Towards an Active Role of Financial Institutions in Preventing Problem Gambling: A Proposed Conceptual Framework and Taxonomy of Financial Wellbeing Indicators

The transformation of gambling into a largely digital commodity has created a need for online payment technologies to facilitate online gambling, thereby also raising the question of what role these actors can play in the promotion of Responsible Gambling (RG). With the means and access they maintain, financial institutions are in a unique position to alleviate financial pitfalls, yet their role in the gambling context has thus far received little scrutiny. The objective of this study was to conduct an extant literature review to develop an initial set of financial indicators tailored for financial institutions, enabling them to engage in the RG initiatives. We conducted a two-step narrative literature review to identify both general Financial Well-Being (FWB) indicators across financial research disciplines, and one specific to gambling. A literature search over the past 20 years was performed across the following academic databases: Medline (Ovid), Sociological Abstracts (ProQuest), Web of Science (Clarivate), and PsycInfo (EBSCO). Manifest content analysis was used in step one to review general financial well-being, yielding a general FWB conceptual framework. In step two, we applied latent content analysis to the gambling-specific literature, linking essential concepts of gambling-related financial harms to the broader FWB literature. This resulted in a tentative taxonomy of indicators applicable to financial institutions with gambling customers. In tandem with the FWB conceptual framework, the preliminary taxonomy could provide a foundation for financial institutions catering to gambling customers to engage in the duty of care agenda, potentially broadening player protection beyond the current operator-focused RG measures.

Offering an auto-play feature likely increases total gambling activity at online slot-machines: preliminary evidence from an interrupted time series experiment at a real-life online casino

Auto-play is a ubiquitous feature in online casino gambling and virtual slot machines especially, allowing gamblers to initiate spin sequences of pre-set length and value. While theoretical accounts diverge on the hypothesized causal effect on gambling behavior of using the auto-play feature, observational findings show that this feature is used to a higher degree by problem and/or high-intensity gamblers, suggesting that banning this feature may constitute a global responsible gambling measure. Direct, experimental research on causal effects of offering auto-play at online casinos is however lacking. Here, we report the findings of an interrupted time series experiment, conducted at a real-life online casino in Sweden, in which the auto-play feature was made available during a pre-set duration on 40 online slot machines, with 40 matched slots serving as control. Aggregated time series on daily betted amount, spins and net losses were analyzed using a structural Bayesian framework that compared observed developments during the peri-intervention period to modeled counterfactual estimates. Results suggest that offering an auto-play feature on online casinos likely increases total gambling activity in terms of betted amount (approx.+ 7-9%) and (perhaps) number of spins (approx. +3%) but has no effect on net losses. Limitations of studying auto-play effects on a population-level, as well as the complexities of banning this feature within a complex ecosystem of non-perfect channelization to licensed providers, are discussed, including suggestions for future research.

Reaching out to big losers: Exploring intervention effects using individualized follow-up

OBJECTIVE

Previous research suggests that a brief duty-of-care telephone call to high expenditure customers was associated with lower gambling over the subsequent year. The current aim was to assess effects on individual trajectories rather than overall group effects reported previously. The objective was to identify different patterns of individual change over the follow-up year and explore differential responses of subgroups of individuals.

METHOD

A matched pair design contrasting the outcome for telephone intervention with a no-intervention control condition. Five hundred and ninety-six statistical pairs randomly drawn from the top 0.5% of customers based upon annual expenditure at Norsk Tipping, Norway. Primary outcome measure was gambling theoretical loss (TL), derived from the Norsk Tipping gambling data warehouse. Player trajectories across time were identified using growth mixture modeling to assess differential intervention effects on homogenous subgroups of individuals.

RESULTS

Relatively low, medium, and high TL subgroups were identified. The telephone intervention was associated with greater reductions than the control condition for all three subgroups but showed the strongest effect for the subgroup with the highest TL. The intervention was most effective for casino and sport gamblers, male, young, and middle-aged.

CONCLUSIONS

A brief duty of care telephone contact with high expenditure customers showed sustained effects over 12 months, in particular for individuals showing the highest level of TL. Examining trajectories using advanced statistical models identified customer characteristics most strongly associated with reduced TL. These findings can guide prevention strategies with evidence-based knowledge about differential effects. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

One size does not fit all. Should gambling loss limits be based on income?

Background

Previous research has suggested empirically based gambling loss limits, with the goal of preventing gambling related harm in the population. However, there is a lack of studies relating gambling loss limits to individual factors such as income. The current study examines whether gambling loss limits should be income-specific.

Materials and methods

The dataset was derived from three representative cross-sectional surveys of the Norwegian population and consisted of 14,630 gamblers. Four income groups, based on a quartile approximation, were formed. Gambling related harm was measured with the Problem Gambling Severity Index (PGSI), and precision-recall (PR) analyses were used to identify loss limits for the different income groups at two levels of gambling severity: moderate-risk gambling and problem gambling.

Results

For both levels of gambling severity, we found the lowest income group to have the lowest gambling loss limits, and the highest income group to have the highest loss limits, which compared to the loss limits for the total sample, were lower and higher, respectively. Calculating the cut-offs for moderate-risk gamblers, we found a consistently ascending pattern from the lowest to the highest income group. Calculating the cut-offs for problem gamblers, we found a similar pattern except for the two middle income groups.

Conclusion

The results suggest that income moderates empirically derived gambling loss limits. Although replication is required, income-based gambling loss limits may have higher applied value for preventing gambling related harm, compared to general loss limits aimed at the entire population.

Low-quality employment trajectories and mental health disorders among Swedish and migrant workers

Aim

This study aims to examine the effects of low-quality employment trajectories on severe common mental disorders (CMD) according to Swedish and foreign background.

Methods

This is a longitudinal study based on Swedish population registries (N = 2,703,687). Low- and high-quality employment trajectories observed across five years (2005-2009) are the exposure with severe CMD as outcome (2010-2017). Adjusted hazard ratios (HR) were calculated using Cox regression stratified according to background (first-generation (i) EU migrants, (ii) non-EU migrants, (iii) second-generation migrants, (iv) Swedish-born with Swedish background) and sex. The reference group were Swedish-born with Swedish background in a Constant high-quality employment trajectory.

Results

Second-generation migrants had an increased risk of CMD compared to Swedish-born with Swedish background when following low-quality employment trajectories (e.g., male in Constant low-quality HR: 1.53, 95% CI: 1.41-1.68). Female migrant workers, especially first-generation from non-Western countries in low-quality employment trajectories (e.g., Constant low-quality HR: 1.65, 95% CI:1.46 - 1.87), had a higher risk of CMD compared to female Swedish-born with Swedish background. The confidence interval for CMD risk showed little differences between migrant groups (1st and 2nd generation) compared to the reference group.

Conclusions

Low-quality employment trajectories appear to be determinants of risk for CMD, having a differential impact according to background of origin and sex. We observe a higher risk for severe CMD across migrant groups, especially second-generation migrants, compared to Swedish-born with Swedish background. Further qualitative research is recommended to understand the mechanism behind the differential mental health impact of low-quality employment trajectories according to foreign background.

Key messages

• First and second-generation migrants in low quality employment have higher risk of severe common mental disorders compared to Swedish born with Swedish background workers in low quality employment.

• Policies targeting working conditions in low-quality employment and promoting workers mental well-being are essential to reduce this higher risk for developing CMD, especially for migrant populations.

The causal effect of switching from precarious to standard employment on mortality in Sweden

Background

Precarious employment (PE) is a well-known social determinant of health and health inequalities, yet the effect of PE on mortality has not been explored sufficiently and high-quality longitudinal studies are lacking. When studying this effect, several methodological factors must be considered, one of them being the immortal time bias or prevalent user bias. A framework that helps us overcome these biases is the target trial. Therefore, the aim of this study is to estimate the causal effect of switching from precarious to standard employment (SE) on the 12-year risk of all-cause mortality among precariously employed workers aged 20-55 in Sweden.

Methods

We emulated the target trial as a series of 11 target trials (starting at any year between 2005 and 2016), such that each individual may participate in multiple trials using Swedish register data (N = 251274). We classified individuals as: a) workers that at baseline (start) move from PE to SE and then followed while in SE or b) continuation of PE over follow-up. All-cause mortality was measured from 2006 to 2017. We pooled data for all 11 emulated trials and used pooled logistic regression to estimate intention-to-treat effects via hazard ratios and standardized survival curves.

Results

The following results are preliminary. Individuals that continued on PE were 185,480 and those that initiated SE were 65,794. Over the 12-year follow-up, 1553 individuals died. The estimated observational analogue of the intention-to-treat 12-year survival difference for all cause-mortality between workers that continued on PE and those that initiated SE was of -0.2%, and the HR:0.82, 95%CI:0.72-0.94.

Conclusions

The following conclusions are preliminary. According to our results, we find indication that shifting from PE to SE decreased the risk of death. Our study highlights the crucial role of decent employment conditions for health.

Key messages

In search of lower risk gambling levels using behavioral data from a gambling monopolist

BACKGROUND AND AIMS

Lower-risk recommendations for avoiding gambling harm have been developed as a primary prevention measure, using self-reported prevalence survey data. The aim of this study was to conduct similar analyses using gambling company player data.

METHODS

The sample (N = 35,753) were Norsk Tipping website customers. Gambling indicators were frequency, expenditure, duration, number of gambling formats and wager. Harm indicators (financial. social, emotional, harms in two or more areas) were derived from the GamTest self-assessment instrument. Receiver operating characteristics (ROC) curves were performed separately for each of the five gambling indicators for each of the four harm indicators.

RESULTS

ROC areas under the curve were between 0.55 and 0.68. Suggested monthly lower-risk limits were less than 8.7 days, expenditure less than 54 €, duration less than 72-83 min, number of gambling formats less than 3 and wager less than 118-140€. Most risk curves showed a rather stable harm level up to a certain point, from which the increase in harm was fairly linear.

DISCUSSION

The suggested lower-risk limits in the present study are higher than limits based on prevalence studies. There was a significant number of gamblers (5-10%) experiencing harm at gambling levels well below the suggested cut-offs and the risk increase at certain consumption levels.

CONCLUSIONS

Risk of harm occurs at all levels of gambling involvement within the specific gambling commercial environment assessed in an increasingly available gambling market where most people gamble in multiple commercial environments, minimizing harm is important for all customers.

SARS-CoV-2 and pregnancy outcomes under universal and non-universal testing in Sweden: register-based nationwide cohort study

OBJECTIVE

To assess associations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and pregnancy outcomes considering testing policy and test-positivity-to-delivery interval.

DESIGN

Nationwide cohort study.

SETTING

Sweden.

POPULATION

From the Pregnancy-Register we identified 88 593 singleton births, 11 March 2020-31 January 2021, linked to data on SARS-CoV-2-positivity from the Public Health Agency, and information on neonatal care admission from the Neonatal Quality Register. Adjusted odds ratios (aORs) were estimated stratified by testing-policy and test-positivity-to-delivery interval.

MAIN OUTCOME MEASURES

Five-minute Apgar score, neonatal care admission, stillbirth and preterm birth.

RESULTS

During pregnancy, SARS-CoV-2 test-positivity was 5.4% (794/14 665) under universal testing and 1.9% (1402/73 928) under non-universal testing. There were generally lower risks associated with SARS-CoV-2 under universal than non-universal testing. In women testing positive >10 days from delivery, generally no significant differences in risk were observed under either testing policy. Neonatal care admission was more common (15.3% versus 8.0%; aOR 2.24, 95% CI 1.62-3.11) in women testing positive ≤10 days before delivery under universal testing. There was no significant association with 5-minute Apgar score below 7 (1.0% versus 1.7%; aOR 0.64, 95% CI 0.24-1.72) or stillbirth (0.3% versus 0.4%; aOR 0.72, 95% CI 0.10-5.20). Compared with term births (2.1%), test-positivity was higher in medically indicated preterm birth (5.7%; aOR 2.70, 95% CI 1.60-4.58) but not significantly increased in spontaneous preterm birth (2.3%; aOR 1.12, 95% CI 0.62-2.02).

CONCLUSIONS

Testing policy and timing of test-positivity impact associations between SARS-CoV-2-positivity and pregnancy outcomes. Under non-universal testing, women with complications near delivery are more likely to be tested than women without complications, thereby inflating any association with adverse pregnancy outcomes compared with findings under universal testing.

TWEETABLE ABSTRACT

Testing policy and time from SARS-CoV-2 infection to delivery influence the association with pregnancy outcomes.

Outcome of treatment of MDR-TB or drug-resistant patients treated with bedaquiline and delamanid: Results from a large global cohort

The World Health Organization (WHO) recommends countries introduce new anti-TB drugs in the treatment of multidrug-resistant tuberculosis. The aim of the study is to prospectively evaluate the effectiveness of bedaquiline (and/or delamanid)- containing regimens in a large cohort of consecutive TB patients treated globally. This observational, prospective study is based on data collected and provided by Global Tuberculosis Network (GTN) centres and analysed twice a year. All consecutive patients (including children/adolescents) treated with bedaquiline and/or delamanid were enrolled, and managed according to WHO and national guidelines. Overall, 52 centres from 29 countries/regions in all continents reported 883 patients as of January 31st 2021, 24/29 countries/regions providing data on 100% of their consecutive patients (10-80% in the remaining 5 countries). The drug-resistance pattern of the patients was severe (>30% with extensively drug-resistant -TB; median number of resistant drugs 5 (3-7) in the overall cohort and 6 (4-8) among patients with a final outcome). For the patients with a final outcome (477/883, 54.0%) the median (IQR) number of months of anti-TB treatment was 18 (13-23) (in days 553 (385-678)). The proportion of patients achieving sputum smear and culture conversion ranged from 93.4% and 92.8% respectively (whole cohort) to 89.3% and 88.8% respectively (patients with a final outcome), a median (IQR) time to sputum smear and culture conversion of 58 (30-90) days for the whole cohort and 60 (30-100) for patients with a final outcome and, respectively, of 55 (30-90) and 60 (30-90) days for culture conversion. Of 383 patients treated with bedaquiline but not delamanid, 284 (74.2%) achieved treatment success, while 25 (6.5%) died, 11 (2.9%) failed and 63 (16.5%) were lost to follow-up.

Transitioning Between Online Gambling Modalities and Decrease in Total Gambling Activity, but No Indication of Increase in Problematic Online Gambling Intensity During the First Phase of the COVID-19 Outbreak in Sweden: A Time Series Forecast Study

Introduction: The COVID-19 outbreak will likely have a public health impact beyond immediate disease transmission. Little is known about whether social distancing and other societal changes has provoked an increase in gambling, whether decreased betting opportunities due to paused sports events spurred gamblers to transition to online casino gambling, or whether any of these factors have had an impact on problem gambling.

Methods: Data on lookup queries against the Swedish Gambling Paus registry, logging all initiated gambling sessions by all licensed gambling providers, from 2019-01-01 (start of registry) to 2020-04-08 (well into the first phase of the outbreak) were analyzed using TBATS time series forecasting to estimate trends after the first domestic COVID-19 death. Obfuscated data on daily total wagered and deposited amounts, split by modality (casino or betting, and low and high intensity, respectively) for the equivalent period were supplied by a licensed online gambling provider.

Results: Total gambling activity decreased by 13.29% during the first phase of the outbreak compared to forecast. Analyses of online gambling data revealed that although betting decreased substantially in synchrony with a slight increase in online casino gambling, there was no increase in likely problematic, high-intensity gambling and neither did total online gambling increase.

Conclusions: This first, preliminary study revealed no increase in Swedish gambling activity, total or specifically online, in the first phase of the COVID-19 outbreak. Future research should examine whether pandemic-induced transitioning between gambling modalities and/or increased participation in gambling, leads to long-term effects on prevalence of problem gambling.

Reaching out to big losers leads to sustained reductions in gambling over 1 year: a randomized controlled trial of brief motivational contact

BACKGROUND AND AIMS

A previous randomized controlled trial demonstrated that telephone- and letter-based motivational interventions with high-expenditure gamblers had significant short-term positive effects on gambling and use of responsible gambling tools. This post-trial follow-up examined outcomes in gambling expenditure over 12 months.

DESIGN

Observational study following a three-arm randomized controlled trial.

SETTING

Customers of Norsk Tipping (NT) gambling platforms, Norway.

PARTICIPANTS

A total of 1003 statistical triplets from the top 0.5% of customers based upon annual expenditure, matched on sex, age and net losses. Mean age was 53.4 years; 19% were women, mean yearly loss for 2016 was 88 197 NoK. Interventions and comparator Feedback intervention by telephone, letter or a no-contact control condition.

MEASUREMENTS

Primary outcome measure was gambling theoretical loss, derived from the NT customer database. Secondary outcomes were responsible gambling customer actions and whether or not the participant was retained as an NT customer.

FINDINGS

Per-protocol analyses of triplets who received the telephone call or letter as randomly assigned (n = 596) showed a positive and sustained effect over 12 months: the telephone group showed a 30% reduction in theoretical loss (d = 0.44) and the letter group 13% (d = 0.18), both outperforming the control group with a 7% reduction (d = 0.11). The telephone condition was superior to both the letter and control conditions in per-protocol (P < 0.001) and to control condition in intention-to-treat analyses (ITT) (P < 0.001). Individuals in the telephone condition took more responsible gambling actions. The letter condition had better outcomes than the control in the ITT-only analysis (P < 0.001). More than 93% were still customers a year after the intervention.

CONCLUSIONS

Personal contact with high-expenditure gambling customers in Norway that provided individualized feedback on expenditures was associated with reduced theoretical losses and greater use of responsible gambling tools over a 12-month period, compared with no contact. Telephone intervention with customers had a larger impact than a mailed letter.

SAT0069 TUBERCULOSIS IN BIOLOGIC-NAÏVE PATIENTS WITH RHEUMATOID ARTHRITIS - RISK FACTORS AND TUBERCULOSIS CHARACTERISTICS

Background:

The risk of tuberculosis (TB) has decreased in biologic disease modifying anti-rheumatic drugs (bDMARDs) treated rheumatoid arthritis (RA) patients, but remains unaltered 4-fold increased in bio-naïve RA patients compared to the general population in Sweden (1). In absolute numbers, most TB cases in contemporary RA patients occur in the group of bio-naïve patients. Knowledge about risk factors for TB and TB characteristics in bio-naïve RA patients is still limited.

Objectives:

To investigate risk factors for TB and TB characteristics in bio-naïve RA patients.

Methods:

Population-based case-control study. A national bio-naïve RA cohort was identified from the National Patient Register and the Swedish Rheumatology Quality Register. RA cases with TB were identified by linkage to the Swedish Tuberculosis Register (with mandatory TB registration) 2001-2014 (n=42). For each case, four matched RA controls without TB were identified. Clinical data were obtained from medical records. Univariate and multivariable logistic regression analyses were used to estimate risk for TB expressed as adjusted (adj) odds ratio (OR) with 95% confidence intervals (CI).

Results:

After review of the medical records and validation of diagnoses, 31 cases with RA and TB and 122 controls remained in the study. The TB cases had a median of 3 (1-6) reported TB risk factors, and almost 90% were born before 1950. Only one case was screened for TB (with negative result of tuberculin skin test). Active TB occurred at a mean of 15 years after RA diagnosis, and all except three cases were considered as reactivation of latent TB. Exposure to leflunomide (5 cases, 4 controls) (adj OR 6.02; 95% CI 1.47-24.65) and azathioprine (5 cases, 6 controls) (adj OR 3.85; 95% CI 1.06-13.79) were associated with increased risk for TB. Methotrexate, used in 67.7% of cases and 73.9% of controls, was not associated with increased risk of TB (adj OR 0.83; 95% CI 0.34-1.98). Exposure to corticosteroids was more common among cases than controls (74.2% vs 53.8%, p= 0.04), and was associated with an adj OR for TB of 2.44 (95% CI 1.00-5.92). No significant differences were identified between prednisolone-treated cases and controls in terms of maximum dose ever of prednisolone, treatment duration before TB, or cumulative dose of prednisolone during the last year before diagnosis of TB. Obstructive pulmonary disease was the only comorbidity linked to an increased TB risk (adj OR 3.94; 95% CI 1.45-10.69). Pulmonary TB dominated (84%) followed by TB lymphadenitis (19%). Treatment success was 94%, comparable to TB patients in general.

Conclusion:

Several RA-associated risk factors may contribute to increased TB risk in bio-naïve RA patients (treatment with leflunomide, azathioprine, or prednisolone and concomitant obstructive lung disease). We could not confirm previous findings of an association with the use of moderate to high doses of prednisolone (≥15 mg). TB risk seems difficult to predict with precision in the individual bio-naïve patient based on RA-associated risk factors. To further decrease the TB risk in RA patients TB screening should also be considered in the group of bio-naïve patients.

References:

[1] Arkema EV et al. Are patients with rheumatoid arthritis still at an increased risk of tuberculosis and what is the role of biological treatments? Ann Rheum Dis 2015;74:1212-17.

Disclosure of Interests:

Johanna Sundbaum: None declared, Elizabeth Arkema: None declared, Judith Bruchfeld: None declared, Jerker Jonsson: None declared, Johan Askling Grant/research support from: JA acts or has acted as PI for agreements between Karolinska Institutet and the following entities, mainly in the context of the ARTIS national safety monitoring programme of immunomodulators in rheumatology: Abbvie, BMS, Eli Lilly, Merck, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB Pharma, Eva Baecklund: None declared

Tuberculosis in the Circumpolar Region, 2006-2012

SETTING

The northern circumpolar jurisdictions Canada (Northwest Territories, Nunavik, Nunavut, Yukon), Finland, Greenland, Norway, Russian Federation (Arkhangelsk), Sweden and the United States (Alaska).

OBJECTIVE

To describe and compare demographic, clinical and laboratory characteristics, including drug resistance and treatment completion, of tuberculosis (TB) cases in the northern circumpolar populations.

DESIGN

Descriptive analysis of all active TB cases reported from 2006 to 2012 for incidence rate (IR), age and sex distribution, sputum smear and diagnostic site characteristics, drug resistance and treatment completion rates.

RESULTS

The annual IR of TB disease ranged from a low of 4.3 per 100 000 population in Northern Sweden to a high of 199.5/100 000 in Nunavik, QC, Canada. For all jurisdictions, IR was higher for males than for females. Yukon had the highest proportion of new cases compared with retreatment cases (96.6%). Alaska reported the highest percentage of laboratory-confirmed cases (87.4%). Smear-positive pulmonary cases ranged from 25.8% to 65.2%. Multidrug-resistant cases ranged from 0% (Northern Canada) to 46.3% (Arkhangelsk). Treatment outcome data, available up to 2011, demonstrated >80% treatment completion for four of the 10 jurisdictions.

CONCLUSION

TB remains a serious public health issue in the circumpolar regions. Surveillance data contribute toward a better understanding and improved control of TB in the north.

Reaching out to big losers: A randomized controlled trial of brief motivational contact providing gambling expenditure feedback

Gambling disorder is a public health issue in many countries, and expectations that the gambling industry protects individuals from harm are increasing. The primary objective of this study was to investigate the effects of providing personalized feedback on gambling intensity among high consumers of venue-based and online gambling in Norway. A randomized controlled trial design was used to evaluate how behavioral feedback by telephone or letters sent via surface mail affects subsequent gambling expenditure and use of responsible gambling tools and whether a follow-up contact increases the effect. Gambling expenditure, the primary outcome, was measured using theoretical loss, which is the actual cost to the player, adjusted for the house advantage. From the top .5% of customers based upon annual expenditure, a sample of 1,003 statistical triplets, matched on sex, age, and net losses, were randomly assigned to the feedback intervention by telephone, letter, or a no-contact control condition. Participants assigned to the phone call or letter were also randomly assigned to receive or not receive a subsequent follow-up contact. The results showed that over 12 weeks, theoretical loss decreased 29% for the phone and 15% for the letter conditions, compared with 3% for the control group. A positive effect of the follow-up contact was limited to participants who at the initial call indicated an interest in receiving a follow-up call. Contacting high consumers about their gambling expenditure appears to be an effective method for gambling companies to meet their duty to care for customers. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

GamTest: Psychometric Evaluation and the Role of Emotions in an Online Self-Test for Gambling Behavior

Recent increases in the number of online gambling sites have made gambling more available, which may contribute to an increase in gambling problems. At the same time, online gambling provides opportunities to introduce measures intended to prevent problem gambling. GamTest is an online test of gambling behavior that provides information that can be used to give players individualized feedback and recommendations for action. The aim of this study is to explore the dimensionality of GamTest and validate it against the Problem Gambling Severity Index (PGSI) and the gambler's own perceived problems. A recent psychometric approach, exploratory structural equation modeling (ESEM) is used. Well-defined constructs are identified in a two-step procedure fitting a traditional exploratory factor analysis model as well as a so-called bifactor model. Using data collected at four Nordic gambling sites in the autumn of 2009 (n = 10,402), the GamTest ESEM analyses indicate high correspondence with the players' own understanding of their problems and with the PGSI, a validated measure of problem gambling. We conclude that GamTest captures five dimensions of problematic gambling (i.e., overconsumption of money and time, and monetary, social and emotional negative consequences) with high reliability, and that the bifactor approach, composed of a general factor and specific residual factors, reproduces all these factors except one, the negative consequences emotional factor, which contributes to the dominant part of the general factor. The results underscore the importance of tailoring feedback and support to online gamblers with a particular focus on how to handle emotions in relation to their gambling behavior.

Field Determination of Multipollutant, Open Area Combustion Source Emission Factors with a Hexacopter Unmanned Aerial Vehicle

An emission sensor/sampler system was coupled to a National Aeronautics and Space Administration (NASA) hexacopter unmanned aerial vehicle (UAV) to characterize gases and particles in the plumes emitted from open burning of military ordnance. The UAV/sampler was tested at two field sites with test and sampling flights spanning over 16 hours of flight time. The battery-operated UAV was remotely maneuvered into the plumes at distances from the pilot of over 600 m and at altitudes of up to 122 m above ground level. While the flight duration could be affected by sampler payload (3.2 to 4.6 kg) and meteorological conditions, the 57 sampling flights, ranging from 4 to 12 min, were typically terminated when the plume concentrations of CO2 were diluted to near ambient levels. Two sensor/sampler systems, termed "Kolibri," were variously configured to measure particulate matter, metals, chloride, perchlorate, volatile organic compounds, chlorinated dioxins/furans, and nitrogen-based organics for determination of emission factors. Gas sensors were selected based on their applicable concentration range, light weight, freedom from interferents, and response/recovery times. Samplers were designed, constructed, and operated based on U.S. Environmental Protection Agency (EPA) methods and quality control criteria. Results show agreement with published emission factors and good reproducibility (e.g., 26% relative standard deviation for PM2.5). The UAV/Kolibri represents a significant advance in multipollutant emission characterization capabilities for open area sources, safely and effectively making measurements heretofore deemed too hazardous for personnel or beyond the reach of land-based samplers.

Measuring Gambling Reinforcers, Over Consumption and Fallacies: The Psychometric Properties and Predictive Validity of the Jonsson-Abbott Scale

Traditionally, gambling and problem gambling research relies on cross-sectional and retrospective designs. This has compromised identification of temporal relationships and causal inference. To overcome these problems a new questionnaire, the Jonsson-Abbott Scale (JAS), was developed and used in a large, prospective, general population study, The Swedish Longitudinal Gambling Study (Swelogs). The JAS has 11 items and seeks to identify early indicators, examine relationships between indicators and assess their capacity to predict future problem progression. The aims of the study were to examine psychometric properties of the JAS (internal consistency and dimensionality) and predictive validity with respect to increased gambling risk and problem gambling onset. The results are based on repeated interviews with 3818 participants. The response rate from the initial baseline wave was 74%. The original sample consisted of a random, stratified selection from the Swedish population register aged between 16 and 84. The results indicate an acceptable fit of a three-factor solution in a confirmatory factor analysis with 'Over consumption,' 'Gambling fallacies,' and 'Reinforcers' as factors. Reinforcers, Over consumption and Gambling fallacies were significant predictors of gambling risk potential and Gambling fallacies and Over consumption were significant predictors of problem gambling onset (incident cases) at 12 month follow up. When controlled for risk potential measured at baseline, the predictor Over consumption was not significant for gambling risk potential at follow up. For incident cases, Gambling fallacies and Over consumption remained significant when controlled for risk potential. Implications of the results for the development of problem gambling, early detection, prevention, and future research are discussed.

Trends and differences in tuberculosis incidences and clustering among natives in Denmark, Sweden and Finland: comparison of native incidences and molecular epidemiology among three low-incidence countries

OBJECTIVES

To compare the epidemiology of tuberculosis (TB) in Denmark, Sweden and Finland, by focusing on the native population in order to identify epidemiologic differences and thus indirectly possible differences in TB control.

METHODS

TB incidence trends from 1990 through 2015 were compared among the countries. In addition, for the periods 2012-2013 and 2014-2015, genotyping data were compared. Genotyping was performed using the 24-locus mycobacterial interspersed repetitive unit-variable number of tandem repeat (MIRU-VNTR) method in Denmark and Sweden. For Finland, spoligotyping in conjunction with the 15-locus MIRU-VNTR method was used for 2012-2013 and translated into the 24-locus MIRU-VNTR when feasible, and for 2014-2015 only MIRU-VNTR was used. Both incidence trends and molecular epidemiology were assessed for native cases.

RESULTS

The average annual rate of change in TB incidence for native Danes was -2.4% vs. -6.1% and -6.9% for native Swedes and Finns respectively. In 2012-2013 Denmark had 52 native cases in the largest transmission chain vs. three cases in Sweden and ten in Finland, and during the same period the clustering rate for native Danes was 48.8% vs. 6.5% and 18.2% for native Swedes and Finns respectively. For 2014-2015, a similar pattern was seen.

CONCLUSIONS

The decline of TB among natives in Denmark is slower than for Sweden and Finland, and it seems Denmark has more active transmission among natives. The focused assessment on basic native TB epidemiology reveals striking differences in TB transmission among otherwise similar low-TB-incidence countries.

Gambling Motives in a Representative Swedish Sample of Risk Gamblers

Motives for gambling have been shown to be associated with gambling involvement, and hence important in the understanding of the etiology of problem gambling. The aim of this study was to describe differences in gambling motives in different subgroups of lifetime risk gamblers, categorized by: age, gender, alcohol- and drug habits and type of game preferred, when considering the level of risk gambling. A random Swedish sample (n = 19,530) was screened for risk gambling, using the Lie/Bet questionnaire. The study sample (n = 257) consisted of the respondents screening positive on Lie/Bet and completing a postal questionnaire about gambling and motives for gambling (measured with the NODS-PERC and the RGQ respectively). When considering the level of risk gambling, motives for gambling were not associated with gender, whereas younger persons gambled for the challenge more often than did older participants. Card/Casino and Sport gamblers played to a greater extent for social and challenge reasons then did Lotto/Bingo-gamblers. EGM-gamblers played more for coping reasons than did Lotto/Bingo gamblers. However, this association turned non-significant when considering the level of risk gambling. Moderate risk gamblers played for the challenge and coping reasons to a greater extent than low risk gamblers motives for gambling differ across subgroups of preferred game and between gamblers with low and moderate risk. The level of risk gambling is intertwined with motives for gambling and should be considered when examining gambling reasons.

Acute Neurological Illness in a Kidney Transplant Recipient Following Infection With Enterovirus-D68: An Emerging Infection?

We report the first case of enterovirus-D68 infection in an adult living-donor kidney transplant recipient who developed rapidly progressive bulbar weakness and acute flaccid limb paralysis following an upper respiratory infection. We present a 45-year-old gentleman who underwent pre-emptive living-donor kidney transplantation for IgA nephropathy. Eight weeks following transplantation, he developed an acute respiratory illness from enterovirus/rhinovirus that was detectable in nasopharyngeal (NP) swabs. Within 24 h of onset of respiratory symptoms, the patient developed binocular diplopia which rapidly progressed to multiple cranial nerve dysfunctions (acute bulbar syndrome) over the next 24 h. Within the next 48 h, asymmetric flaccid paralysis of the left arm and urinary retention developed. While his neurological symptoms were evolving, the Centers for Disease Control reported that the enterovirus strain from the NP swabs was, in fact, Enterovirus-D68 (EV-D68). Magnetic resonance imaging of the brain demonstrated unique gray matter and anterior horn cell changes in the midbrain and spinal cord, respectively. Constellation of these neurological symptoms and signs was suggestive for postinfectious encephalomyelitis (acute disseminated encephalomyelitis [ADEM]) from EV-D68. Treatment based on the principles of ADEM included intensive physical therapy and other supportive measures, which resulted in a steady albeit slow improvement in his left arm and bulbar weakness, while maintaining stable allograft function.

Tuberculosis control in big cities and urban risk groups in the European Union: a consensus statement

In low-incidence countries in the European Union (EU), tuberculosis (TB) is concentrated in big cities, especially among certain urban high-risk groups including immigrants from TB high-incidence countries, homeless people, and those with a history of drug and alcohol misuse. Elimination of TB in European big cities requires control measures focused on multiple layers of the urban population. The particular complexities of major EU metropolises, for example high population density and social structure, create specific opportunities for transmission, but also enable targeted TB control interventions, not efficient in the general population, to be effective or cost effective. Lessons can be learnt from across the EU and this consensus statement on TB control in big cities and urban risk groups was prepared by a working group representing various EU big cities, brought together on the initiative of the European Centre for Disease Prevention and Control. The consensus statement describes general and specific social, educational, operational, organisational, legal and monitoring TB control interventions in EU big cities, as well as providing recommendations for big city TB control, based upon a conceptual TB transmission and control model.

Challenges in diagnosing extrapulmonary tuberculosis in the European Union, 2011

In the European Union (EU) 72,334 tuberculosis (TB) cases were notified in 2011, of which 16,116 (22%) had extrapulmonary tuberculosis (EPTB). The percentage of TB cases with EPTB ranged from 4% to 48% in the reporting countries. This difference might be explained by differences in risk factors for EPTB or challenges in diagnosis. To assess the practices in diagnosis of EPTB we asked European Union/European Economic Area (EU/EEA) countries to participate in a report describing the diagnostic procedures and challenges in diagnosing EPTB. Eleven EU Member States participated and reports showed that in the majority EPTB is diagnosed by a pulmonologist, sometimes in collaboration with the doctor who is specialised in the organ where the symptoms presented. In most countries a medical history and examination is followed by invasive procedures, puncture or biopsy, to collect material for confirmation of the disease (by culture/histology/cytology). Some countries also use the tuberculin skin test or an interferon-gamma-release-assay. A wide variety of radiological tests may be used. Countries that reported challenges in the diagnosis of EPTB reported that EPTB is often not considered because it is a rare disease and most medical professionals will not have experience in diagnosing EPTB. The fact that EPTB can present with a variety of symptoms that may mimic symptoms of other pathologies does pose a further challenge in diagnosis. In addition, obtaining an appropriate sample for confirmation of EPTB was frequently mentioned as a challenge. In summary, diagnosis of EPTB poses challenges due to the diversity of symptoms with which EPTB may present, the low level of suspicion of clinicians, and due to the difficulty in obtaining an adequate sample for confirmation.

Challenges in diagnosing extrapulmonary tuberculosis in the European Union, 2011

In the European Union (EU) 72,334 tuberculosis (TB) cases were notified in 2011, of which 16,116 (22%) had extrapulmonary tuberculosis (EPTB). The percentage of TB cases with EPTB ranged from 4% to 48% in the reporting countries. This difference might be explained by differences in risk factors for EPTB or challenges in diagnosis. To assess the practices in diagnosis of EPTB we asked European Union/European Economic Area (EU/EEA) countries to participate in a report describing the diagnostic procedures and challenges in diagnosing EPTB. Eleven EU Member States participated and reports showed that in the majority EPTB is diagnosed by a pulmonologist, sometimes in collaboration with the doctor who is specialised in the organ where the symptoms presented. In most countries a medical history and examination is followed by invasive procedures, puncture or biopsy, to collect material for confirmation of the disease (by culture/histology/cytology). Some countries also use the tuberculin skin test or an interferon-gamma-release-assay. A wide variety of radiological tests may be used. Countries that reported challenges in the diagnosis of EPTB reported that EPTB is often not considered because it is a rare disease and most medical professionals will not have experience in diagnosing EPTB. The fact that EPTB can present with a variety of symptoms that may mimic symptoms of other pathologies does pose a further challenge in diagnosis. In addition, obtaining an appropriate sample for confirmation of EPTB was frequently mentioned as a challenge. In summary, diagnosis of EPTB poses challenges due to the diversity of symptoms with which EPTB may present, the low level of suspicion of clinicians, and due to the difficulty in obtaining an adequate sample for confirmation.

Internet-based treatment of pathological gambling with a three-year follow-up

Effective therapies for pathological gambling exist, but their use is limited to about 10% of the target population. In an attempt to lower the barriers for help, Internet-based cognitive behavioural therapy (ICBT) has been shown to be effective when delivered to anon-depressed sample with pathological gambling. This study sought to extend this finding to a larger, more representative population, and also test a model to predict responder status. Following advertisement, a total of 284 participants started an 8-week ICBT programme with minimal therapist contact via e-mail and weekly telephone calls of less than 15 min. The average time spent on each participant, including telephone conversations, e-mail, and administration, was 4 h. In addition to a mixed effects model to evaluate the effectiveness of the treatment, two logistic regression analyses were performed with the following eight pre-defined response predictor variables: work-life satisfaction, primary gambling activity, debts due to gambling, social support, personal yearly salary, alcohol consumption, stage of change, and dissociative gambling. ICBT resulted in statistically significant reductions in the scores of pathological gambling, anxiety, and depression as well as an increase in quality of life compared to pre-treatment levels. Follow-ups carried out in the treatment group at 6, l8, and 36 months indicated that treatment effects were sustained. Using the eight predictor variable model rendered an acceptable predictive ability to identify responders both at post-test (AUC = .72, p < .01) and at 36-month follow-up (AUC = .70, p < .01). We conclude that ICBT for pathological gamblers, even if depressed, can be effective and that outcome can partly be predicted by pre-treatment characteristics.

Risk of tuberculosis in a large sample of patients with coeliac disease--a nationwide cohort study

BACKGROUND

Research suggests a positive association between coeliac disease and tuberculosis (TB), but that research has often been limited to in-patients and small sample size. We examined the relationship between TB and coeliac disease.

AIM

To examine the association of TB and coeliac disease.

METHODS

We collected biopsy data from all pathology departments in Sweden (n=28) to identify individuals who were diagnosed with coeliac disease between 1969 and 2007 (Marsh 3: villous atrophy; n=29,026 unique individuals). Population-based sex- and age-matched controls were selected from the Total Population Register. Using Cox regression, we calculated hazard ratios (HRs) for TB from data in the Swedish national health registers.

RESULTS

Individuals with coeliac disease were at increased risk of TB (HR=2.0; 95% CI=1.3-3.0) (during follow-up, 31 individuals with coeliac disease and 74 reference individuals had a diagnosis of TB). The absolute risk of TB in patients with coeliac disease was 10/100,000 person-years with an excess risk of 5/100,000. Risk estimates were the highest in the first year. Restricting our outcome to a diagnosis of TB confirmed by (I) a record of TB medication (HR=2.9; 95% CI=1.0-8.3), (II) data in the National Surveillance System for Infectious Diseases in Sweden (HR=2.6; 95% CI=1.3-5.2) or (III) positive TB cultivation (HR=3.3; 95% CI=1.6-6.8) increased risk estimates. The positive association between coeliac disease and TB was also observed before the coeliac disease diagnosis (odds ratio=1.6; 95% CI=1.2-2.1).

CONCLUSION

We found a moderately increased risk of tuberculosis in patients with coeliac disease.

An overview of prevalence surveys of problem and pathological gambling in the Nordic countries

Estimates of the prevalence of gambling problems among adults by sampling from whole population registries have been made in Finland, Iceland, Norway, and Sweden. The studies in Norway and Sweden are fairly similar, showing a higher prevalence in Sweden according to the South Oaks Gambling Screen Revised (SOGS-R), and similar prevalence according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) screens. The difference is unexpected because Norway has relatively more gambling machines and Norwegian citizens spend more money on gambling. However, the low response rates in Norway may explain the result. Preliminary results from Iceland (2005) with a DSM-IV screen do not differ from those from Norway and Sweden concerning prevalences of pathological gambling, but differ from Norway concerning problem gamblers. However, different DSM-IV screens were used in the three countries, and response rates differed. With these reservations, the past-year prevalence of pathological gambling in Iceland, Norway, and Sweden is about 0.3%, as estimated from DSM-IV screens. Studies of gambling problems among young people have only been performed in Norway.

Mental and somatic health in a non-clinical sample 10 years after a diagnosis of encopresis

The aim of this study was to assess the relation between the diagnosis of encopresis at 8 and 10 years of age, and mental and somatic health 10 years later. The importance of type of encopresis (primary or secondary) at 8 years was also studied. Subjects were a non-clinical encopretic sample (N=73) and control subjects (N=75) [2]. Seven assessment variables from conscription surveys provided information about mental and somatic health status at 18 years of age. Former encopretics (n=66) did not differ significantly from the controls (n=67) at 18 years of age, although there were consistent, small negative differences. The boys who at 10 years of age had still been encopretic did not differ significantly at 18 years of age from the boys who at 10 years had recovered from encopresis, and the signs indicating the small differences varied. For former primary and secondary encopretic boys, there were two significant differences, the men in the secondary group being more often exempted from conscription than the primary group and the control cases. The results indicate that boys with non-clinical encopresis show only small, if any, mental and somatic disturbances at the beginning of adulthood. Comprehensive investigations of encopretic patients are recommended as important clinical problems, in addition to encopresis, might be present.

Late detection of a shigellosis outbreak in a school in Madrid

Even though shigellosis in Spain is rare, an indigenous outbreak is occasionally detected. We describe an outbreak in a school in Madrid caused by person-to-person transmission of Shigella sonnei. After the detection of Shigella sonnei in a stool sample from a 3 year old girl, an investigation at her school was initiated. Questionnaires were distributed to the parents of 520 pupils attending the school. A case was defined as a school case if it was the first case in a child's household, and as a household case if other members of the household had fallen ill first. We identified 88 cases (60 pupils and 28 of their family members). The attack rate (AR) was 12% in the school and 32% in the families. There was a significant association between higher AR and lower age. The outbreak lasted for two months. The length and the shape of the epidemic curve of the 60 cases in pupils suggests person-to-person transmission. Shigella sonnei isolated from 5 different cases were typed by pulsed field gel electrophoresis (PFGE) and was found to be an identical strain. The prolonged duration of the outbreak was probably due to delayed detection, and stopped as soon as control measures were introduced.

Late detection of a shigellosis outbreak in a school in Madrid

Even though shigellosis in Spain is rare, an indigenous outbreak is occasionally detected. We describe an outbreak in a school in Madrid caused by person-to-person transmission of Shigella sonnei. After the detection of Shigella sonnei in a stool sample from a 3 year old girl, an investigation at her school was initiated. Questionnaires were distributed to the parents of 520 pupils attending the school. A case was defined as a school case if it was the first case in a child’s household, and as a household case if other members of the household had fallen ill first. We identified 88 cases (60 pupils and 28 of their family members). The attack rate (AR) was 12% in the school and 32% in the families. There was a significant association between higher AR and lower age. The outbreak lasted for two months. The length and the shape of the epidemic curve of the 60 cases in pupils suggests person-to-person transmission. Shigella sonnei isolated from 5 different cases were typed by pulsed field gel electrophoresis (PFGE) and was found to be an identical strain. The prolonged duration of the outbreak was probably due to delayed detection, and stopped as soon as control measures were introduced.

Quantitative collagen as a golden standard in differential diagnosing of fibrotic changes in liver tissue

Determining a presence and degree of liver fibrosis provides means for diagnosing disease related processes. We have used two data mining methods, discriminant and regression analyses, to acquire knowledge from the data of 211 patients. We have shown and discussed that quantitative collagen has a distinguished discriminating power and can serve as a golden standard. We have additionally succeeded to obtain a formula consisting of standardised blood tests that can replace quantitative collagen. Practical implications of this is a non-invasive and cost efficient patient examination. All the results are now left for clinical evaluation and so is the current way of histopathological classifications.

Identification and characterization of a highly conserved protein absent in the Alport syndrome (A), mental retardation (M), midface hypoplasia (M), and elliptocytosis (E) contiguous gene deletion syndrome (AMME)

We recently described a novel contiguous gene deletion syndrome (AMME) in Xq22.3 that includes Alport syndrome (A), mental retardation (M), midface hypoplasia (M), and elliptocytosis (E). While the Alport syndrome is due to deletion of the COL4A5 gene, no other genes are known in the region with the exception of our recent finding of the FACL4 gene. In our effort to isolate additional genes from the deleted region, we have identified the gene named AMMECR1 (Alport syndrome, mental retardation, midface hypoplasia, and elliptocytosis chromosomal region gene 1). RACE experiments and screening of cDNA libraries enabled us to obtain the entire ORF of the gene (1002 bp) followed by about 2 kb of 3'UTR. AMMECR1 is composed of six exons, shows a ubiquitous 6.5-kb transcript, and codes for a protein with a molecular mass of 35.5 kDa. Sequence analysis revealed that this gene is conserved in several species ranging from Caenorhabditis elegans and yeast to micro-organisms. Exon 2 of AMMECR1 encodes a domain consisting of six amino acids identically conserved throughout the course of evolution and whose function is as yet unknown. Analysis of the predicted protein product using ExPAsy tools raises the possibility that the gene may code for a regulatory factor potentially involved in the development of AMME contiguous gene deletion syndrome.

On the Singlet Spectrum of ZrS

Three electronic transitions in the singlet manifold of the zirconium sulphide (ZrS) molecule have been rotationally analyzed. They are the B1Pi-X1Sigma+, C1Sigma+-X1Sigma+, and E1Sigma+-X1Sigma+ systems with (0,0) band heads at 924.60, 731.51, and 494.47 nm, respectively. The ground state X1Sigma+ has an equilibrium bond distance of 2.15661(4) Å. Perturbations in the B1Pi and C1Sigma+ states are discussed. Copyright 1998 Academic Press.

New chemical descriptors relevant for the design of biologically active peptides. A multivariate characterization of 87 amino acids

In this study 87 amino acids (AA.s) have been characterized by 26 physicochemical descriptor variables. These descriptor variables include experimentally determined retention values in seven thin-layer chromatography (TLC) systems, three nuclear magnetic resonance (NMR) shift variables, and 16 calculated variables, namely six semiempirical molecular orbital indices, total, polar, and nonpolar surface area, van der Waals volume of the side chain, log P, molecular weight, and four indicator variables describing hydrogen bond donor and acceptor properties, and side chain charge. In the present study, the data from a previous characterization of 55 AA.s from our laboratory have been extended with data for 32 additional AA.s and 14 new descriptor variables. The new 32 AA.s were selected to represent both intermediate and more extreme physicochemical properties, compared to the 20 coded AA.s. The new extended and updated principal property scales, the z-scales, were calculated and aligned to previously reported z(old)-scales. The appropriateness of the extended z-scales were validated by the use in quantitative sequence-activity modeling (QSAM) of 89 elastase substrate analogues and in a QSAM of 29 neurotensin analogues.

beta-cell-specific inactivation of the mouse Ipf1/Pdx1 gene results in loss of the beta-cell phenotype and maturity onset diabetes

To study the late beta-cell-specific function of the homeodomain protein IPF1/PDX1 we have generated mice in which the Ipf1/Pdx1 gene has been disrupted specifically in beta cells. These mice develop diabetes with age, and we show that IPF1/PDX1 is required for maintaining the beta cell identity by positively regulating insulin and islet amyloid polypeptide expression and by repressing glucagon expression. We also provide evidence that IPF1/PDX1 regulates the expression of Glut2 in a dosage-dependent manner suggesting that lowered IPF1/PDX1 activity may contribute to the development of type II diabetes by causing impaired expression of both Glut2 and insulin.