015]. Alcoholics reported more CBDs [F(1,161) = 12.02, p = 0.0007], regardless of sex. They also reported more ADDRT [F(1,173) = 44.12, p = 0.0001] than did controls. There were also sex [F(1,173) = 13.31, p = 0.0004] and group by sex effects [F(1,173) = 3.93, p = 0.05]. Female alcoholics reported more ADDRT symptoms than any other group. Regression equations conducted to clarify the relation between group, sex, CBDs, ADDRT, and cognitive efficiency indicated that the best predictor of cognitive efficiency was group classification (alcoholic versus control). That is, although symptoms of behavioral disorders were reported significantly more frequently by both male and female alcoholic subjects, these symptoms could not account for the cognitive impairment observed in either sex.

The mild generalized dysfunction hypothesis of alcohol abuse's deleterious effects on cognitive processes has gained support from a number of studies in which detoxified alcoholics have a lower mean performance level than peer controls on a variety of neuropsychological tests. This approach might obscure consistent but different patterns of preserved and impaired cognitive performance among subgroups of alcoholics, suggestive of alternative hypotheses. To test this possibility, neuropsychological test data from two large, independent samples of alcoholics (sample 1, n = 143; sample 2, n = 130) and controls (sample 1, n = 97; sample 2, n = 83) were subjected to separate centroid hierarchical cluster analyses. For both samples, the majority of alcoholics (94% and 94%) exhibited a pattern of impaired verbal and nonverbal performance and deficits in memory and perceptual motor skill, with normal motor skill. The alcoholics who did not fit this pattern showed more severe or wide-ranging impairments. These findings indicate that empirical support for the mild generalized dysfunction hypothesis of alcoholics' cognitive deficits is not an artifact of averaging. Language: en

To examine possible influences of premorbid and comorbid factors on the neuropsychological test performance of recently abstinent (3-5 weeks) drug abusers, we studied 24 alcoholics, 23 cocaine abusers, and 22 healthy controls of comparable age and education. Both alcoholics and cocaine abusers performed significantly more poorly than controls on most measures of learning and memory, problem solving and abstraction and perceptual-motor speed, but the groups did not differ on the measure of sustained attention. Correlational analyses revealed no significant relationships between measures of childhood and residual hyperactivity and neuropsychological performance; scores on the Beck Depression Inventory were related only to performance on the Wisconsin Card Sorting Test. The findings indicate that abuse of cocaine or alcohol is associated with deficits on neuropsychological tests which cannot be attributed to specific premorbid or comorbid factors such as depression or childhood or residual attention deficit disorder.

Decrements in verbal memory are commonly reported by detoxified treatment-seeking individuals. Although acute nicotine has been shown to improve attentional performance, its effects on verbal memory in substance abusers have not been addressed. Treatment-seeking alcohol-dependent (ALCs, n = 29; 14 male), illicit-stimulant-dependent (predominantly cocaine; STIMs, n = 25; 15 male), and alcohol- and illicit-stimulant-dependent (ALC/STIMs, n = 50; 35 male) participants with comorbid nicotine dependence were studied. Subjects had been abstinent from their drugs of choice for 41 (±18) days and were in short-term abstinence from tobacco (∼8-10 hours). Subjects received double-blind administration of either transdermal nicotine (high dose: 21/14 mg for men and women, respectively, or low dose: 7 mg) or placebo. The Logical Memory (LM) subtest from the Wechsler Memory Scale-Revised (WMS-R) was used to assess immediate and delayed verbal memory recall. Results indicated that STIMs receiving the high dose of nicotine recalled more words at immediate recall than STIMs who received placebo. Trend level differences were also noted at delayed recall between STIM nicotine and placebo doses. Nicotine failed to impact either recall in alcoholic subgroups. Although not the primary focus, results also revealed differences in the forgetting rates between the groups with the ALC/STIMs demonstrating the steepest forgetting slope. In summary, this study suggests that nicotine effects may be differentially experienced by substance-using subgroups; that nicotine may have a direct effect on memory; and that in considering neurocognitive processes (e.g., encoding vs. retrieval), underlying endpoint indicators (e.g., correct recall) may be critical in predicting outcomes.

The recent proposal to dissolve the National Institute on Alcohol Abuse and Alcoholism and National Institute on Drug Abuse and create a new institute for substance use, abuse, and addiction will require significant effort by the staff of both institutes, the Advisory Councils, and outside experts to overcome complex challenges that could threaten its success. Although integration of the grants portfolios can be achieved, harmonization of goals and policies related to legal use of alcohol versus illegal consumption of drugs will present serious challenges. Consolidating the infrastructure of the two existing institutes would entail avoiding encroachment on grant funding. A new institute for substance use, abuse, and addiction would require an enormous amount of cooperation from other institutes since the portfolios of research on alcohol, tobacco, and other drug abuse should logically be transferred to the new institute. In the near term, a structural reorganization would be less efficient and more costly than the individual institutes are currently. Increasing efficiency and reducing costs over time will necessitate careful strategic planning. Success in this difficult task would be made easier and less costly by first implementing carefully placed building blocks of increasing functional reorganization. The newly created institute should increase opportunities for specialization within disorders of addiction, attract new leadership, and build a novel strategic plan that will energize scientists and staff and incorporate ideas of stakeholders to advance the public good in preventing and treating alcohol, tobacco, and all addictions. Attention must be paid to the devil in the details.

Current literature suggests that acute nicotine administration provides a compensatory mechanism by which alcoholics might alleviate attentional deficits. In contrast, chronic smoking is increasingly recognized as negatively affecting neurobehavioral integrity. These opposing effects have not been simultaneously examined. Thus, we sought to a) extend previous work by exploring the effects of acute nicotine effects on vigilance components of attention and replicate previous findings suggesting that treatment-seeking alcoholics experience benefit to a greater extent than do other groups; and b) to examine the impact of chronic smoking on these tasks and across subgroups.Substance abusing participants (N=86) were recruited and subgrouped on the basis of dependency criteria as either alcoholics, alcoholics with co-morbid stimulant dependence, or stimulant dependent individuals. Groups of cigarette-smoking (N=17) and non-smoking (N=22) community controls were recruited as comparison groups. Smoking subjects were assigned a placebo, low, or high dose nicotine patch in a double-blind placebo controlled fashion. Non-smoking controls were administered either a placebo or low dose. Testing occurred after dose stabilization.General linear models indicated greater sensitivity to acute nicotine administration among alcoholics than other groups when controlling for the effect of intensity of smoking history, as reflected by pack-years. Pack-years correlated negatively with performance measures in alcoholics but not stimulant abusing subgroups or smoking controls. Finally, regression analyses demonstrated that pack-years predicted poorer performance only for the alcoholic subgroup.These results support previous work finding a compensatory effect of acute nicotine administration on attentional performance in alcoholics and reinforce the consideration of recent nicotine use as a confound in neurocognitive studies of alcoholics. Of particular interest is the finding that smoking history as reflected in pack-years predicted poorer performance, but only among alcoholics. Further systematic study of these opposing effects among alcoholics and other groups using a broader array of tasks is needed.

The decades-old debate about the optimum organizational structure of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and National Institute on Drug Abuse (NIDA) has reached a crescendo with the recent deliberations of the Scientific Management Review Board, which, despite the lack of a crisis, proposed a structural reorganization that would dissolve the two institutes and create a new institute for substance use, abuse, and addiction, in hope of new scientific and public health advances (Collins, 2010). For a new institute to succeed, a multitude of potential challenges need to be negotiated effectively. Notably, new funds will be needed, even in the current difficult national economic climate, to coalesce the infrastructure of NIAAA and NIDA and incorporate addiction-related research currently conducted by other National Institutes of Health (NIH) institutes. To succeed, the new institute would also require an enormous amount of cooperation from other institutes as the portfolios of research in the areas of alcohol, tobacco, and other drug abuse are transferred to it. Thus, in the near term, a structural reorganization would be less efficient and more costly than the individual institutes are currently. Only with careful strategic planning would it be possible to increase efficiency and reduce costs over time. If the process moves forward smoothly, Dr. Francis Collins, NIH Director, has proposed launching the new entity by October 2012. However, if reorganization is to be unveiled slowly and progressively over the next 2 years with gradual integration of two disparate cultures, another approach could be to intensify and strengthen current collaborations through an NIAAA–NIDA Joint Task Force. The NIH Director could determine a specific percentage of resources from each institute to be committed for collaborative research agendas modeled on the same governance and operational structures currently used by the Neuroscience Blueprint and the Basic Behavioral Research Operations Network. In this way, a clearer road map could be developed that provides for due diligence and critical information gathering to understand the practical needs and challenges of developing an informed organizational approach. Predetermined milestones can be used to evaluate progress and adjust course as needed to ensure a viable plan that incorporates all relevant research. Importantly, although there are common mechanisms mediating the rewarding effects of alcohol and other drugs, distinctions also exist. For example, there is considerable evidence that substances of abuse express their addictive potential, in part, through similar brain circuits, most notably the cortico-mesolimbic dopamine circuit (Johnson, 2010). Nevertheless, despite decades of research, the approach of direct antagonism of cortico-mesolimbic dopamine receptors has not yet yielded efficacious medicines to treat addiction. In fact, pharmacological differences between alcohol and other drugs might hold the key to successful medications development for these different disorders. Thus, rather than focusing on a narrow conceptualization of the addiction circuitry, the new institute should seek diligently to understand how diverse and complex mechanisms contribute to abuse of alcohol and other substances. Nutt et al. (2010) noted that in the United Kingdom, the overall harm to both the individual and others was greatest for alcohol. Alcohol is the addictive substance that is most commonly used by the United States population, with a prevalence of about 65.4% (Table ​(Table1;1; Grant et al., 2011). Addiction to alcohol is, however, far less common, as a proportion of its use, than addiction to many other drugs of abuse. Nonetheless, Rehm et al. (2009) found that the total economic cost of alcohol abuse in the United States in 1998 was nearly $235 billion (adjusted to 2007 international dollars). The harm to society attributed to alcohol consumption often results from alcohol use disorders that include the inappropriate use of alcohol in situations such as before driving or by underage drinkers, rather than addiction to alcohol. A 2010 fact sheet from the Centers for Disease Control and Prevention reports that during 2000–2004, annual health-related economic losses in the United States due to cigarette smoking were estimated at $193 billion ($96 billion in direct medical costs plus $97 billion in lost productivity). Data from the Office of National Drug Control Policy in 2002 showed that the total economic impact in the United States of all illicit drugs combined was about $200 billion, but 60% of that amount was related to incarceration. Hence, the new institute should focus on (1) alcohol use disorders, including alcoholism, (2) tobacco addiction, and (3) illicit drug addictions as a group, in that order. Table 1 Past-year liability for various types of substance dependence, based on 200 million United States adults ≥18 years of age (2001–2002). Careful thought is needed to determine the programmatic components of the new institute. Fragmentation or segregation of ongoing programs such as those involving fetal alcohol spectrum disorders, alcoholic liver disease, or prevention and treatment does not serve the public good and must be avoided. Tobacco research should be a major focus of a new institute and not the sole purview of the National Cancer Institute (NCI) or National Heart, Lung and Blood Institute (NHLBI) so that the prevention and treatment of tobacco addiction is not subsumed by the study of its general health consequences. Indeed, tobacco is, by far, the most addictive of all the drugs (Table ​(Table1),1), followed by heroin and crack cocaine (percentage of past-year users with past-year dependence; Grant et al., 2011). It would certainly be unreasonable to expect scientists within NCI and NHLBI to be experts on addiction, and for many, such specialist training would be lacking. Comorbid alcohol and drug addiction is at the interface of a collaborative scientific enterprise and, in the future, should receive appropriate funding and opportunities for development. Because of the strong interrelationship between alcohol and tobacco use, abuse, and addiction, a new institute would not be well grounded if it did not incorporate both. It is intriguing to consider whether parts of the National Institute of Mental Health should also be included within this new institute to address prevention and treatment of comorbid substance use disorder and mental illness, as well as some behavioral addictive disorders. These deliberations have identified an opportunity to increase collaboration and broaden the thinking and vision of scientists to promote public health. If a new institute for substance use, abuse, and addiction is established, new leadership that is credible and respected by both the alcohol and drug addiction communities is needed to drive the new institute, inspire new vistas, build more intensive collaborations, and motivate staff to do what they have always done best – serve the public good. Otherwise, the path toward a structural reorganization of a new institute that meets some of the promise proposed for it, even with careful and strategic planning, could become a famished road (Okri, 1992) that simply consumes people and resources with no tangible gains. Success in this difficult task would be made easier and less costly by first implementing carefully placed building blocks of increasing functional reorganization. Indeed, for the structural reorganization of a new institute to succeed, attention needs to be paid to the devil in the details.

In an attempt to clarify the nature of the problem-solving deficits exhibited by chronic alcoholics, the California Card Sorting Test (CCST) and other measures of abstraction and problem solving were administered to 23 alcoholics and 16 nonalcoholic controls, equated for age, education and vocabulary. On the CCST, the alcoholics exhibited three types of deficits which appeared to be relatively independent. First, the alcoholics generated and identified fewer correct concepts than controls, although they executed concepts normally when cued by the examiner. Second, the alcoholics made more perseverative sorting responses and perseverative verbal explanations for their sorting behavior than did controls. Third, alcoholics provided less complete verbal explanations of the concepts that they correctly generated or identified. The differential importance of these factors on various measures of problem solving may help to explain the varied patterns of inefficient problem solving exhibited by alcoholics.

Visual-spatial learning in young adult nonalcoholic men and women with (FH+) and those without (FH-) a family history of alcoholism was investigated using nonsense shapes of high and low verbal association value. Four groups of FH+ and FH- men and women, 16 subjects in each group, were tested. The male FH+ group required significantly more trials to reach learning criterion and made more errors than the male FH- group; the FH effect was not significant in females although similar trends were present. Women exhibited significantly poorer visual-spatial learning compared to the men. High compared to low verbal association shapes were learned in fewer trials with fewer errors by all groups. There were no significant FH by verbal association interactions, indicating that the impaired visual-spatial learning in the FH+ men could not be ascribed to the meaningfulness dimension of the nonsense shapes. These results suggest that the impaired visual-spatial learning found in adult children of alcoholics (ACOAs) might be due in part to premorbid cognitive deficits.

Chronic alcoholics demonstrate cognitive deficits when compared with nonalcoholics. These deficits are typically attributed to the direct effects of ethanol and its metabolites on the central nervous system (CNS). There are other factors, however, that differentiate alcoholics from controls, such as personality or behavioral characteristics. These factors may affect neuropsychological performance and thus alter the interpretation of alcoholic cognitive deficits as resulting solely from alcohol's toxic effects. To investigate this question, male and female alcoholics and peer nonalcoholic controls were compared on personality, behavioral, and cognitive measures. Alcoholics had greater numbers of antisocial behaviors, childhood behavioral disorder symptoms (CBD), and affective symptomatology, and had poorer neuropsychological performance than controls. The three personality and behavioral factors were positively intercorrelated with each other, and were negatively related to cognitive performance. The CBD factor proved to be the most consistent predictor of neuropsychological performance for both alcoholics and controls, and males and females. While the behavioral factors differentiated alcoholics from controls and predicted performance, significant differences between the groups in cognitive performance still remained when these factors were taken into account.

Chronic alcohol abuse is associated with a wide range of cognitive deficits, including impairment in perceptual-motor skills, visual-spatial functions, learning/memory, and abstraction and problem solving. In Korsakoff patients, despite normal IQs, these deficits are pronounced, especially in episodic memory and new learning. Procedural memory (learning of simple, repetitive skills), however, is relatively intact. New evidence suggests that orbitobasal frontal lobe dysfunction in addition to diencephalic lesions contributes to the deficits found in Korsakoff patients. A genetically controlled thiamine deficiency has been hypothesized to account for the development of the Wernicke-Korsakoff disorder. Prognosis for the recovery from Korsakoff's syndrome is poor, although evidence suggests that these patients should be able to learn simple repetitive tasks involving procedural memory. In non-Korsakoff sober alcoholics the aforementioned cognitive deficits are less severe but nonetheless significant. These performance deficits are not easily accounted for by the current neuropsychologic hypotheses, although neuroanatomic changes frequently accompany chronic alcohol abuse. Family history, although a significant predictor of later alcoholism, does not appear to play a major role in determining alcohol-related cognitive deficits. A history of childhood behavioral disorders is associated with greater cognitive impairment. The means by which its effect is expressed, however, is unclear. The most parsimonious explanation focuses on the possibility that these disorders are the manifestation of inherited temperament traits that increase vulnerability to a variety of negative outcomes including antisocial personality and alcoholism. Significant recovery of cognitive function can occur but may be contingent on factors such as age and continued abstinence.

Aims: The effect of transdermal nicotine on stress reactivity was investigated in currently smoking, detoxified, substance-dependent individuals (65% alcohol dependent, n = 51; 31 male) following a psychosocial stressor. Methods: Using a randomized, double-blind, placebo-controlled design, subjects were assigned to receive either active transdermal nicotine (low or high dose) or placebo. Six hours following nicotine administration, subjects performed a laboratory psychosocial stressor consisting of two 4-min public-speaking sessions. Results: Consistent with prior reports, substance-dependent individuals displayed a blunted stress response. However, a review of the cortisol distribution data encouraged additional analyses. Notably, a significant minority of the substance-dependent individuals (33%) demonstrated elevated poststress cortisol levels. This group of responders was more likely to be alcohol dependent and to have received the high dose of nicotine [χ2(2) = 32, P

This study was conducted to determine whether alcoholic and control subjects respond differently to manipulations that either enhance personal involvement (PI) or reduce negative affect (R, relaxation) on tests of neuropsychological function. In Phase 1, 48 male alcoholics and 36 male control subjects completed neuropsychological tasks under standard instructional sets. In Phase 2, subjects completed equivalent forms of these tests under one of three randomly assigned conditions; the PI condition in which subjects were encouraged to identify specific ways of improving their performance, the R condition in which subjects participated in a short relaxation exercise designed to reduce anxiety, or a No Treatment (NT) condition in which no attempt to manipulate the subjects' involvement or affect was made. Alcoholics were inferior to controls in both Phase 1 and Phase 2 [Fs (1,82) > 5.03, ps < 0.03]. The experimental manipulation differentially affected measures of negative affect and effort in the predicted direction. There were no group x condition interactions. Alcoholic and control subjects responded comparably to the experimental manipulations. This investigation, in combination with others using related manipulations, reinforces the hypothesis that alcohol-related cognitives dysfunction reflects an underlying deficit in brain states.

Verbal memory was evaluated in groups of 36 community controls, 50 pseudoneurological controls, 50 alcoholics, and 50 brain-damaged patients. All participants were men between the ages of 22-61. Groups did not differ in age or educational levels (F < 1). Groups were compared on their performance on the Luria Memory Words Test. Dependent variables included the number of correct words over learning trials, the trial of best performance, and the number of words recalled at three delayed trials (2, 8, and 30 min after learning). Brain-damaged subjects were inferior to community controls on all measures. Pseudoneurological controls were inferior to community controls on delayed recall, but were equivalent on measures of learning. Alcoholics were inferior to controls on measures of learning but did not differ on measures of recall. Implications regarding the underlying deficit in alcoholics' verbal memory, the use and interpretation of the Luria Memory Words test, and the use of pseudoneurological patients as controls are discussed.

The sensitivity of the Wechsler Memory Scale with Russell's Revision to the effects of IQ and brain damage was assessed in groups of brain-damaged (N = 64) and nonbrain-damaged (N = 64) subjects. Brain-damaged and nonbrain-damaged subjects were divided into subgroups equated on age and IQ for each of three IQ ranges (80–89, 90–99, 100–109). Some Wechsler Memory Scale subtests were affected only by IQ, others were affected by IQ and brain-damage status, and still others were affected only by brain-damage status. Measures of recall efficiency were most useful in discriminating brain-damaged and nonbrain-damaged subjects. We concluded that specific Wechsler Memory Scale subtests are useful in assessing memory deficits in brain-damaged patients.

OBJECTIVES It is widely recognized that individuals with alcohol or illicit substance abuse disorders often smoke cigarettes. However, few studies have examined the direct effects of nicotine among substance abuse subgroups. The current study examined patterns of electroencephalographic (EEG) activity in alcohol-dependent (AD), stimulant-dependent (StimD), alcohol- and stimulant-dependent (ASD) participants, as well as community controls (CC). All participants were regular smokers. METHODS After overnight nicotine abstinence, subjects were administered either a high (14 or 21 mg) or low (7mg) dose transdermal nicotine patch. EEG data were collected during a 2 minute eyes open and 5 minute eyes closed baseline recording session, which occurred as part of a larger study of brain electrophysiology. RESULTS The most interesting finding was a differential pattern of nicotine dose effects by group. EEGs of Controls and ASD participants did not distinguish between high and low nicotine doses; whereas, nicotine administration in the AD and StimD groups resulted in opposite findings across a range of spectral bands. CONCLUSIONS Although further research is warranted, these results may have implications for the study of smoking cessation and attentional functioning among substance abusers in treatment. These data suggest that nicotine-related changes in neurophysiology may be associated with specific brain areas and/or specific drug histories and reinforce the need for caution in generalizing among such groups.

Objective: Perceived impairment and psychomotor performance following acute alcohol administration in older (ages 50-74, n = 42; 22 male) and younger (ages 25-35, n = 26; 12 male) adults were investigated in this study. Method: Double-blind, placebo-controlled alcohol administration techniques were designed to produce peak levels of breath alcohol concentration consistent with an episode of social drinking (40 mg/100 ml). Behavioral measures (Trail Making Test, Forms A and B), as well as measures of self-reported perceived intoxication and impairment, were administered on the ascending and descending limbs at common time points after beverage ingestion. Results: Results indicated that psychomotor performance differences did not parallel self-reported levels of perceived impairment. Relative to younger adults, older adults exhibited performance deficits on the ascending limb while simultaneously reporting less perceived impairment. Conversely, on the descending limb, older adults who received alcohol reported more perceived impairment than did those who received placebo, although psychomotor performance between these two groups of older drinkers did not differ. For younger participants, a moderate dose of alcohol facilitated performance on the ascending limb; however, these differences were not reflected on the descending limb. Conclusions: These results reinforce the common knowledge that self-reported measures may not provide an accurate reflection of performance outcomes and, importantly, that older adults may be impaired even under a moderate dose of alcohol, although they may not be aware (i.e., report) of this impairment. Language: en

Verbal fluency deficits in female alcoholics (n = 48) were investigated using Thurstone's Word Fluency Test (TWFT) and a category fluency test. Overall, alcoholics performed less well than did controls (n = 36). Simple effects indicate that although controls performed less well on category fluency than on the TWFT, alcoholics did not differ between the two tests. Simple effects also show that controls' performance was superior to that of alcoholics on the category fluency test, but the groups did not differ on the TWFT. The pattern of results suggests that the process of shifting rapidly between categories is more difficult than perusing a mental lexicon. Correlations between these tasks and other tests of cognitive functioning suggest that the TWFT and the category fluency test may be assessing different types of verbal fluency.

This study investigated whether male and female alcoholics and controls differed in their ability to solve an ecologically valid measure of abstraction. Ninety-one alcoholics (39 females, 52 males) and 61 community controls (36 females, 26 males) completed a battery of abstraction tasks including a Piagetian-type task, the Plant Task. The Plant Task demands that subjects predict the outcome of an unseen plant given a specific treatment regime. No group differences in the ability to correctly predict the unseen plant's outcome were obtained. Alcoholics were significantly poorer than controls in isolating the relevant variable (chi 2 (1) = 8.24, p = 0.004). There were no sex differences in the ability to isolate the relevant variable. However, there was a sex effect in the number of irrelevant explanations (chi 2 (3) = 15.58, p = 0.001) with females producing more than males and female alcoholics more than any of the other three cells. These data suggest that (1) alcoholics may exhibit subtle abstraction deficits most readily observed in tasks examining process as opposed to final performance, (2) males and females differ in their response patterns regarding irrelevant material, and (3) further empirical study of the Plant Task may support its use in experimental and clinical settings.

To assess its construct validity and application, Cloninger's Tridimensional Personality Questionnaire (TPQ) was administered to 267 inpatient substance abusers. One hundred seventy-two of the patients were alcoholic, 47 abused stimulants, and 48 abused other drugs, primarily benzodiazepines, marijuana, or were polysubstance abusers. Of the sample 33.8% were female. Analyses were conducted to (1) determine whether TPQ scores could be used to classify alcoholics as either Cloninger Type I or Type II; (2) examine the intercorrelations of TPQ scales and identify differences in these patterns due to drug of choice; (3) replicate previously obtained gender differences on the TPQ. The results indicate that (1) TPQ scores did not classify the alcoholics into the expected frequencies for Type I and Type II; (2) the scales were not independent and did not give rise to any differences among drug user groups, but (3) did confirm previously reported gender differences. These results indicate that Cloninger's model and the TPQ must be subjected to careful empirical study prior to their widespread acceptance.

A short self-report instrument that could predict neuropsychological impairment in at-risk patients would be advantageous to clinicians treating alcoholics. Seventy-three Veterans Administration alcoholics and 36 control subjects were administered a 50-item self-report symptom checklist, the Neuronpsychological Impairment Scale (NIS); psychological measures of anxiety and depression; and a battery of neuropsychological tests known to be sensitive to brain dysfunction

s / Drug and Alcohol Dependence 146 (2015) e118–e201 e177 increases in SOWS and OOWS scores (P

Prosthetic mesh reinforcement is now routine in the management of inguinal hernia but can cause considerable pain and stiffness around the groin. The aim of this study was to compare the outcome after laparoscopic TEP inguinal repair using new lightweight or traditional heavyweight mesh performed in a single unit. Between November 2004 and March 2005, 113 patients underwent laparoscopic TEP inguinal repair using either lightweight (28 g/m(2)) or heavyweight (85 g/m(2)) mesh. Follow-up data was obtained using case note review and telephone-based questionnaire in April 2005. Follow-up information was obtained for 93 (83%) out of 113 patients. There was no difference between the two groups in the incidence of pain/discomfort at mean 3-month follow-up (45 vs 41%, Mann-Whitney U, P=0.641). However, there was a significant inverse correlation between the length of time since operation and severity of pain/discomfort in the lightweight group (P=0.001, Pearson test), suggesting a faster speed of recovery with lightweight mesh. Laparoscopic TEP inguinal hernia repair with lightweight mesh yields promising early results. Whilst there was no significant difference in pain or recurrence in the short term, post-operative pain scores improved earlier in patients with lightweight mesh compared to heavyweight mesh. This merits further study, with larger cohorts and longer follow-up, to determine the benefits of lightweight mesh.

Background The role of liver function tests (LFTs) in evaluating common bile duct (CBD) stones in patients with cholelithiasis has been studied widely. However, it is not clear whether these predictive models are useful in inflammatory gallstone disease. Methods A review was undertaken of 385 consecutive patients admitted as an emergency for acute calculous gallbladder disease. The diagnosis of calculous cholecystitis was confirmed by ultrasonography or histological confirmation of acute or chronic inflammation of the gallbladder. Patients with obvious jaundice, defined as a bilirubin level above 80 µmol/l, and gallstone pancreatitis were excluded. Results Some 216 patients met the inclusion criteria, of whom 28 (13·0 per cent) were found to have CBD stones. LFT results were not significantly different in patients with chronic, acute or complicated acute cholecystitis. Using several cut-off levels, γ-glutamyl transpeptidase (GGT) had the highest specificity, positive predictive value and negative predictive value, comparable to a scoring system that combined all LFTs. Bilirubin was the least specific and predictive. A cut-off point for GGT at 90 units/l produced a sensitivity of 86 per cent (24 of 28), specificity of 74·5 per cent (140 of 188), and positive and negative predictive values of 33 per cent (24 of 72) and 97·2 per cent (140 of 144) respectively. This represented a one in three chance of CBD stones when the GGT level was above 90 units/l and a one in 30 chance when the level was less than 90 units/l. Conclusion Selection criteria based on GGT can be used in acute calculous cholecystitis to identify high-risk patients who would benefit most from further imaging to exclude choledocholithiasis.

Background This study evaluated the role of laparoscopic surgery in the early management of acute gallbladder disease in a single large UK teaching hospital. Methods Details of all emergency admissions for acute gallbladder disease from January 2000 to December 2001 were identified and additional information from the hospital records was reviewed retrospectively. Results Three hundred and eighty-five patients with gallstone disease (243 acute biliary pain, 142 acute cholecystitis) and 15 with acalculous disease were identified. The conversion rate was higher during early laparoscopic surgery for acute calculous cholecystitis than in operations for acute biliary pain (19 versus 4 per cent; P = 0·002). In patients with acute calculous cholecystitis the conversion rate was significantly lower in operations within 48 h of admission (one of 26) than when surgery was delayed beyond 48 h (14 of 52) or subsequently carried out electively (seven of 21) (P = 0·014). Elective surgery for previous acute cholecystitis was associated with a higher conversion rate (seven of 21 patients) than elective surgery for biliary pain (three of 65) (P = 0·002). Conclusion Laparoscopic cholecystectomy for acute calculous cholecystitis should be performed, where possible, within the first 48 h of admission.

The bombing of the Alfred P. Murrah Federal Office Building in Oklahoma City was the most devastating terrorist activity that has occurred in America. Prevention of revictimization of persons seriously affected by the bombing was central to the planned response to this tragedy. Coordination and collaboration among local, state, and national agencies promoted effective clinical services provision, research facilitation, and prevention of revictimization. Information gathered from this cooperative effort will contribute to the effort to minimize the potential for such tragedies in the future as well as help to develop prevention and intervention strategies to reduce the effects when the next such disaster occurs.

Introduction: Patients with lower abdominal scars are generally excluded from laparoscopic hernia repair due to the perceived technical difficulty and risk of visceral injury. This study examines the outcome of a series of patients who underwent totally extraperitoneal (TEP) inguinal hernia repair despite previous lower abdominal surgery. Methods: Retrospective review of 47 consecutive patients who underwent TEP inguinal hernia repair in the presence of lower abdominal scars between 1993 and 2002. Results: Thirty-five unilateral and 12 bilateral TEP hernia repairs were performed in the presence of 20 appendicectomy, 10 lower midline, 18 suprapubic and 5 paramedian incisions. Two cases were converted to open repair. There were no major complications and no early or late recurrences. Median operating time was 67.5 min and 83% of patients were managed as day cases. Conclusions: Totally extraperitoneal laparoscopic hernia repair can be carried out safely in the presence of scars from previous lower abdominal surgery.

Substance abuse treatment programs have long contended that any post-treatment alcohol use is indicative of relapse. Recent studies, however, suggest more inclusive definitions. Zweben and Cisler (1996, 1999) consider both the drinking quantity and negative drinking consequences. Their proposed cutoffs integrate the 1995 NIAAA guidelines for sensible and high risk drinking levels with the objective assessment of drinking-related consequences into the definition of relapse. Our study applied this model to a group of detoxified alcoholics in a post-treatment followup project. We asked if: (1) Zweben and Cisler's drinking categories could be found in our sample; (2) whether subgroups defined by post-treatment drinking patterns differed with respect to their pre-treatment alcohol consumption levels, years of alcoholic drinking and drinking related problems; and (3) whether post-treatment drinking patterns were associated with differential psychosocial functioning at followup. Thirteen percent of the total sample (N=61) was found to meet Zweben and Cisler's moderate drinking category; 34% were abstinent, 27% heavy drinkers and 13 participants (26%) were unclassifiable. At treatment completion (T1), those who became moderate drinkers reported higher levels of self-confidence, but were otherwise similar to both abstainers and heavy drinkers. At followup (T2), approximately 1 year after initial testing (T1), groups differed on measures of emotional discharge, avoidance and logical coping skills and information seeking, suggesting a possible association between post-treatment drinking patterns and psychosocial functioning.

The 1995 Oklahoma City bombing killed 168 people, including 19 children, and injured hundreds more. Children were a major focus of concern in the mental health response. Most services for them were delivered in the Oklahoma City Public Schools where approximately 40,000 students were enrolled at the time of the explosion. Middle and high school students in the Oklahoma City Public Schools completed a clinical assessment 7 weeks after the explosion. The responses of 2720 students were analyzed to explore predictors of posttraumatic stress symptomatology, functioning, and treatment contact. Posttraumatic stress symptomatology was associated with initial reaction to the incident and to bomb-related television exposure. Functional difficulty was associated with initial reaction and posttraumatic stress symptomatology. Only 5% of the students surveyed had received counseling. There was no relationship between posttraumatic stress symptomatology and counseling contact for students with the highest levels of posttraumatic stress. Implications for school-based services are discussed.

Background: Although previous studies have found stimulant (i.e., cocaine, methamphetamine) abusers and alcoholics to have neuropsychological deficits, research examining which cognitive abilities are most affected by concurrent exposure to these substances is lacking. To address this issue, detoxified men and women who met criteria for dependence of (a) alcohol only (ALC) (n= 15); (b) stimulants only (STIM) (n= 15); and (c) both alcohol and stimulants (A/STIM) (n= 15) were compared with age- and education-matched community controls (n= 15). Methods: Tasks that measured visual spatial skills, problem-solving and abstraction, short-term memory, cognitive flexibility, and gross motor speed were administered to participants. For each test, both speed and accuracy were assessed and an efficiency ratio (accuracy/time) was derived. Based on an average of these efficiency ratios, an overall performance index of cognitive efficiency was obtained. Results: Overall, controls performed more efficiently than all other groups. However, they were statistically significantly better only in relation to the A/STIM and STIM groups (p < 0.01). Individual comparisons revealed that the ALC group performed significantly better than the STIM group, although the ALC group did not differ from either the control or A/STIM groups (p≤ 0.05). This pattern of results was relatively consistent across the individual subtests of problem-solving/abstraction, short-term memory, and cognitive flexibility. Conclusions: As expected, substance abuse was associated with cognitive inefficiency. More importantly, these findings suggest that the cognitive effects of chronic stimulant abuse are not additive with those of alcohol abuse. That is, singly addicted stimulant abusers demonstrated similar or greater neurocognitive impairments than individuals who abuse alcohol and stimulants concurrently. The reason for this pattern is speculative but may be attributed to alcohol's opposing actions on cerebrovascular effects brought on by stimulant abuse.

The current study examined electrophysiological measures of cognitive efficiency in alcoholics and controls using a negative priming paradigm derived from DeSchepper and Treisman (J. Exp. Psychol. Learn. Mem. Cog. 22 (1996) 27). In this task, sets of novel shapes were presented: Two overlapping green and red shapes on the left and a single white shape on the right. Participants were instructed to ignore the red shape, but to determine whether the green shape was the same as or different from the white shape. On primed trials, previously red (to be ignored; i.e., irrelevant) shapes became green (relevant) shapes in a second component of the task. Participants who were capable of ignoring irrelevant stimuli were expected to experience more difficulty in the primed condition. Therefore, we predicted that, if alcohol-related impairment in cognitive efficiency is due to inability to respond “appropriately” (i.e., ignore irrelevant stimuli), alcoholics would experience less negative priming than normal controls. Both amplitude and latency of the P300 component of the event-related potential were measured in response to each trial condition. Using a 2×2 (group×condition) ANOVA with repeated conditions, a significant pattern of group×condition interactions was observed at right frontal, F4 ( p =.05) and central parietal, Pz ( p =.03) electrode sites on measures of P300 amplitude. A significant group×condition latency interaction was observed at the central parietal electrode, Pz ( p =.006). Overall, controls exhibited increased P300 amplitude and latency in response to negatively primed trials. As predicted, alcoholics did not demonstrate this pattern, a finding consistent with alcohol-related cognitive inefficiency.