Overtime: Long-Term Betting Trajectories Among Highly-Involved and Less-Involved Online Sports Bettors

Online sports gambling involvement is discontinuous in nature, with small groups of highly involved gamblers exhibiting betting behavior that is distinctly greater than other gamblers. There is some question about whether these groups, defined by exceedingly high levels of play, also have equivalently high rates of gambling problems, and whether they maintain these play levels over time. The current study builds on past work by examining the long-term trajectories of play and voluntary self-exclusion patterns across two years among a cohort of 32,262 highly-involved and less-involved online sports gamblers. We also examine the relative importance of betting behavior change as a risk factor for gambling problems by testing whether high involvement as compared to escalation of involvement is a better predictor of future self-exclusion. Measures included betting activities, transactional activities, and self-exclusion activities on a European online betting platform between February 2015 and January 2017. Results showed that bettors who were most highly involved in the first 8 months of the study in terms of number of bets and net loss were more likely to continue gambling on the platform in months 9-24 than others. Bettors who were most highly involved in the first 8 months of the study in terms of net loss and amount wagered were more likely to use self-exclusion than others, and more likely to have multiple self-exclusions. Escalations in frequency of play and average bet size within the first 8 months emerged as significant predictors of self-exclusion, even when controlling for high involvement.

Multimodal monitoring in patients with acute brain injury - A survey from critical care providers

BACKGROUND

Multimodal neuromonitoring (MMM) aims to improve outcome after acute brain injury, and thus admission in specialized Neurocritical Care Units with potential access to MMM is necessary. Various invasive and noninvasive modalities have been developed, however there is no strong evidence to support monitor combinations nor is there a known standardized approach. The goal of this study is to identify the most used invasive and non-invasive neuromonitoring modalities in daily practice as well as ubiquitousness of MMM standardization.

METHODS

In order to investigate current availability and protocolized implementation of MMM among neurocritical care units in US and non-US intensive care units, we designed a cross-sectional survey consisting of a self-administered online questionnaire of 20 closed-ended questions disseminated by the Neurocritical Care Society.

RESULTS

Twenty-one critical care practitioners responded to our survey with a 76% completion rate. The most commonly utilized non-invasive neuromonitoring modalities were continuous electroencephalography followed by transcranial doppler. The most common invasive modalities were external ventricular drain followed by parenchymal intracranial pressure (ICP) monitoring. MMM is most utilized in patients with subarachnoid hemorrhage and there were no differences regarding established institutional protocol, 24-h cEEG availability and invasive monitor placement between teaching and non-teaching hospitals. MMM is considered standard of care in 28% of responders' hospitals, whereas in 26.7% it is deemed experimental and only done as part of clinical trials. Only 26.7% hospitals use a computerized data integration system.

CONCLUSION

Our survey revealed overall limited use of MMM with no established institutional protocols among institutions. Ongoing research and further standardization of MMM will clarify its benefit to patients suffering from severe brain injury.

Reversible Cerebral Vasoconstriction Syndrome and Female Sex: A Narrative Review

Reversible cerebral vasoconstriction syndrome (RCVS) refers to segmental, multifocal constriction of intracranial arteries along with acute headache and resolves within weeks. It occurs more commonly in women, and 1 well-known manifestation of RCVS is postpartum angiopathy. Furthermore, the female sex is included in scoring systems designed to assist with diagnosing RCVS. Nonetheless, the literature is mixed regarding the true role of female and pregnancy-related factors in the pathophysiology of RCVS, and it is similarly unclear whether management of this disorder differs by sex. Given the association of RCVS with female sex and the importance of highlighting, recognizing, and managing stroke etiologies in women, herein, the author reviews what is currently known and unknown about the topic of RCVS in women.

Leaving no culture undrawn: Time to revisit the CLABSI and CAUTI metrics

Central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are quality metrics for many ICUs, and financial ramifications can be applied to hospitals and providers who perform poorly on these measures. Despite some perceived benefits to tracking these metrics, there are a range of issues associated with this practice: lack of a solid evidence base that documenting them has led to decreased infection rates, moral distress associated with identifying these infections, problems with their definitions, and others. We discuss each of these concerns while also including international perspectives then recommend practical steps to attempt to remediate use of the CLABSI and CAUTI metrics. Specifically, we suggest forming a task force consisting of key stakeholders (e.g., providers, Centers for Medicare & Medicaid Services (CMS), patients/families) to review CLABSI and CAUTI-related issues and then to create a summary statement containing recommendations to improve the use of these metrics.

Second Session at the Virtual Poker Table: A Contemporary Study of Actual Online Poker Activity

Technological advancements and worldwide television exposure led to a poker boom in the early 2000s, and poker (both live and online) has retained some of that popularity today. The present study examined online poker playing trends based on actual electronic betting records data for 2489 subscribers to a major global internet gambling operator from 2015 to 2017. We found that overall financial involvement (median total overall spend: €439.7) and time commitment (median number of sessions: 43) during the two-year study period were relatively moderate. We identified the top 1% by total overall spend as a subgroup of highly involved players with disproportionately higher financial involvement (median total overall spend: €272,581.4) and time commitment (median number of sessions: 1149). Our results were similar to those reported in LaPlante et al.'s (Comput Hum Behav 25(3):711-717, 2009. https://doi.org/10.1016/j.chb.2008.12.027 ) study of online poker betting records, suggesting that players' levels of involvement are similar to those from ten years ago despite numerous changes to the online poker environment. We also analyzed records of deposits and withdrawals, and we observed similar indicators of moderate gambling behavior within the overall sample (median two-year total amount deposited: €176.4). In contrast to popular beliefs about internet gambling, in our sample, most online poker play was arguably moderate. However, a small percentage of highly involved players play poker at extreme levels and require closer scrutiny.

External ventricular drain use is associated with functional outcome in aneurysmal subarachnoid hemorrhage

Purpose

External ventricular drains (EVD) are commonly used in aneurysmal subarachnoid hemorrhage (aSAH) patients and can be life-saving by diverting cerebrospinal fluid. However, the overall relationship between EVD use and outcome is poorly understood.

Methods

In an exploratory analysis of an aSAH patient cohort, we examined EVD use in relation to modified Rankin Scale (mRS) at hospital discharge and at 6 months (unfavorable outcome = mRS > 2) using univariable and multivariable analyses.

Results

EVDs were placed in 31 of 56 (55.4%) patients and more often in women than men (66.7% vs 35.0%, p = 0.022) despite similar rates of hydrocephalus. Women had greater ICU [18 (13.5–25) vs 11.5 (6.5–18.5) days, p = 0.014] and hospital lengths of stay (LOS) [20.5 (16.5–34) vs 13.5 (10.5–27) days, p = 0.015] than men and greater mRS at discharge [4 (3–5) vs 3 (2–3.5), p = 0.011] although mRS at 6 months was similar. Patients with EVDs had longer ICU and hospital LOS and greater mRS at discharge [5 (3–6) vs 2 (2–3), p < 0.001] and at 6 months [4 (2–6) vs 1 (0–2), p = 0.001] than those without an EVD. In multivariable models, EVD use was associated with unfavorable 6-month outcome accounting for age, sex, and admission modified Fisher scale, but not in models adjusting for Hunt and Hess scale and World Federation of Neurological Surgeons scale.

Conclusion

In an aSAH cohort, the use of EVDs was associated with female sex and longer LOS, and may be linked to functional outcomes at discharge and at 6 months, although these associations warrant further investigation.

COVID-19 and telehealth in the intensive care unit setting: a survey

Background

Coronavirus disease (COVID-19) has led to changes in how healthcare is delivered. Here, through the administration of surveys, we evaluated telehealth use and views in US intensive care units (ICUs) during the pandemic.

Methods

From June 2020 to July 2021, voluntary, electronic surveys were provided to ICU leaders of Johns Hopkins Medical Institution (JHMI) hospitals, members of the Neurocritical Care Society (NCS) who practice in the US, and Society of Critical Care Medicine (SCCM) members practicing adult medicine.

Results

Response rates to our survey were as follows: 18 of 22 (81.8%) JHMI-based ICU leaders, 22 of 2218 (1.0%) NCS members practicing in the US, and 136 of 13,047 (1.0%) SCCM members. COVID-19 patients were among those cared for in the ICUs of 77.7, 86.4, and 93.4% of respondents, respectively, in April 2020 (defined as the peak of the pandemic). Telehealth technologies were used by 88.9, 77.3, and 75.6% of respondents, respectively, following the start of COVID-19 while only 22.2, 31.8, and 43.7% utilized them prior. The most common telehealth technologies were virtual meeting software and telephone (with no video component). Provider, nurse, and patient communications with the patient’s family constituted the most frequent types of interactions utilizing telehealth. Most common reasons for telehealth use included providing an update on a patient’s condition and conducting a goals of care discussion. 93.8–100.0% of respondents found telehealth technologies valuable in managing patients. Technical issues were noted by 66.7, 50.0, and 63.4% of respondents, respectively.

Conclusions

Telehealth use increased greatly among respondents following the start of COVID-19. In US ICUs, telehealth technologies found diverse uses during the pandemic. Future studies are needed to confirm our findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08197-7.

Sustainability of Intravenous Alteplase Administration via Telephone-Based Consult: Data from a US Health System

OBJECTIVES

Telephone-based consults using remote imaging review and standardization of evaluation but without visualizing the patient are an alternative to video-telestroke consults but are less well-studied. We aim to demonstrate the safety and efficacy of telephone-based acute consults in which IV tPA was administered over nearly a decade within one health system.

MATERIALS AND METHODS

Clinical characteristics and outcomes were compared between a community hospital (spoke; uses telephone-based consults) and the academic comprehensive stroke center (hub; uses oversight of on-site neurology trainees) from 2008-2017. In both institutions acute therapy decisions are made by the same stroke neurologists.

RESULTS

2518 acute ischemic stroke consults were evaluated at hub and 2049 at spoke. Of these, 191 patients received IV tPA at hub and 184 at spoke. Patients at hub were younger (median (IQR): 61 (51-74) vs 69 (56-81) years, p = 0.0021) but admission National Institutes of Health Stroke Scale (NIHSS) was similar. There were no differences between door-to-needle times (69 (56-101) vs 69 (51-92) minutes, p = 0.13), last known well-to-tPA times (157 (113-202) vs 144 (110-175) minutes, p = 0.053), and rates of overall intracranial hemorrhage (ICH) after tPA (n = 23 (13.5%) vs 31 (17.0%), p = 0.35). In multivariable analyses, hospital was not an independent predictor of ICH after tPA.

CONCLUSIONS

In a large dataset over nearly a decade, assessment for IV tPA administration using telephone assessment along with imaging review and emergency department standardization resulted in similar safety and outcomes as in the presence of on-site stroke/neurology expertise. Future studies are needed to confirm these findings.

Developing and validating lower risk online gambling thresholds with actual bettor data from a major Internet gambling operator

OBJECTIVE

To help individuals avoid potential negative consequences associated with their gambling, researchers have developed lower risk limits for time and financial involvement among populations of land-based gamblers. The present study extended these efforts to online gambler populations with prospective longitudinal data.

METHOD

We used receiver operating characteristic curve analysis and logistic regression models predicting a positive Brief Biosocial Gambling Screen (BBGS; Gebauer et al., Canadian Journal of Psychiatry, 55, 2010, 82-90) to develop lower risk limits for six measures of gambling involvement among subscribers to an online gambling operator. We also tested the utility of these six newly developed online limits and three existing land-based limits for the BBGS outcome and proxies for gambling problems including: (a) voluntary self-limiting, (b) voluntary self-exclusion, (c) closing one's account, and (d) being assigned a flag for potential problem gambling by customer service.

RESULTS

We identified five optimal limits for lower risk online gambling with adequate sensitivity and specificity for predicting BBGS-positive status, and four of those that also received additional empirical support. These four empirically supported gambling limits were: (a) wagering 167.97 Euros or less each month; (b) spending 6.71% or less of one's annual income on online gambling wagers; (c) losing 26.11 Euros or less on online gambling per month; and (d) demonstrating variability (i.e., standard deviation) in daily amount wagered of 35.14 Euros or less during one's duration active.

CONCLUSIONS

Our findings have implications for lower risk gambling limits research and suggest that unique limits might apply to online and land-based gambler populations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Recommendations for improving adolescent addiction recovery support in six northwest tribal communities

American Indian and Alaska Native (AI/AN) communities offer tangible and intangible resources, including centuries of indigenous wisdom and resiliency, to support their young people in recovery from substance use disorders. At the same time, tribal youth returning home from residential or inpatient treatment are vulnerable to relapse, especially if they encounter the same environmental triggers in which their substance misuse developed. This study endeavored to learn about community stakeholder perceptions of existing strengths and needs for supporting recovering adolescents among six tribal communities of the Inland Northwest. Using a Tribal Participatory Research approach, we conducted Group Level Assessments with key stakeholders representing educators/coaches, medical and behavioral health providers, social service providers, cultural leaders/elders, and legal professionals among each participating tribe (N = 166). We used content analysis to identify emergent themes among participants' recommendations for improving recovery support. The five emergent themes were (1) Communication, Collaboration, and Accountability among Tribal Departments and Agencies; (2) Community-wide Education; (3) The Importance of Providing Wraparound/Supportive Services; (4) Youth-focused Education, Services, and Events; and (5) Recovery Coaching Model. AI/AN culture was infused within nearly all recommendations for improving recovery support that composed these themes. We discuss specific ways to implement these recommendations, including the forthcoming development of a culturally-grounded community-wide mental health training program developed specifically for, and with, these tribes.

Treatment of Subarachnoid Hemorrhage-associated Delayed Cerebral Ischemia With Milrinone: A Review and Proposal

Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage continues to be associated with high levels of morbidity and mortality. This complication had long been thought to occur secondary to severe cerebral vasospasm, but expert opinion now favors a multifactorial etiology, opening the possibility of new therapies. To date, no definitive treatment option for DCI has been recommended as standard of care, highlighting a need for further research into potential therapies. Milrinone has been identified as a promising therapeutic agent for DCI, possessing a mechanism of action for the reversal of cerebral vasospasm as well as potentially anti-inflammatory effects to treat the underlying etiology of DCI. Intra-arterial and intravenous administration of milrinone has been evaluated for the treatment of DCI in single-center case series and cohorts and appears safe and associated with improved clinical outcomes. Recent results have also brought attention to the potential outcome benefits of early, more aggressive dosing and titration of milrinone. Limitations exist within the available data, however, and questions remain about the generalizability of results across a broader spectrum of patients suffering from DCI. The development of a standardized protocol for milrinone use in DCI, specifically addressing areas requiring further clarification, is needed. Data generated from a standardized protocol may provide the impetus for a multicenter, randomized control trial. We review the current literature on milrinone for the treatment of DCI and propose a preliminary standardized protocol for further evaluation of both safety and efficacy of milrinone.

Changes to the playing field: A contemporary study of actual European online sports betting

BACKGROUND AND AIMS

Online sports wagering is a popular and still growing gambling activity around the world. Like other types of gambling, it can lead to problems that include devastating financial, social, and health-related harms. The first analysis of actual online sports wagering activity (LaBrie et al., 2007) suggested that levels of financial and time involvement were more moderate than anticipated from earlier self-report studies. However, these findings are now more than a decade old.

METHODS

The current study examined actual online sports wagering activity of a similar cohort of 32,262 gamblers who subscribed to a European online betting platform in February 2015 to understand how sports betting might have changed in ten years. Measures included subscriber characteristics, betting activities, and transactional activities.

RESULTS

Players placed a median of 15 bets during the 8-month study period, made a median of 2.5 bets per betting day, had a median bet size of 6.1 euros, and experienced a median net loss of 25 euros. We were able to distinguish highly involved bettors in the top 2% of total wagered, net loss, and number of bets, whose behavior differed from that of the rest of the sample.

DISCUSSION AND CONCLUSIONS

Sports wagering behavior has remained relatively stable over time despite legislative changes and an increase in popularity, with a small subset of subscribers exhibiting disproportionately high engagement, transactional activity, and in-game betting. Further investigation of individual trajectories of wagering behavior and engagement with different types of sports wagering products is merited.

Green Flags and headache: A concept study using the Delphi method

OBJECTIVE

The aim of this study was to collect and rate Green Flags, that is, symptoms or pieces of information indicating that a patient is more likely to suffer from a primary than from a secondary headache.

BACKGROUND

When assessing headaches, a central question to be answered is whether the pain is primary or secondary to another disorder. To maximize the likelihood of a correct diagnosis, relevant signs and symptoms must be sought, identified, and weighed against each other.

METHODS

The project was designed as a Delphi study. In the first round, an expert panel proposed green flags that were rated anonymously in two subsequent rounds. Proposals with an average rating of 4.0 and higher on a scale from 0 to 5 reached consensus.

RESULTS

Five Green Flags reached consensus: (i) "The current headache has already been present during childhood"; (ii) "The headache occurs in temporal relationship with the menstrual cycle"; (iii) "The patient has headache-free days"; (iv) "Close family members have the same headache phenotype"; and (v) "Headache occurred or stopped more than one week ago."

CONCLUSIONS

We propose five Green Flags for primary headache disorders. None being a pathognomonic sign, we recommend searching for both Green Flags and Red Flags. If both are present, a secondary headache should be suspected. Overall, the application of the Green Flag concept in clinical practice is likely to increase diagnostic accuracy and improve diagnostic resource allocation. Prospective studies in clinical populations should be conducted to validate these Green Flags.

Understanding American Indian Youth in Residential Recovery from Substance Use Disorder: Risk and Protective Experiences and Perceived Recovery Support

Historical trauma has contributed to the reality that addiction disproportionately affects tribal communities, including American Indian youth. We sought to understand American Indian youths' own experiences and perceptions of the environments to which they return after completing residential treatment for substance use disorder. We recruited three cohorts of American Indian residents of a substance use disorder treatment facility (N = 40). These residents completed a survey that measured risk and protective factors, as well as actual risk behaviors, including drug use, gambling, and violence. Participants were at risk not only for substance use disorders, but for other negative outcomes, and had elevated scores on several community, family, and school risk factors, including perceived availability of drugs, community disorganization, family history of antisocial behavior, favorable parental attitudes toward drug use, academic failure, and low school commitment. At the same time, they were exposed to community-level and family protective factors, and they engaged in many tribal cultural activities. When compared to a national sample of American Indian students of similar age, youth in our sample scored similarly on protective factors, including indicators of community, family, and school opportunities and rewards for prosocial involvement, as well as family attachment, suggesting potential resources and strengths for supporting recovery.

Evaluating the Computerized Assessment and Referral System (CARS) Screener: Sensitivity and Specificity as a Screening Tool for Mental Health Disorders among DUI Offenders

Background/Purpose: A growing body of evidence suggests that people who are arrested for driving under the influence (DUI) of alcohol are more likely to screen positive for psychiatric disorders than the general population. Additionally, psychiatric comorbidity has been shown to increase vulnerability to criminal re-offense. However, DUI programs face many barriers to screening for psychiatric disorders. This paper evaluates the sensitivity and specificity of a screening tool developed for these programs, the Computerized Assessment and Referral System (CARS) Screener. Methods: We used data from 381 DUI offenders in Massachusetts, as well as a secondary data source, the National Comorbidity Survey-Replication (NCS-R: N = 9,282) to examine the accuracy of the CARS Screener when compared to full assessment. Results: Based on both sets of analyses, we found that the CARS Screener offers a sensitive and specific method to screen for many psychiatric disorders. Specifically, the CARS Screener has a high sensitivity and specificity for bipolar disorder, intermittent explosive disorder, depressive disorders, generalized anxiety disorder, alcohol and drug use disorders, gambling disorder, post-traumatic stress disorder, panic attacks, and social phobia. Conclusion: The CARS Screener appears to be an effective tool that will help DUI programs better understand and address the mental health issues facing their clients.

Primary intraventricular hemorrhage outcomes in the CLEAR III trial

BACKGROUND

Intraventricular hemorrhage occurs due to intracerebral hemorrhage with intraventricular extension or without apparent parenchymal involvement, known as primary intraventricular hemorrhage.

AIMS

We evaluated the prognosis of primary intraventricular hemorrhage patients in the CLEAR III trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage).

METHODS

In patients with primary intraventricular hemorrhage versus those with secondary intraventricular hemorrhage, we compared intraventricular alteplase response and outcomes including modified Rankin Scale, Barthel Index, National Institutes of Health Stroke Scale (NIHSS), and extended Glasgow Outcome Scale (eGOS) at 30, 180, and 365 days. Outcomes were also compared in primary intraventricular hemorrhage patients who received intraventricular alteplase versus placebo (normal saline) and in matched primary and secondary intraventricular hemorrhage patients using inverse-probability-weighted regression adjustment.

RESULTS

Of 500 patients enrolled in CLEAR III, 46 (9.2%) had primary intraventricular hemorrhage. Combining both treatment groups, primary intraventricular hemorrhage patients had larger intraventricular hemorrhage volumes (median: 34.2 mL vs. 20.8 mL, p < 0.01) but similar intraventricular hemorrhage removal (51.0% vs. 59.0%, p = 0.24) compared to secondary intraventricular hemorrhage patients, respectively. Confirming previous studies, primary intraventricular hemorrhage patients achieved better NIHSS, modified Rankin Scale, Barthel Index, and eGOS scores at days 30, 180, and 365, respectively (all p < 0.01), although mortality was similar to secondary intraventricular hemorrhage patients; matching analysis yielded similar results. Primary intraventricular hemorrhage patients who received intraventricular alteplase (n = 19) and saline (n = 27) achieved similar outcomes.

CONCLUSIONS

In CLEAR III, primary intraventricular hemorrhage patients who survived achieved better long-term outcomes than surviving secondary intraventricular hemorrhage patients with similar mortality. Outcomes and safety were similar between primary intraventricular hemorrhage patients receiving alteplase and those receiving saline.

Status Epilepticus, Refractory Status Epilepticus, and Super-refractory Status Epilepticus

PURPOSE OF REVIEW

Status epilepticus, refractory status epilepticus, and super-refractory status epilepticus can be life-threatening conditions. This article presents an overview of the three conditions and discusses their management and outcomes.

RECENT FINDINGS

Status epilepticus was previously defined as lasting for 30 minutes or longer but now is more often defined as lasting 5 minutes or longer. A variety of potential causes exist for status epilepticus, refractory status epilepticus, and super-refractory status epilepticus, but all three ultimately involve changes at the cellular and molecular level. Management of patients with status epilepticus generally requires several studies, with EEG of utmost importance given the pathophysiologic changes that can occur during the course of status epilepticus. Status epilepticus is treated with benzodiazepines as first-line antiepileptic drugs, followed by phenytoin, valproic acid, or levetiracetam. If status epilepticus does not resolve, these are followed by an IV anesthetic and then alternative therapies based on limited data/evidence, such as repetitive transcranial magnetic stimulation, therapeutic hypothermia, immunomodulatory agents, and the ketogenic diet. Scores have been developed to help predict the outcome of status epilepticus. Neurologic injury and outcome seem to worsen as the duration of status epilepticus increases, with outcomes generally worse in super-refractory status epilepticus compared to status epilepticus and sometimes also to refractory status epilepticus.

SUMMARY

Status epilepticus can be a life-threatening condition associated with multiple complications, including death, and can progress to refractory status epilepticus and super-refractory status epilepticus. More studies are needed to delineate the best management of these three entities.

Succinate links atrial dysfunction and cardioembolic stroke

OBJECTIVE

To determine whether altered metabolic profiles represent a link between atrial dysfunction and cardioembolic (CE) stroke, and thus whether underlying dysfunctional atrial substrate may contribute to thromboembolism risk in CE stroke.

METHODS

A total of 144 metabolites were measured using liquid chromatography-tandem mass spectrometry in plasma samples collected within 9 hours of stroke onset in 367 acute stroke patients. Stroke subtype was assigned using the Causative Classification of Stroke System, and CE stroke (n = 181) was compared to non-CE stroke (n = 186). Markers of left atrial dysfunction included abnormal atrial function (P-wave terminal force in lead V1, PTFV₁ >4,000 μV·ms), left atrial enlargement on echocardiography, and frank atrial fibrillation on ECG. Stroke recurrence risk was assessed using CHADS₂ and CHA₂DS₂-VASc scores. Associations between metabolites and CE stroke, atrial dysfunction, and stroke recurrence risk were evaluated using logistic regression models.

RESULTS

Three tricarboxylic acid metabolites-succinate (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.36-2.15, p = 1.37 × 10^-6), α-ketoglutarate (OR 1.62, 95% CI 1.29-2.04, p = 1.62 × 10^-5), and malate (OR 1.58, 95% CI 1.26-1.97, p = 2.57 × 10^-5)-were associated with CE stroke. Succinate (OR 1.36, 95% CI 1.31-1.98, p = 1.22 × 10^-6), α-ketoglutarate (OR 2.14, 95% CI 1.60-2.87, p = 2.08 × 10^-8), and malate (OR 2.02, 95% CI 1.53-2.66, p = 1.60 × 10^-7) were among metabolites also associated with subclinical atrial dysfunction. Of these, succinate was also associated with left atrial enlargement (OR 1.54, 95% CI 1.23-1.94, p = 1.06 × 10^-4) and stroke recurrence based on dichotomized CHADS₂ (OR 2.63, 95% CI 1.68-4.13, p = 3.00 × 10^-6) and CHA₂DS₂-VASc (OR 2.43, 95% CI 1.60-3.68, p = 4.25 × 10^-6) scores.

CONCLUSIONS

Metabolite profiling identified changes in succinate associated with CE stroke, atrial dysfunction, and stroke recurrence, revealing a putative underlying link between CE stroke and energy metabolism.

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.