HOMOCYSTEINE LEVELS IN PATIENTS CLASSIFIED ACCORDING TO LESCH'S TYPOLOGY

Multidimensional alcoholism typologies: could they guide clinical practice? Results from a 3-month prospective study

OBJECTIVE

The current nosological classifications may describe a syndrome of "alcoholism" that is too heterogeneous to produce prognostic models for clinical management. Multidimensional alcoholism typologies (ATs) could represent a valuable paradigm in the search for targeted treatment. The main goal of this study was to evaluate the clinical implications of 3 empirically-validated ATs, focusing on various measures of clinical performance.

METHOD

This was a 3-month naturalistic study in which drinking status, and participation in the clinical protocol and group psychotherapy were recorded and used as indicators of treatment performance. The clinical profiles of the subtypes were also compared and graphically presented. Alcohol-dependent outpatients were classified according to the Cloninger, Lesch, and NETER typologies.

RESULTS

The results showed that the type II (Cloninger), type IV (Lesch), and sociopathic and addictopathic (NETER) subgroups showed a worse outcome in terms of abstinence rates and clinical healthcare resource use.

CONCLUSIONS

Our findings point to the need to differentiate multidimensional alcoholism subtypes before planning the clinical management of alcohol use disorders.

Ethanol induced adaptations in 5-HT2c receptor signaling in the bed nucleus of the stria terminalis: implications for anxiety during ethanol withdrawal

One of the hallmarks of alcohol dependence is the presence of a withdrawal syndrome during abstinence, which manifests as physical craving for alcohol accompanied by subjective feelings of anxiety. Using a model of chronic intermittent ethanol (CIE) vapor in mice, we investigated the role of serotonin2c receptor (5HT2c-R) signaling in the BNST as a neural substrate underlying ethanol-induced anxiety during withdrawal. Mice were subjected to a 5-day CIE regimen of 16 h of ethanol vapor exposure followed by an 8 h "withdrawal" period between exposures. After the 5th and final exposure, mice were withdrawn for 24 h or 1 week before experiments began. Anxiety-like behavior was assessed in the social approach, light dark, and open field tests with mice showing deficits in social, but not general anxiety-like behavior that was alleviated by pretreatment with the 5HT2c-R antagonist SB 242,084 (3 mg/kg, i.p.) 24 h and 1 week post-CIE. Using immunohistochemistry and whole cell patch clamp electrophysiology, we also found that CIE increased FOS-IR and enhanced neuronal excitability in the ventral BNST (vBNST) 24 h into withdrawal in a 5HT2c-R dependent manner. This enhanced excitability persisted for 1 week post-CIE. We also found that mCPP, a 5HT2c/b agonist, induced a more robust depolarization in cells of the vBNST in CIE mice, confirming that 5HT2c-R signaling is upregulated in the vBNST following CIE. Taken together, these results suggest that CIE upregulates 5HT2c-R signaling in the vBNST, leading to increased excitability. This enhanced excitability of the vBNST may drive increased anxiety-like behavior during ethanol withdrawal.

LAT software induced savings on medical costs of alcohol addicts' care--results from a matched-pairs case-control study

Lesch Alcoholism Typology (LAT) is one of the most widely used clinical typologies of alcohol addiction. Study tested whether introduction of LAT software in clinical practice leaded to improved outcomes and reduced costs. Retrospective matched-pairs case-control cost comparison study was conducted at the Regional Addiction Center of the University Clinic in Serbia involving 250 patients during the four-year period. Mean relapse frequency followed by outpatient detoxification was 0.42 ± 0.90 vs. 0.70 ± 1.66 (LAT/non-LAT; p = 0.267). Adding relapses after inpatient treatment total mean-number of relapses per patient was 0.70 ± 1.74 vs. 0.97 ± 1.89 (LAT/non-LAT; p = 0.201). However, these relapse frequency differentials were not statistically significant. Total hospital costs of Psychiatry clinic based non-LAT addicts' care (€ 54,660) were significantly reduced to € 36,569 after initiation of LAT. Mean total cost per patient was reduced almost by half after initiation of LAT based treatment: € 331 ± 381 vs. € 626 ± 795 (LAT/non-LAT; p = 0.001). Mean cost of single psychiatry clinic admission among non-LAT treatment group was € 320 ± 330 (CI 95% 262-378) and among LAT € 197 ± 165 (CI 95% 168-226) (p = 0.019). Mean LAT software induced net savings on psychiatric care costs were € 144 per patient. Total net savings on hospital care including F10 associated somatic co-morbidities amounted to € 295 per patient. More sensitive diagnostic assessment and sub-type specific pharmacotherapy and psychotherapy following implementation of LAT software lead to significant savings on costs of hospital care.

Serbian and Austrian alcohol-dependent patients: a comparison of two samples regarding therapeutically relevant clinical features

AIMS

To support the Serbian Expert Board in setting up reimbursement for modern pharmacotherapeutic support, we compared a Serbian sample of alcohol-dependent patients with an Austrian sample, in order to detect differences that might inhibit the introduction of anti-craving medications in Serbia.

METHODS

One hundred and twenty-seven (116 males) alcohol-dependent patients in Serbia and 136 in Austria (78 males) were enrolled consecutively from January 2011 to March 2012 and were assessed using the Lesch alcoholism typology instrument (LAT).

RESULTS

Age of onset was slightly higher in the Austrian sample (28.5 vs. 30.0; P = 0.10). The Serbian sample showed a higher rate of anxiety disorders than the Austrian sample (89.8 vs. 26.5%, P ≤ 0.0001). Suicidal tendencies, independent of alcohol intake or withdrawal syndrome, were higher in the Austrian sample (1.6 vs. 13.2% P ≤ 0.0001). There was no difference between the two samples in Lesch-Type IV (26 vs 28); there was a slight excess in the Serbian sample of Type I (15 vs. 10). In Austria, significantly more Type II patients (32 vs. 52) had been included, while the Serbian sample comprised significantly more Type III patients.

CONCLUSIONS

Austrian and Serbian patients are quite similar, without any showing any factor that would detract from the potential value of modern anti-craving medications in Serbia. The differences in anxiety disorders might be due to the 1990s war and should be investigated further.

Alcohol and drugs in epilepsy: pathophysiology, presentation, possibilities, and prevention

The potentially serious outcomes from ingestion of and dependence on toxins make this an important topic for epileptologists. We must be aware of the potential for harm from compounds that may be freely available, yet patients may try to conceal their use. Problematic compounds may cause seizures either acutely or on withdrawal: Their use may reduce effectiveness of antiepileptic drugs, or may simply promote and enhance chaotic lifestyles. Any or all of these factors may worsen seizure control or even directly cause seizures. This article highlights the pathophysiology behind provoked seizures, provides clues to diagnosis, and then outlines the steps that clinicians should take to reduce the deleterious effects of toxic compounds.

The impact of temperament in the course of alcohol dependence

AIMS

The aim of this study was to assess the impact of temperamental traits in alcohol dependent patients on the course of illness.

METHODS

The case files of 116 alcohol dependent patients, according to ICD-10 and DSM-IV-TR, were examined retrospectively. All patients were in treatment between 02/08 and 03/09 at the Psychiatric Department of the General Hospital Vienna, either at the alcohol outpatient clinic or the psychiatric ward, which has the treatment focus on alcohol dependence. The brief TEMPS-M auto-questionnaire was used to assess the temperamental distribution. The dimensions of alcohol dependence have been assessed using the Lesch Alcoholism Typology, a computerized structured interview. The potential effect of temperamental scores on various outcomes describing the course of illness is investigated using multi-variable regression models.

RESULTS

Cyclothymic score was the only temperament which significantly influenced the age of onset of alcohol abuse and age of onset of alcohol dependence. Backward selection among temperaments exhibits depressive temperament as most important effect regarding the likelihood of suicide-attempts in the patient's case history and anxious temperament as most important effect regarding having psychiatric treatment focusing on alcohol dependence prior to current in- or outpatient stay.

LIMITATIONS

The sample size of this study is small compared to the number of investigated outcomes and temperaments. Further, a healthy control group, matched for age and gender, was not available for comparison of the temperament sub-scores.

CONCLUSION

Dominant cyclothymic, but also depressive and anxious temperament, seem to be negative predictors for the course of illness in alcohol dependence. Regarding positive long term outcome specific evidence based medical treatment approaches are needed for these patients.

Prevalence of the metabolic syndrome in men and women with alcohol dependence: results from a cross-sectional study during behavioural treatment in a controlled environment

AIMS

Prevalence of metabolic syndrome (MetS) in men and women who use alcohol has been inconsistent in the literature. The aim of this study is to compare the prevalence of MetS in patients with a diagnosis of alcohol dependence who are currently abstinent in a controlled environment, and in control subjects followed in primary care from a similar region in Northern Germany.

DESIGN

Cross-sectional study.

SETTING

In-patient cognitive behavioural therapy.

PARTICIPANTS

One hundred and ninety-seven men and women with alcohol dependence during behavioural treatment in a controlled environment were compared to 1158 subjects from primary care from a similar region in northern Germany.

MEASUREMENTS

We used the American Heart Association/National Heart, Lung and Blood Institute (AHA/NHBLI) criteria to determine the rate of MetS and each single criterion of MetS in both groups.

FINDINGS

The prevalence of MetS was almost twice as high in men and women with alcohol dependence compared to control subjects (30.6% versus 17.0%). With respect to the single criteria, elevations were found for fasting glucose and blood pressure in both genders and for triglycerides in women only. High density lipoprotein (HDL)-cholesterol was higher in men and women with alcohol dependence.

CONCLUSIONS

Our results demonstrate an increased rate of MetS, increased blood pressure and dysregulation of glucose and lipid metabolism in alcohol-dependent patients. Whether high HDL-cholesterol has cardioprotective effects in this context remain doubtful.

Comparison of alcohol-dependent patients at a gastroenterological and a psychiatric ward according to the Lesch alcoholism typology: implications for treatment

AIMS

To assess the clinical and biological status of alcohol-dependent patients admitted to a psychiatric or a gastroenterological ward, assessing and comparing dimensions important for prescribing treatment for withdrawal and relapse prevention.

METHODS

Eighty patients, alcohol-dependent according to international classification of diseases tenth revision and diagnostic and statistical manual, text revised, version IV, admitted to the Vienna General Hospital between January 2005 and  November 2006, were examined, of whom 44 were admitted to the psychiatric ward and 36 to the gastroenterological ward. Dimensions of alcohol dependence were assessed using a computerized structured interview, the Lesch alcoholism typology (LAT). Biological markers and the model for end-stage liver disease (MELD) score defined the severity of alcohol-related physical disturbances.

RESULTS

As might be expected, gastroenterological patients had more advanced physical diseases than psychiatric patients, and affective disorders and suicidal tendencies were significantly commoner among the psychiatric patients. Thus, LAT Type II patients were overrepresented at the gastroenterological ward and LAT Type III patients at the psychiatric ward.

CONCLUSION

The severity of somatic diseases and psychiatric disorders as well as the distribution of the four types according to Lesch differ between alcohol-dependent patients admitted to a psychiatric ward or a gastroenterological ward. Regarding the positive long-term outcome, different evidence-based medical treatment approaches for withdrawal and relapse prevention are needed for these patients.

Non-right-handedness and free serum testosterone levels in detoxified patients with alcohol dependence

AIMS

The influence of testosterone on the extent of hemispheric dominance has been discussed not just during the first two trimesters of pregnancy but also later in life. An increase in free serum testosterone levels has been found during and after the detoxification phase of patients with alcohol dependence.

METHODS

In 250 participants (125 men and 125 women) with alcohol dependence immediately after the direct withdrawal phase (Day 21) and in 250 healthy age- and gender-matched participants, free testosterone in the serum was determined and handedness was assessed as a peripheral marker of central hemispheric dominance.

RESULTS

Patients with alcohol dependence were 2.7-fold (odds ratio, OR: 2.66; 95% confidence interval, CI: 1.62-4.38) and men 4.1-fold (OR: 4.12; 95% CI: 2.44-6.98) more likely to be non-right-handed (NRH). In addition to male gender, non-right-handedness and alcohol dependence contributed statistically significantly to higher serum testosterone levels. Testosterone values of patients with alcohol dependence differed significantly between the four different Lesch subtypes; in particular, participants with alcohol dependence classified according to Lesch subtype IV were found to have significantly higher serum testosterone levels (F = 20.5; P < 0.001) when compared to participants classified according to Lesch subtypes I-III.

CONCLUSIONS

An alteration of hemispheric dominance and thus an exogenously modifiable neuronal plasticity may be demonstrated directly on a population at risk.

Acute benzodiazepine administration induces changes in homocysteine metabolism in young healthy volunteers

PURPOSE

High cortisol plasma concentrations have been shown to be associated with increases in homocysteine levels. Here we studied whether decreases in cortisol concentration, induced by an acute oral dose of a benzodiazepine, could decrease homocysteine, and if changes were similar in both genders.

METHODS

This was a double-blind, cross-over design study of acute oral flunitrazepam (1.2 mg) and placebo in young, healthy, male and female (n=21) volunteers. Blood samples were collected 3 h after ingestion (after peak-plasma concentration of flunitrazepam was reached). Various biochemical parameters were analysed, such as plasma homocysteine, cysteine, folate, vitamins B6, B12, and sexual hormones.

RESULTS

Flunitrazepam reduced cortisol (p=0.0011), cysteine (p=0.014) and homocysteine (p=0.028) concentrations, irrespective of gender. No correlations were found between cortisol and other biochemical markers (all r's<0.03). Concentration of cysteine and homocysteine were negatively correlated with plasma flunitrazepam concentration, suggesting that changes in these amino acids might be related to the metabolism of this benzodiazepine.

CONCLUSION

Acute administration of flunitrazepam decreases plasma homocysteine and cysteine by mechanisms that seem unrelated to changes in cortisol. Given the importance of homocysteine as a marker of life-threatening disorders, the mechanisms involved in the decrease of these amino acids are potential targets for clinical application.

Alcohol withdrawal seizures

The topic of alcohol withdrawal syndrome (AWS), including delirium tremens and especially seizures, is reviewed. From mice and rat studies, it is known that both N-methyl-d-aspartate (NMDA) and gamma-aminobutyric acid (GABA) receptors are involved in AWS. During alcohol intoxication chronic adaptations of NMDA and GABA receptors occur, and during alcohol withdrawal a hyperexcitable state develops. In studies on humans, during intoxication the NMDA receptors are activated and mediate tonic inhibition. In withdrawal, a rebound activation of these receptors occurs. Both GABA-A and GABA-B receptors, especially the alpha2 subunit of GABA-A receptors, are also likely involved. Homocysteine increases with active drinking, and in withdrawal, excitotoxicity likely is induced by a further increase in homocysteine, viewed as a risk factor for AWS and also as a screening tool. The dopamine transporter gene is also associated with AWS. Characteristics involves changes in the ECG, especially an increase in QT interval, and EEG changes, including abnormal quantified EEG, at times periodic lateralized epileptiform discharges, and especially seizures, usually occurring 6-48h after the cessation of drinking. Therapy has emphasized benzodiazepines, mainly diazepam and lorazepam, but more standard antiepileptic drugs, like carbamazepine and topiramate, are also effective and safe.

Herp mRNA expression in patients classified according to Lesch's typology

Chronic alcoholism is associated with hyperhomocysteinemia. Herp (homocysteine-induced endoplasmic reticulum [ER] protein) levels are elevated as a response to ER stress prior to mitochondrial dysfunction and cell death. The Lesch classification system has been applied in many studies and has been found useful. This study was undertaken to assess Herp mRNA expression in actively drinking patients with alcoholism who were classified according to Lesch's typology. Herp mRNA expression levels were measured by quantitative PCR in the blood of 76 male alcoholic patients. Patients were classified according to Lesch's typology (type I-IV). With respect to Lesch's typology, a significant difference in Herp mRNA expression regarding the four subtypes could be shown (F[3,72]=2.83, P=.044). In a logistic regression model (dependent variable Herp dichotomized by a median-split; adjusted for age and homocysteine levels) the subtype II differed statistically significant from the others (odds ratio, 5.75; 95% confidence interval, 2.07-15.98; P=.001). Type II alcoholic patients had a statistically significant higher expression of Herp mRNA due to upregulation of the expression of this neuroprotective cell non-chaperone by toxic effects of ethanol. These findings might explain why type II patients do not express severe withdrawal symptomatology (i.e., withdrawal seizures). These findings may be useful in the understanding and treatment considerations of different subtypes of alcohol dependence.

Protective effect against alcohol dependence of the thermolabile variant of MTHFR

BACKGROUND

Hyperhomocysteinemia is frequently observed in alcohol-dependent subjects, in particularly in those with marked withdrawal symptoms. The common C677T transition on the methylenetetrahydrofolate reductase (MTHFR) gene influences homocysteinemia. Our objective was to study the prevalence of the MTHFR C677T polymorphism in alcohol-dependent subjects and the influence of this polymorphism on symptoms associated with alcoholism.

METHODS

MTHFR C677T polymorphism was determined in 93 control subjects and 242 alcohol-dependent subjects. Serum homocysteine, folate and vitamin B12 levels together with hepatic biological parameters were determined in the control and alcohol-dependent subjects.

RESULTS

Hyperhomocysteinemia is frequently observed in alcohol-dependent subjects, particularly in those with marked withdrawal symptoms. Alcohol-dependent subjects showed a significant decrease in MTHFR 677TT prevalence (9%, 21/242) compared to controls (18%, 17/93) (p<0.02). The relative risk estimated as an odds ratio for alcoholism in subjects with the TT genotype is 0.42 (odd ratio 95% confidence interval, 0.21-0.83). Moreover, drinkers with TT genotype presented lower values for markers of alcohol misuse (p<0.05), better liver function tests, a lower frequency of relapses and no marked withdrawal symptoms as assessed by the Lesch typology.

CONCLUSION

MTHFR 677TT genotype could play a protective role against alcohol dependence. Moreover, when subjects with MTHFR 677TT genotype become dependent to alcohol, they seem to constitute a subgroup of alcoholic patients with a decreased risk for developing neurotoxic withdrawal symptoms and hepatic toxicity.

Genetics of Lesch's typology of alcoholism

It is widely accepted that dopamine and serotonin (5-HT) neurotransmission can be critically involved in the development of alcohol abuse and alcohol dependence. Lesch's typology of alcoholism has been gaining increasing popularity as it qualitatively differentiates patients into different treatment response subgroups. The aim of the present study was to evaluate a possible genetic background of Lesch's typology with special emphasis placed on dopamine- and serotonin-related genes. 122 alcoholics (the mean age: 35+/-9 years) were investigated. According to Lesch's typology, 58 patients were of type I, 36 patients of type II, 11 patients of type III, and 17 patients of type IV. Alcohol drinking and family history was assessed by means of a structured interview, based on the Semi-Structured Assessment for the Genetics of Alcoholism. 150 control subjects without psychiatric disorders were also recruited. The control group was ethnically-, age- and gender-matched to the patients. The DRD2 TaqIA, exon 8, and promoter -141C ins/del polymorphisms as well as COMT Val158Met, 5HTT 44 bp del in promoter, and DAT 40 bp VNTR polymorphisms were detected by means of PCR. No significant differences were observed when the whole group of alcoholics and the controls were compared. Similarly, there were no differences between either the Lesch type I or type II alcoholics and the control subjects. No significant differences were observed between type I and type II alcoholics. Alleles frequencies were not calculated for the Lesch type III and type IV alcoholics since the number of patients was too small. The present results argue against any major role of the investigated polymorphisms in either Lesch type I or type II alcoholism. More comprehensive studies are needed to define the role of the investigated polymorphisms in Lesch type III and type IV alcoholism.

NETER 1 alcoholic 5 subtypes: Validity with Lesch four evolutionary subtypes

Objective. To validate NAT (NETER's alcoholic typology), taking into account the differentiated distribution of the measures used as external criteria in alcohol-dependent sub-groups and its relationship with Lesch's alcoholic typology (LAT). Method. A sample of 133 alcohol-dependent patients integrated in the alcoholism unit of the Psychiatric Service of Santa Maria University Hospital were included in the study. Results and Conclusions. Convergent validity was assured by the agreement between the subtypes of the two typologies (NAT and Lesch), considering the same underlying model of alcoholism development: anxiopathic subtype of NAT and Type II (model of anxiety, alcohol as conflict solution) of Lesch and the tymopathic subtype of NAT and type III (model of depression, alcohol as antidepressant) of Lesch. Discriminant analysis (external criteria) showed significant differences between the subtypes in the following variables: gender; tobacco; beer and whisky consumption; daily average of drinks; clinical conditions such as delirium tremens, alcoholic blackouts and seizures; severity of alcohol-related problems; psychological dimensions such as psychological maturity and extroversion; and suicidal ideation during the alcohol consumption period. A more exhaustive description of alcoholic sub-groups may improve genetic studies of alcoholism and provide the alcoholic patient with an adequate specific therapeutic protocol.

Role of Appetite-Regulating Peptides in Alcohol Craving: An Analysis in Respect to Subtypes and Different Consumption Patterns in Alcoholism

BACKGROUND

A role of appetite-regulating peptides like leptin and ghrelin in the neurobiology of alcohol craving has been proposed by several studies. Aim of this analysis was to search for differences regarding an association between these peptides and alcohol craving with respect to different subtypes and beverage consumption patterns in patients with alcohol dependence.

METHODS

We analyzed a sample of 188 patients at admission for alcohol detoxification regarding leptin and ghrelin (n=117) serum levels. Craving was measured using the Obsessive Compulsive Drinking Scale (OCDS). Patients were classified according to Lesch's typology of alcohol dependence and according to their preferred type of alcoholic beverage (beer, wine, spirits).

RESULTS

Using general linear models to analyze a possible interaction between subtypes and leptin/ghrelin levels with respect to craving, we found a significant positive association for leptin in patients of Lesch's types 1 and 2, and in patients consuming beer or wine. Ghrelin levels showed a significant trend regarding an association with craving in patients of Lesch's type 1. In the other subgroups we found no significant results.

CONCLUSIONS

Our findings show that appetite-regulating peptides may be of special importance regarding alcohol craving in subtypes of patients. This may explicate at least in part previous contradictory findings.

Prolactin serum levels and alcohol craving - an analysis using Lesch's typology

BACKGROUND

Prolactin secretion is closely connected to dopaminergic transmission that is known to play a crucial role in mediating reinforcement and craving in alcoholism.

OBJECTIVES

The study was performed to analyze the association between prolactin serum levels and alcohol craving during withdrawal differentiating alcohol-dependent patients using Lesch's typology.

METHODS

We assessed 115 male patients with the Obsessive Compulsive Drinking Scale at early alcohol withdrawal. In addition, serum was obtained to measure prolactin concentration and the patients were classified according to Lesch's typology into one of four subgroups.

RESULTS

Correlation analysis showed a significant association between prolactin serum levels and the extent of craving in Lesch's type 2 patients (r=0.32, p=0.015; n=57); however, no association was found for any other subgroup. The results were confirmed comparing patients with low and high craving (Mann-Whitney U test: Z=-2.805, p=0.005).

CONCLUSIONS

In patients of Lesch's type 2, who are characterized to suffer from anxiety and to use alcohol because of its anxiolytic effects, prolactin is associated with craving during early alcohol withdrawal.

Lowered DNA methyltransferase (DNMT-3b) mRNA expression is associated with genomic DNA hypermethylation in patients with chronic alcoholism

DNA methyltransferases (DNMTs) are involved within the epigenetic control of DNA methylation processes. Recently, it has been shown that the genomic DNA methylation in patients with alcoholism is increased. In the present controlled study we observed a significant decrease of mRNA expression of DNMT-3a and DNMT-3b when comparing alcoholic patients (n = 59) with healthy controls (n = 66): DNMT-3a (t = -2.38, p = 0.019), DNMT-3b (t = -2.65, p = 0.008). No significant differences were seen for DNMT-1 and Mbd-2 (Methyl-CpG-Binding-Domain protein 2) expression. Additionally, we observed a significant negative correlation between DNMT-3b expression and the blood alcohol concentration (r = -0.45, p = 0.003) which might explain the decrease of DNMT-3b mRNA expression in alcoholic patients. Using a multivariate model we observed that the increase (10%) of genomic DNA methylation in patients with alcoholism was significantly associated with their lowered DNMT-3b mRNA expression (multiple linear regression, p = 0.014). Since methylation of DNA is an important epigenetic factor in regulation of gene expression these findings may have important implications for a possible subsequent derangement of epigenetic control in these patients.

An assessment of the potential value of elevated homocysteine in predicting alcohol-withdrawal seizures

PURPOSE

Higher homocysteine levels were found in actively drinking patients with alcohol dependence. Recent studies have shown that high homocysteine levels are associated with alcohol-withdrawal seizures. The aim of the present study was to calculate the best predictive cutoff value of plasma homocysteine levels in actively drinking alcoholics (n = 88) with first-onset alcohol-withdrawal seizures.

METHODS

The present study included 88 alcohol-dependent patients of whom 18 patients had a first-onset withdrawal seizure. All patients were active drinkers and had an established diagnosis of alcohol dependence, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Sensitivity and specificity were calculated by using every homocysteine plasma level found in the study population as cut-off value. A Bayes theorem was used to calculate positive (PPV) and negative (NPV) predictive values for all cutoff values used.

RESULTS

The highest combined sensitivity and specificity was reached at a homocysteine plasma cutoff value of 23.9 microM. Positive predictive values ranged from 0.23 to 0.745; the maximum was reached at a homocysteine plasma level of 41.7 microM. Negative predictive values ranged from 0.50 to 0.935, with a maximum at a homocysteine plasma level of 15.8 microM.

CONCLUSIONS

Homocysteine levels above this cutoff value on admission are a useful screening tool to identify actively drinking patients at higher risk of alcohol-withdrawal seizures. This pilot study gives further hints that biologic markers may be helpful to predict patients at risk for first-onset alcohol-withdrawal seizures.

GLUTAMIC ACID IN WITHDRAWAL AND WEANING IN PATIENTS CLASSIFIED ACCORDING TO CLONINGER'S AND LESCH'S TYPOLOGIES

AIMS

Though glutamic acid is well known as a working excitatory in the CNS, its impact on the modulation of alcohol withdrawal symptoms and withdrawal fits are not yet clear. The study has been undertaken to examine the levels of glutamic acid in chronic alcohol-dependent patients at different stages of alcohol withdrawal and weaning and to examine any existence of any differences according to Cloninger's and Lesch's typologies.

PATIENTS AND METHODS

One hundred and fifty-nine alcohol-dependent patients were assessed according to Cloninger's and Lesch's typologies and related to abstinence duration, age, and gender. Blood samples were taken for mean corpuscular volume (MCV), gamma-glutamyltransferase (GGT) and glutamic acid, in order to find primarily any differences in glutamic acid according to the typologies, age, abstinence duration, and liver damage.

RESULTS

There was no significant association between Cloninger's and Lesch's typologies. Cloninger's types 1 and 2 had an equal distribution of GGT and duration of abstinence, while Lesch's type I had more patients with high GGT, and more patients who were sober for a maximum of 2 days. Unlike in Lesch's types, glutamic acid levels did not differ according to Cloninger's types, as significantly higher glutamic acid values were found in Lesch's types I and IV. Glutamic acid values did not differ significantly in different age groups.

CONCLUSIONS

Our study findings of varying glutamic acid levels seen in Lesch's typology, higher in types I and IV than in types II and III, are of significant clinical value and can be interpreted differently, as in type I high levels of glutamic acid is seen as a kindling phenomenon, while in type IV elevated levels might be related to either compulsivity of frequent repetition of drinking or withdrawal.

Epigenetic DNA hypermethylation of the HERP gene promoter induces down-regulation of its mRNA expression in patients with alcohol dependence

BACKGROUND

Elevated plasma homocysteine concentrations can influence genomic and gene-specific DNA methylation in peripheral blood cells. The aim of this study was to investigate in patients with alcohol dependence, who show chronically elevated homocysteine levels, whether DNA methylation pattern within the HERP (homocysteine-induced endoplasmic reticulum protein) promoter region and expression of HERP mRNA is altered.

METHODS

The HERP mRNA expression level was measured by quantitative PCR in the blood of 66 male alcoholic patients and 55 nondrinking healthy controls. Epigenetic genomic DNA methylation status and HERP promoter methylation were measured with a nonradioactive elongation assay.

RESULTS

We observed a significant increase (7.6%) in the HERP promoter DNA methylation in patients with alcohol dependence (t test, t = -2.45, p < 0.02) when compared with healthy controls (80.4%, SD 14.5), which was significantly associated with their elevated homocysteine levels (multiple linear regression, p < 0.007). Furthermore, we found a significantly lower HERP mRNA expression in patients with alcohol dependence (t test, -7.61 DeltaCT; SD 1.87, p < 0.001) when compared with healthy controls (-6.04 DeltaCT; SD 2.41). The lowered HERP mRNA expression in alcoholic patients was best explained by the hypermethylation of the regulatory HERP gene promoter (regression analysis, p = 0.004).

CONCLUSIONS

To our knowledge, this is the first study evaluating HERP mRNA expression and its specific gene promoter methylation in alcoholic patients. As hypermethylation of DNA is an important epigenetic factor in the down-regulation of gene expression, and as HERP has been considered to play an essential role within the intracellular defense system, these findings may be useful in the understanding and treatment of different disease conditions associated with alcohol dependence.

DIFFERENT ALLELE-DISTRIBUTION OF MTHFR 677 C → T AND MTHFR −393 C → A IN PATIENTS CLASSIFIED ACCORDING TO SUBTYPES OF LESCH'S TYPOLOGY

AIMS

The typology by Lesch distinguishes between four subtypes: type 1 (model of allergy), type 2 (model of anxiety or conflict), type 3 (alcohol as an antidepressant), and type 4 (alcohol as adaptation). Taking into account that alcohol dependence is associated with elevated homocysteine levels, this study was undertaken to investigate different MTHFR (methylenetetrahydrofolate reductase) genotypes related to homocysteine metabolism in patients with alcohol dependence who were classified according to Lesch's typology (LT).

SUBJECTS AND METHODS

134 non-abstinent chronic alcoholics (112 males, 22 females; mean age 44.2 (SD 8.9) years) were classified according to LT and divided into four groups: LT 1 (n = 26), LT 2 (n = 65), LT 3 (n = 58), and LT 4 (n = 18). Total plasma homocysteine levels and MTHFR genotypes -393, 677, and 1,793 were determined.

RESULTS

We observed a significantly higher frequency of the thermolabile MTHFR 677 C-->T variant (TT) in patients classified as subtype LT4 when compared with subtypes LT2 and LT3 (P = 0.005). Furthermore, for the MTHFR -393 C --> A-polymorphism, significantly more AC/AA variants were found in subtype LT4 (P = 0.034). No differences in allele-distribution were detected for MTHFR 1793.

CONCLUSION

To our knowledge, this is the first study evaluating MTHFR genotypes in patients who were classified according to LT. Significantly different distributions of MTHFR 677 and -393 variants within Lesch Type 4 as compared with Types 2 and 3 hint at genetic determination of Lesch subtypes.

NETER alcoholic typology (NAT)

AIMS

To establish an alcohol-dependent drinker's clinical typology, based on patients attending the Alcoholism Unit of Santa Maria's General Hospital in Lisbon, Portugal.

METHODS

A multivariate statistical analysis was used to extract the typology solution.

RESULTS

We obtained five factors: Anxiopathic, typifies anxious functioning; Heredopathic, congregates familiar and genetic influences on alcoholism; Thimopathic, typified by affective symptomatology; Sociopathic, characterized by disruptive behaviours under alcohol influence; and Adictopathic, isolates younger individuals who consume alcohol and other types of psychoactive substances.

CONCLUSIONS

There are increasingly alcoholic polymorphic subtypes derived from the interactive complexity between genetic/family and psychosocial factors.

VOLUME INTAKE AND CRAVING IN ALCOHOL WITHDRAWAL

AIMS

It has been shown that beer consumption is associated with alcohol craving, in contrast to wine or spirits consumption. The present study was undertaken to evaluate whether the daily volume intake of alcoholic beverages is associated with craving in patients undergoing alcohol withdrawal.

METHODS

A total of 158 male patients were assessed using the obsessive compulsive drinking scale (OCDS) at admission. The daily volume intake of alcoholic beverages was calculated by adding the volume of all regularly consumed alcoholic beverages, disregarding their alcohol percentage. Lesch's typology was used to classify patients for subgroup analysis.

RESULTS

The daily volume intake of alcoholic beverages correlated significantly with the extent of the OCDS (r = 0.33; P < 0.001). With general linear models, we found a significant association of the calculated daily volume intake of all alcoholic beverages with craving (F = 6.426; P = 0.012), but not for the daily ethanol intake. Differentiating the patients according to Lesch's typology a significant association was particularly found in Lesch Type 2 (model of anxiety) patients (F = 11.31; P = 0.001).

CONCLUSION

Our results support the hypothesis that volume intake is associated with craving and suggest a role of pathophysiological changes in volume regulating mechanisms (such as vasopressin or ANP) in the neurobiology of alcohol craving, particularly in male patients of Lesch's Type 2 undergoing alcohol withdrawal.

RECURRENT DETOXIFICATIONS ARE ASSOCIATED WITH CRAVING IN PATIENTS CLASSIFIED AS TYPE 1 ACCORDING TO LESCH'S TYPOLOGY

AIMS

Recurrent detoxifications have been suggested to be associated with elevated alcohol craving. The aim of this investigation was to study the influence of preceding detoxifications on craving in patients with alcoholism classified according to Lesch's typology.

METHODS

We examined 192 patients (154 men, 38 women) after admission for detoxification treatment. Craving was assessed using the Obsessive Compulsive Drinking Scale, and patients were classified into one of the four subgroups of Lesch's typology. The number of preceding detoxifications was assessed with a structured interview.

RESULTS

Lesch's typology type 4 patients showed significantly higher craving scores than type 1-3 patients (Mann-Whitney U-Test; P < 0.05). With respect to the influence of recurrent detoxifications, we found a significant correlation between the number of preceding detoxifications and the extent of craving for the whole population (Spearman's rho r = 0.241, P = 0.001, N = 192), particularly for patients of Lesch's type 1 (Spearman's rho r = 0.534, P = 0.001, N = 37). No significant association was found for patients of the other subgroups (Lesch's type 2-4).

CONCLUSION

The influence of recurrent detoxifications on craving is especially important in patients with Lesch's type 1. Our results underline the importance of the kindling effect particularly in this group of patients, possibly mediated by an increase of glutamatergic neurotransmission. Furthermore, our results emphasize the need to classify patients with alcohol-dependency in addiction research.

Alpha-synuclein protein levels are increased in alcoholic patients and are linked to craving

BACKGROUND

Alpha synuclein has been found to be increased in dopamine neurones of cocaine abusers and in rats whose alcohol preference is inbred. Furthermore, increased alpha-synuclein messenger RNA expression has been linked to craving in patients with alcoholism. The aim of the current study was to investigate whether protein levels of alpha synuclein in alcoholics are changed and possibly influence alcohol craving.

METHODS

The alpha-synuclein protein expression level was measured by enzyme-linked immunosorbent assay in the serum of 49 male alcoholics and 50 nondrinking healthy controls. Alcohol craving was assessed by the Obsessive-Compulsive Drinking Scale total score, including subscales for obsessive and compulsive craving.

RESULTS

Alpha-synuclein protein expression in patients with alcoholism (14.33 ng/ml; SD, 13.01 ng/ml) was significantly higher (t test, T = 3.66, p < 0.0001) when compared with that of healthy controls (5.92 ng/ml; SD, 9.72 ng/ml). Using a multivariate analysis, all craving scores (Obsessive-Compulsive Drinking Scale total score and obsessive and compulsive subscale scores) in alcoholics were significantly associated with their alpha-synuclein protein levels (multiple linear regression, p < 0.014).

CONCLUSIONS

To our knowledge, this is the first study evaluating alpha-synuclein protein expression in alcoholics. The current study provides further evidence of altered alpha-synuclein levels in patients with alcoholism and their linkage to alcohol craving. Because alpha synuclein is involved in the modulation of dopaminergic neurotransmission, these results deliver further pathophysiological explanations of craving mechanisms.

Short-term cognition deficits during early alcohol withdrawal are associated with elevated plasma homocysteine levels in patients with alcoholism

Higher plasma homocysteine levels have been found in actively drinking alcoholics as well as in early abstinent patients. Furthermore, elevated homocysteine levels are associated with cognitive decline in dementia and in healthy elderly people. The aim of this prospective study was to investigate a possible association between homocysteine serum levels and clinically well known cognitive deficits during alcohol withdrawal. We examined 89 patients (67 men, 22 women) during early withdrawal treatment. Cognitive function was assessed using the c.I.-Test. Patients with cognitive deficits showed significantly higher homocysteine serum levels (Mann-Whitney-U, p=0.004) than patients without cognitive deficits, while the difference in blood alcohol concentration was not significant. Using logistic regression analysis, cognitive deficits were best predicted by high homocysteine serum levels (Wald chi2=4.071, OR=1.043, 95% CI 1.001-1.086, p<0.05), which was confirmed by Receiver Operating Curves (AUC=0.68, 95% CI=0.57-0.79, p=0.004). The present results show first evidence of an association between elevated plasma homocysteine levels in alcoholics and cognition deficits in patients undergoing alcohol withdrawal.

Influence of beer, wine and spirits consumption on craving

The importance of craving in alcoholism and the efficacy of treatment has been the subject of various studies. This study focuses on the consumption of different alcoholic beverages and their effect on craving, which has not yet been investigated. Therefore we assessed 197 inpatients using the Obsessive Compulsive Drinking Scale (OCDS) on the day of admission and after 1 week, distinguishing between the total score, the obsessive and the compulsive subscale. Socio-demographic data and the type of alcoholic beverage were recorded. Analysing data, the amount of beer consumption showed a significant influence on craving in male but not in female patients. These results were significant for the total score and both subscales of the OCDS (OCDS total score; day 0: Spearman's rho = 0.31; p = 0.001; logistic regression, dependent variable dichotomized OCDS total score day 0: OR = 1.18; 95% CI = 1.04 - 1.34; p = 0.011). On the other hand we, did not find any significant results for the amount of other beverages such as wine and spirits. Receiver operating curves analysis showed that beer consumption significantly predicts craving [area under the curve (AUC) = 0.66; p = 0.002]. We conclude that higher beer consumption is associated with higher withdrawal craving, at least in male patients. In addition, it is an important predictor for both obsessive and compulsive craving. Further studies are needed to clarify the pathophysiological basis of this finding.

Joint analysis of the NACP-REP1 marker within the alpha synuclein gene concludes association with alcohol dependence

Various studies have linked alcohol dependence phenotypes to chromosome 4. One candidate gene is NACP (non-amyloid component of plaques), coding for alpha synuclein. Recently, it has been shown that alpha synuclein mRNA is increased in alcohol-dependent patients within withdrawal state. This increase is significantly associated with craving, especially obsessive craving. On the basis of these observations, the present study analysed two polymorphic repeats within the NACP gene. We found highly significant longer alleles of NACP-REP1 in alcohol-dependent patients compared with healthy controls (Kruskal-Wallis test, chi(2)=99.5; df=3, P<0.001). In addition, these lengths significantly correlate with levels of expressed alpha synuclein mRNA (chi(2)=8.83; df=2, P=0.012). The present results point to a novel approach for a genetic determination of craving, a key factor in the genesis and maintenance not only of alcoholism but also of addiction in general.

Elevated alpha synuclein mRNA levels are associated with craving in patients with alcoholism

BACKGROUND

Alpha synuclein has been found elevated in dopamine neurons of cocaine abusers and in rats whose alcohol preference is inbred.

METHODS

The alpha synuclein mRNA expression level was measured by quantitative polymerase chain reaction in the blood of 75 male alcoholics and 69 nondrinking healthy control subjects. Alcohol craving was assessed by the Obsessive-Compulsive Drinking Scale total score, including subscales for obsessive and compulsive craving.

RESULTS

The alpha synuclein expression in patients with alcoholism (2.79 DeltaCT; SD = 1.69; p = .021) was significantly higher when compared with healthy control subjects (2.20 DeltaCT; SD = 1.59). Increased alpha synuclein levels significantly predict Obsessive-Compulsive Drinking Scale total score (odds ratio = 1.44, 95% confidence interval: 1.01-2.06, p = .042) and especially Obsessive-Compulsive Drinking Scale obsessive subscale (odds ratio = 1.74, 95% confidence interval: 1.18-2.58, p = .005) but not Obsessive-Compulsive Drinking Scale compulsive subscale alcohol craving.

CONCLUSIONS

Higher levels of alpha synuclein are associated with an increase in alcohol craving. The present results provide a novel pathophysiological approach to the explanation of craving mechanisms.