Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list

A minority of headache patients have a secondary headache disorder. The medical literature presents and promotes red flags to increase the likelihood of identifying a secondary etiology. In this review, we aim to discuss the incidence and prevalence of secondary headaches as well as the data on sensitivity, specificity, and predictive value of red flags for secondary headaches. We review the following red flags: (1) systemic symptoms including fever; (2) neoplasm history; (3) neurologic deficit (including decreased consciousness); (4) sudden or abrupt onset; (5) older age (onset after 65 years); (6) pattern change or recent onset of new headache; (7) positional headache; (8) precipitated by sneezing, coughing, or exercise; (9) papilledema; (10) progressive headache and atypical presentations; (11) pregnancy or puerperium; (12) painful eye with autonomic features; (13) posttraumatic onset of headache; (14) pathology of the immune system such as HIV; (15) painkiller overuse or new drug at onset of headache. Using the systematic SNNOOP10 list to screen new headache patients will presumably increase the likelihood of detecting a secondary cause. The lack of prospective epidemiologic studies on red flags and the low incidence of many secondary headaches leave many questions unanswered and call for large prospective studies. A validated screening tool could reduce unneeded neuroimaging and costs.

Externalizing and self-medicating: Heterogeneity among repeat DUI offenders

AIM

Despite significant reductions in Driving Under the Influence (DUI) in the United States during recent decades, DUI continues to be a major public health threat. The current study investigated the intersection of two domains known to influence DUI: criminal history and psychiatric comorbidity.

METHODS

DUI recidivists (N = 743) attending a court-mandated two-week inpatient DUI program completed a computerized mental health assessment as part of their intake to that program. Participants' criminal records were obtained 4-5 years after program attendance.

FINDINGS

This study identified three primary repeat DUI offender subtypes with distinct patterns of criminal behavior and psychiatric comorbidity: (Type I) those whose DUI emerges from a pattern of drinking to cope with mood and anxiety problems, (Type II) those whose DUI emerges as part of a larger pattern of externalizing and criminal behavior, and (Type III) those whose DUI offenses reflect more acute triggers and isolated episodes of excessive drinking.

CONCLUSION

These findings suggest that current treatment models used in DUI programs are inadequate to address the heterogeneity in the population of DUI recidivists and that earlier and more comprehensive screening would allow for better targeting of resources to DUI offender subtypes.

An empirical review of gambling expansion and gambling-related harm

Abstract. Aims: To discuss and review the latest research related to gambling expansion. Method: We completed a literature review and empirical comparison of peer reviewed findings related to gambling expansion and subsequent gambling-related changes among the population. Results: Although gambling expansion is associated with changes in gambling and gambling-related problems, empirical studies suggest that these effects are mixed and the available literature is limited. For example, the peer review literature suggests that most post-expansion gambling outcomes (i. e., 22 of 34 possible expansion outcomes; 64.7 %) indicate no observable change or a decrease in gambling outcomes, and a minority (i. e., 12 of 34 possible expansion outcomes; 35.3 %) indicate an increase in gambling outcomes. Conclusions: Empirical data related to gambling expansion suggests that its effects are more complex than frequently considered; however, evidence-based intervention might help prepare jurisdictions to deal with potential consequences. Jurisdictions can develop and evaluate responsible gambling programs to try to mitigate the impacts of expanded gambling.

How do homeless adults change their lives after completing an intensive job-skills program? A prospective study

Among people experiencing homelessness, difficulty securing housing is often compounded by concurrent challenges including unemployment, chronic illness, criminal justice involvement, and victimization. The Moving Ahead Program (MAP) is a vocational rehabilitation program that seeks to help adults facing these challenges to secure competitive employment. We prospectively studied how MAP graduates (N = 97) changed from the beginning of MAP to about six months after graduation. We observed a variety of positive outcomes not just in employment and housing but also in health, substance use, and criminal justice involvement. However, these gains were not universal; for instance, participants were less likely to report positive outcomes at follow-up if they started MAP with a serious mental illness, made relatively small gains in work skills, or did not seek mental health treatment during the six months after they completed MAP. These findings might encourage program staff to devote additional resources toward supporting at-risk students.

Already at the Table: Patterns of Play and Gambling Involvement Prior to Gambling Expansion

During 2011, the Governor of Massachusetts signed a bill to allow casino gambling in the state (Commonwealth of Massachusetts 2011). As a result, two resort casinos will begin operations during 2018 and 2019; a smaller slots parlor began operations during June 2015. Prior to this expansion, gambling was widely available in Massachusetts, through the state lottery, off-track betting, and gambling opportunities available in neighboring states. Within this context, it is important to understand the patterns of gambling involvement in the population prior to gambling expansion. The current study examined gambling involvement, patterns of play, and gambling-related problems prior to gambling expansion among a sample of 511 Massachusetts residents who were members of a statewide Internet panel. To measure patterns of play, we asked questions about past-year games played and frequency of play. To measure breadth of involvement, we assessed the number of different games played. To measure depth of involvement, we measured time spent gambling, amount wagered, and amount won or lost. Principal component analysis revealed four play pattern components accounting for more than 50% of the variance in game play frequency. Multiple regression analyses revealed that component scores composed of casino gambling and skill-based gambling (e.g., poker, sports) variables uniquely contributed to the prediction of gambling-related problems, even when depth of involvement was controlled. However, the addition of breadth of involvement to the model resulted in a model where no set of variables contributed significantly, suggesting a complex relationship among play patterns, depth, and breadth of involvement. The study established discrete and distinguishable gambling play patterns associated with gambling-related problems and identified groups of individuals potentially vulnerable to the effects of gambling expansion.

Game On: Past Year Gambling, Gambling-Related Problems, and Fantasy Sports Gambling Among College Athletes and Non-athletes

College students experience higher rates of gambling-related problems than most other population segments, including the general population. Although Division I (D1) athletes often have more at stake than the average student if and when they gamble (e.g., the potential to lose their athletic eligibility), relatively few studies have assessed the gambling behavior of this population and none have specifically assessed fantasy sports gambling. We conducted a study to examine gambling behavior (past-year gambling, gambling-related problems, and fantasy sport gambling) among a sample (N = 692) of college students at a private religiously affiliated university in the Southwest US. The sample for our study was unique in that approximately 30 % of the participants were D1 athletes. We compared the gambling behavior among three groups based on the athlete status: D1 athletes, club/intramural/recreational (CIR) athletes, and non-athletes (NAs). Compared to females in our sample, males observed higher rates of past year gambling, fantasy sports participation, fantasy sports gambling, and gambling-related problems. Among males, we found that CIR athletes observed the highest rates of past year gambling and fantasy sports participation and D1 athletes observed higher rates than NAs. We did not find differences in fantasy sport gambling and past year gambling-related problems based on athlete status in males or females.

The mental health of Indigenous peoples in Canada: A critical review of research

Many scholars assert that Indigenous peoples across the globe suffer a disproportionate burden of mental illness. Research indicates that colonialism and its associated processes are important determinants of Indigenous peoples' health internationally. In Canada, despite an abundance of health research documenting inequalities in morbidity and mortality rates for Indigenous peoples, relatively little research has focused on mental health. This paper provides a critical scoping review of the literature related to Indigenous mental health in Canada. We searched eleven databases and two Indigenous health-focused journals for research related to mental health, Indigenous peoples, and Canada, for the years 2006-2016. Over two hundred papers are included in the review and coded according to research theme, population group, and geography. Results demonstrate that the literature is overwhelmingly concerned with issues related to colonialism in mental health services and the prevalence and causes of mental illness among Indigenous peoples in Canada, but with several significant gaps. Mental health research related to Indigenous peoples in Canada overemphasizes suicide and problematic substance use; a more critical use of the concepts of colonialism and historical trauma is advised; and several population groups are underrepresented in research, including Métis peoples and urban or off-reserve Indigenous peoples. The findings are useful in an international context by providing a starting point for discussions, dialogue, and further study regarding mental health research for Indigenous peoples around the world.

A Prospective Study of Psychiatric Comorbidity and Recidivism Among Repeat DUI Offenders

Psychiatric comorbidity has emerged as a key element distinguishing DUI offenders from others, and, in some cases, distinguishing repeat offenders from first-time offenders. This paper utilizes a prospective design to determine whether the comorbid disorders identified among repeat DUI offenders can predict recidivism. Seven hundred forty-three repeat DUI offenders were recruited from a two-week inpatient treatment program at which they received a standardized mental health assessment and followed across five years post-treatment to track DUI offense, motor vehicle-related offenses, and general criminal offenses. Psychiatric comorbidity, though it did not predict DUI recidivism specifically, predicted criminal re-offense more generally. In addition, there was a specific relationship between lifetime attention deficit disorder and repeated motor vehicle-related offenses. These findings suggest that for many repeat offenders, DUI is one outlet in a constellation of criminal behavior, and that psychiatric comorbidity increases vulnerability for criminal re-offense.

Using cross-game behavioral markers for early identification of high-risk internet gamblers

Using actual gambling behavior provides the opportunity to develop behavioral markers that operators can use to predict the development of gambling-related problems among their subscribers. Participants were 4,056 Internet gamblers who subscribed to the Internet betting service provider bwin.party. Half of this sample included multiple platform gamblers who were identified by bwin.party's Responsible Gambling (RG) program; the other half were controls randomly selected from those who had the same first deposit date. Using the daily aggregated Internet betting transactions for gamblers' first 31 calendar days of online betting activities at bwin.party, we employed a 2-step analytic strategy: (a) applying an exploratory chi-squared automatic interaction detection (CHAID) decision tree method to identify characteristics that distinguished a subgroup of high-risk Internet gamblers from the rest of the sample, and (b) conducting a confirmatory analysis of those characteristics among an independent validation sample. This analysis identified two high-risk groups (i.e., groups in which 90% of the members were identified by bwin.party's RG program): Group 1 engaged in three or more gambling activities and evidenced high wager variability on casino-type games; Group 2 engaged in two different gambling activities and evidenced high variability for live action wagers. This analysis advances an ongoing research program to identify potentially problematic Internet gamblers during the earliest stages of their Internet gambling. Gambling providers and public policymakers can use these results to inform early intervention programs that target high-risk Internet gamblers.

Breadth and depth involvement: Understanding Internet gambling involvement and its relationship to gambling problems

The "involvement effect" refers to the finding that controlling for gambling involvement often reduces or eliminates frequently observed game-specific associations with problem gambling. In other words, broader patterns of gambling behavior, particularly the number of types of games played over a defined period, contribute more to problem gambling than playing specific games (e.g., lottery, casino, Internet gambling). This study extends this burgeoning area of inquiry in three primary ways. First, it tests independently and simultaneously the predictive power of two gambling patterns: breadth involvement (i.e., the number of games an individual plays) and depth involvement (i.e., the number of days an individual plays). Second, it includes the first involvement analyses of actual betting activity records that are associated with clinical screening information. Third, it evaluates and compares the linearity of breadth and depth effects. We conducted analyses of the actual gambling activity of 1,440 subscribers to the bwin.party gambling service who completed an online gambling disorder screen. In all, 11 of the 16 games we examined had a significant univariate association with a positive screen for gambling disorder. However, after controlling for breadth involvement, only Live Action Internet sports betting retained a significant relationship with potential gambling-related problems. Depth involvement, though significantly related to potential problems, did not impact game-based gambling disorder associations as much as breadth involvement. Finally, breadth effects appeared steeply linear, with a slight quadratic component manifesting beyond four games played, but depth effects appeared to have a strong linear component and a slight cubic component.

Right ventricular pacing for right ventricular outflow tract obstruction in a man with biventricular hypertrophic cardiomyopathy

WEBSITE FEATURE

Moving ahead: evaluation of a work-skills training program for homeless adults

This study examines the impact of a work-skills program grounded in an integrated services approach on both employment and related life domains among homeless individuals. Six hundred thirty-eight participants in a 14-week work-skills program at a large day center in New England completed assessments at intake between 1999 and 2007; a subsample of 333 also completed assessments at graduation from the program; a smaller subsample of 55 participants were re-assessed 6 months after graduation. These assessments measured work and related life skills, employment, housing status, general health status, substance use, self-esteem and self-efficacy, and legal involvement. Results revealed improvement in all types of work and related life skills, employment and income, and multiple other life domains from baseline to graduation and follow-up. Exploratory analyses suggested that improvements in work and related life skills were associated with improvement in self-esteem and self-efficacy, and that these improvements predicted stable housing situations at follow-up. Overall, these findings indicate that, for individuals struggling with the challenges of homelessness, completion of a work-skills program has a positive impact on skills and employment, and on a diverse set of life domains.

Impact of chronic kidney disease on risk of incident atrial fibrillation and subsequent survival in medicare patients

Background

Atrial fibrillation (AF) and chronic kidney disease (CKD) are prevalent in the elderly and are independently associated with increased risk of death. We evaluated risk of incident AF with advancing CKD and examined the mortality rate associated with CKD after incident AF in elderly patients.

Methods and Results

This retrospective cohort study used the Medicare 5% database. Point-prevalent Medicare enrollees on December 31, 2006, without preexistent AF or end-stage renal disease were followed up for incident AF through 2008. CKD and AF were identified from International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Associations between CKD stage and incident AF and subsequent risk of death were examined in a Cox proportional-hazards model. Unadjusted survival after incident AF was estimated by the Kaplan-Meier method. CKD was present in 55 962 patients (5.1% of the cohort). Of these, 4952 (8.8%) had CKD stages 1 and 2; 19 795 (35.3%), stages 3 to 5; and 31 215 (55.7%), unknown stage. The hazard ratio for incident AF in CKD stages 3 to 5 was 1.13 (95% confidence interval 1.09 to 1.18). Other stages were not independently associated with incident AF. Survival after incident AF decreased progressively as CKD stage increased (P<0.0001). The 1-year mortality rate for CKD stages 3 to 5 with incident AF was 35.6%. Adjusted hazard ratios for death after incident AF were 1.14 (95% confidence interval 1.00 to 1.30) for CKD stages 1 and 2, 1.27 (95% confidence interval 1.20 to 1.35) for CKD stages 3 to 5, and 1.29 (95% confidence interval 1.23 to 1.36) for unknown stage.

Conclusions

Advanced CKD is associated with increased risk of incident AF. In Medicare patients with incident AF, mortality rates are higher for those with advanced CKD than for those without CKD. (J Am Heart Assoc. 2012;1:e002097 doi: 10.1161/JAHA.112.002097.)

Self-treatment: illicit buprenorphine use by opioid-dependent treatment seekers

Outpatient-based opioid treatment (OBOT) with buprenorphine is an important treatment for people with opioid dependence. No quantitative empirical research has examined rationales for use of illicit buprenorphine by U.S. opioid-dependent treatment seekers. The current study sequentially screened OBOT admissions (n = 129) during a 6-month period in 2009. This study had two stages: (a) a cross-sectional epidemiological analysis of new intakes and existing patients already receiving a legal OBOT prescription (n = 78) and (b) a prospective longitudinal cohort design that followed 76% of the initial participants for 3 months of treatment (n = 42). The primary aims were to establish 2009 prevalence rates for illicit buprenorphine use among people seeking OBOT treatment, to use quantitative methods to investigate reasons for this illicit use, and to examine the effect of OBOT treatment on illicit buprenorphine use behavior. These data demonstrate a decrease in illicit use when opioid-dependent treatment seekers gain access to legal prescriptions. These data also suggest that the use of illicit buprenorphine rarely represents an attempt to attain euphoria. Rather, illicit use is associated with attempted self-treatment of symptoms of opioid dependence, pain, and depression.

PTSD among a treatment sample of repeat DUI offenders

Recent studies indicate that posttraumatic stress disorder (PTSD) is one of the most common psychiatric comorbidities among driving-under-the-influence (DUI) offenders in treatment. Investigation of DUI offenders' PTSD and clinical characteristics could have important implications for prevention and treatment. This prospective study examined the demographic and clinical characteristics of repeat DUI offenders with PTSD symptoms at baseline and 1-year follow-up. Seven hundred twenty-nine DUI offenders admitted to a 2-week inpatient program participated in the study. Participants with PTSD evidenced more severe psychiatric comorbidity and reported a higher DUI recidivism rate at 1-year than those without PTSD. This study suggests a need to address PTSD among DUI offenders, as well as to further develop methodologies for accurately reporting DUI recidivism.

Persistence pays off: follow-up methods for difficult-to-track longitudinal samples

OBJECTIVE

Evolving privacy and confidentiality regulations make achieving high completion rates in longitudinal studies challenging. Periodically reviewing the methods researchers use to retain participants throughout the follow-up period is important. We review the effectiveness of methods to maximize completion rates in a 1-year longitudinal study of repeat driving-under-the-influence (DUI) offenders.

METHOD

During the course of 21 months, we attempted to follow-up with 704 participants of a licensed residential treatment facility for repeat DUI offenders. High rates of lifetime Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, substance-use disorders (97.6%) and nonsubstance- or nongambling-related psychiatric disorders (44.5%) among the sample made tracking participants difficult. To locate participants and complete follow-up interviews, we obtained baseline information, contacted collaterals, sent mailed reminders, searched Internet databases, and gave a monetary incentive for completing study interviews.

RESULTS

We located 608 participants with active telephone numbers (87.4%) and completed interviews with 488 (70.1% of the entire eligible sample and 80.3% of those with active telephone numbers), after an average (SD) of 8.6 (9.1) calls (median = 5.0). Increasing the number of calls continued to yield additional completions at 10, 20, and 30 calls; at approximately 40 telephone calls, the potential return for additional calls did not justify the added effort.

CONCLUSIONS

These results suggest that researchers need to (1) employ more than 10 telephone calls to adequately track difficult-to-follow substance-using populations, and (2) prepare for a subsample of participants who might require more extensive contact. These results highlight the importance of using empirical guidelines to plan estimates for the number of contacts needed to achieve an adequate follow-up completion rate.

Bipolar disorder as a risk factor for repeat DUI behavior

BACKGROUND

Bipolar disorder (BD) is more prevalent among people with substance use disorders (SUD) than the general population. SUD among recidivist driving under the influence (DUI) populations are extremely prevalent; not surprisingly, recent evidence suggests that rates of BD also are elevated among DUI offenders. Studies of BD patients with SUD have found high prevalence of other psychiatric disorders and relatively low rate of treatment engagement. This study examines both the prevalence of other mental disorders and treatment status among a cohort of DUI offenders with BD and SUD.

METHODS

A consecutively selected cohort (N=729) of repeat DUI offenders attending a two-week inpatient treatment program completed a standardized diagnostic interview (the Composite International Diagnostic Interview: CIDI). The CIDI generated DSM-IV diagnoses.

RESULTS

This study yielded three main results for this repeat DUI offender sample: (1) BD is associated with significantly higher lifetime prevalence of alcohol, drug, and non-substance psychiatric disorders (e.g., PTSD); (2) approximately one quarter of BD participants have not discussed their mania with a professional; and (3) only half of the BD participants in this cohort have had mania treatment they consider effective and even fewer have had any treatment during the past twelve months.

LIMITATIONS

Participants were predominantly Caucasian males attending treatment as a sentencing option in a single Massachusetts DUI program.

CONCLUSION

These findings suggest that clinicians in DUI treatment settings should consider both evaluating for BD and initiating therapy.