A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine.

Thesis (M.S.)--State University of New York at Binghamton, Department of Psychology, 2008. / Includes bibliographical references.

Thesis (Ph. D.)--University of Texas at Austin, 2005. / Vita. Includes bibliographical references.

Thesis (Ph.D.)--Baylor University, 2008. / Includes bibliographical references (p. 113-134).

Thesis (Ph. D.)--University of California, San Diego, 2001. / Vita. Includes bibliographical references (leaves 122-132).

The purpose of this project was to determine the time between arrival, assessment, and treatment for patients presenting with alcohol withdrawal syndrome (AWS) to the emergency department (ED) as well as to identify patient and environmental factors that may prolong initiation of the implementation of the clinical institute withdrawal alcohol (CIWA-Ar) protocol for assessment and treatment of AWS. There is clear evidence that rapid assessment and treatment of AWS improves cost, quality, risk, safety and patient outcomes. This project found that patients in the emergency department at Banner University Medical Center South campus (BUMCS) in 2016 on average waited 2 hours and 20 minutes for initial CIWA-Ar assessment and 50 minutes for medication to be administered. When taking into account the physiological process of AWS and the highly variable nature of ethanol metabolism this timeline is suboptimal and significant reduction of these times are recommended. The only factor that was significantly associated with increased wait times was elevated blood alcohol content (BAC). With higher BAC resulting in longer wait times. This is a concerning finding since patients experiencing symptoms of withdrawal in the presence of elevated BAC are at significantly higher risk for the most severe AWS including delirium tremens and seizure.

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Worldwide, alcohol is the third leading risk factor for disease burden, while its harmful use leads to 2.5 million deaths every year. Alcohol dependence (AD) is a complex disease, with devastating effects on individuals, families, and society. It is estimated that 76.3 million people worldwide have suffered from alcohol use disorders (AUD), including alcohol abuse and AD. Alcohol withdrawal or alcohol withdrawal symptom (AWS) refers to a cluster of symptoms that may occur when a heavy drinker suddenly stops or significantly reduces their alcohol intake. These symptoms can start as early as 2 h after the last drink, persist for weeks, and range from mild anxiety and shakiness to severe complications, such as seizures and delirium tremens. Family, twin, and adoption studies have indicated that genetic and environmental factors and their interactions contribute to the development of AD and related phenotypes, with a heritability coefficient of more than 0.5 for AD. Whole-genome linkage and candidate gene association studies have successfully identified several chromosome regions and genes that are related to AD and AWS. Furthermore, gene expression analysis, epigenetic studies, and genome-wide association studies (GWAS) have provided regions and loci for AWS. This chapter reviews the recent findings in genetic studies of AWS.

Notre étude à pour but de déterminer l’implication de la corticostérone centrale sur l’activité du réseau hippocampe-cortex préfrontal (HPC-CPF) ainsi que son rôle dans l’émergence et le maintien d’altération de la mémoire de travail (MDT) durant l’alcoolisation chronique (12% durant 6 mois), ou bien après un sevrage aigu (1semaine) ou prolongé (6 semaines). Les effets du sevrage ont également été comparés à ceux résultant d’un stress chronique léger imprédictible (SCLI) modélisant la dépression. Nos données montrent que le sevrage et le SCLI, mais non l’alcoolisation, induisent des troubles de MDT, un déficit d’activation de pCREB (CPF et HPC) ainsi qu’une augmentation excessive des taux de corticostérone spécifiquement dans le CPF après un sevrage. Sur le plan pharmacologique, l’inhibition de la synthèse de la corticostérone restaure la MDT et l’activité de pCREB dans le CPF, chez les souris sevrées et SCLI. Nos résultats montrent également que l’augmentation de pCREB ou le blocage des récepteurs aux minéralocorticoïdes, dans le CPF, mais non dans l’HPC, restaure la MDT des souris sevrées. Ces résultats démontrent que la perturbation de taux de corticostérone dans le CPF joue un rôle clé dans l’émergence des troubles cognitifs et neuronaux après un sevrage. Nous avons également montré qu’un traitement chronique au Diazépam atténue ces altérations transitoirement. Notre étude suggère que des composés agissant sur l'activité de l’axe corticotrope peuvent constituer des stratégies alternatives pour prévenir l'émergence et le maintien des troubles cognitifs induits par le sevrage. / Our study was aimed to determine the involvement of central corticosterone on the activity of hippocampalprefrontal cortex (HPC-PFC) network and its role in the emergence of working memory (WM) alterations during chronic alcohol consumption (12% for 6 months), or after a short (1 week) or a prolonged (6 weeks) withdrawal periods. The alcohol-withdrawal effects were compared to those resulting from an unpredictable mild chronic stress (UCMS), modeling depression. Our data showed that withdrawal and UCMS, but not alcohol, induced WM disorders and deficits of CREB activation in both the PFC and HPC, and an excessive corticosterone increase specifically in the PFC of withdrawn animals. Pharmacological experiments showed that the inhibition of corticosterone synthesis restored pCREB activity in the PFC of both withdrawn and UCMS mice and improved WM. Furthermore, in withdrawn mice, the increase of pCREB or the blockade of the mineralo-corticoid receptor in the PFC, but not in the HPC, restored WM performance. These results demonstrated that corticosterone dysfunction into the PFC plays a key role in the long-lasting cognitive and neural activity disorders of alcohol-withdrawn mice. We also showed that chronic administration of diazepam reduced such alterations only transitorily. Thus, overall, our study suggests that compounds acting on the GCs activity may constitute alternative strategies to prevent the emergence and maintenance of cognitive disorders induced by alcohol withdrawal.

Abstract A large body of animal studies indicates that reinforcement from alcohol is associated with dopaminergic neurotransmission in the mesocorticolimbic pathway. However, as most psychiatric phenomena cannot be studied with animals, human studies are needed. Furthermore, because of the fluctuating nature of phenomena regarding the status of abuse and withdrawal, repeated observations of the same study subjects under different situations can elucidate a variety of pathophysiological mechanisms. In this study 42 alcoholics were monitored during withdrawal and 30 alcoholics after four weeks of abstinence. 123I-β-CIT SPET was used as a method for the semi quantification of their striatal dopamine transporter (DAT) densities reflecting the function and structure of the dopaminergic system. DAT density was markedly lower during withdrawal among alcoholics as compared to control subjects, but it elevated during abstinence to the level of healthy volunteers. This increases in DAT density during withdrawal and afterwards correlated with the depression scores of alcoholics. DAT density correlated with the Novelty Seeking (NS) personality trait, especially among abstinent alcoholics. After four weeks of controlled abstinence alcoholics with an A1 allele of dopamine receptor D2 were found to have higher DAT densities than alcoholics without it. The results indicate that striatal DAT density is associated with mood, personality, A1 genotype and the length of the abstinence period after heavy alcohol drinking.