A randomized trial of brief interventions for problem and pathological gamblers

Limited research exists regarding methods for reducing problem gambling. Problem gamblers (N = 180) were randomly assigned to assessment only control, 10 min of brief advice, 1 session of motivational enhancement therapy (MET), or 1 session of MET plus 3 sessions of cognitive-behavioral therapy. Gambling was assessed at baseline, at 6 weeks, and at a 9-month follow-up. Relative to assessment only, brief advice was the only condition that significantly decreased gambling between baseline and Week 6, and it was associated with clinically significant reductions in gambling at Month 9. Between Week 6 and Month 9, MET plus cognitive-behavioral therapy evidenced significantly reduced gambling on 1 index compared with the control condition. These results suggest the efficacy of a very brief intervention for reduction of gambling among problem and pathological gamblers who are not actively seeking gambling treatment.     

Effect of oral contrast for abdominal computed tomography on emergency department length of stay

Computed tomography of the abdomen and/or pelvis (CTAP) is frequently used in the emergency department (ED) allowing diagnosis of a variety of conditions, but requiring a prolonged period of preparation. To determine whether not requiring oral contrast for CTAP reduces ED length of stay (LOS). Retrospective cohort of adult patients visiting an academic ED over 13 weeks around a radiology protocol change. Before the change, many CTAPs required oral contrast; thereafter, oral contrast was not required. LOS was compared before and after the change among all adult ED patients. Among patients undergoing CTAP, adjusted LOS and time to CTAP were compared using multivariate linear regression. 20,464 adult ED visits occurred over the study period, including 1,806 where a CTAP was performed. Oral contrast usage decreased from 42.5% of CTAP to 12.2% (difference 30.3%, 95% confidence interval 38.7% to 46.3%). There was no change in LOS among all ED visits. Among ED visits where a CTAP was performed, median time to CTAP decreased by 27 min and median LOS decreased by 30 min. Adjusted LOS decreased from 324 min (312–337) to 297 min (285–309). Not routinely requiring oral contrast for CTAP in the ED is associated with a half-hour reduction in LOS among all patients undergoing CTAP.     

Infection of Tick Cells and Bovine Erythrocytes with One Genotype of the Intracellular Ehrlichia Anaplasma marginale Excludes Infection with Other Genotypes

Anaplasma marginale, a tick-borne rickettsial pathogen of cattle, is endemic in several areas of the United States. Many geographic isolates of A. marginale that occur in the United States are characterized by the major surface protein 1a, which varies in sequence and molecular weight due to different numbers of tandem repeats of 28 or 29 amino acids. Recent studies (G. H. Palmer, F. R. Rurangirwa, and T. F. McElwain, J. Clin. Microbiol. 39:631-635, 2001) of an A. marginale-infected herd of cattle in an area of endemicity demonstrated that multiple msp1α genotypes were present but that only one genotype was found per individual bovine. These findings suggested that infection of cattle with other genotypes was excluded. The present study was undertaken to confirm the phenomenon of infection exclusion of A. marginale genotypes in infected bovine erythrocytes and cultured tick cells. Two tick-transmissible isolates of A. marginale, one from Virginia and one from Oklahoma, were used for these studies. In two separate trials, cattle inoculated with equal doses of the two isolates developed infection with only one genotype. Tick cell cultures inoculated with equal doses of the two isolates became infected with only the Virginia isolate of A. marginale. When cultures were inoculated with different ratios of the Oklahoma and Virginia isolates of A. marginale, the isolate inoculated in the higher ratio became established and excluded infection with the other. When cultures with established infections of one isolate were subsequently infected with the other, only the established isolate was detected. We documented infection exclusion during initial infection in cell culture by labeling each isolate with a different fluorescent dye. After 2 days in culture, only a single isolate was detected per cell by fluorescence microscopy. Finally, when Anaplasma ovis infections were established in cultures that were subsequently inoculated with the Virginia or Oklahoma isolate of A. marginale, A. marginale infection was excluded. These studies confirm that infection exclusion occurs with A. marginale in bovine erythrocytes and tick cells, resulting in the establishment of only one genotype, and appears to be the first report of infection exclusion for Anaplasma and Ehrlichia species.     

Genetic association of low density lipoprotein receptor and Alzheimer's disease

The low density lipoprotein receptor (LDLR) is an attractive candidate gene for genetic association with Alzheimer's disease (AD) because: (i) the LDLR is an apolipoprotein E (apoE) receptor, alleles of which have been associated with AD, (ii) LDLR resides at chromosome 19p13.3 within a region linked to AD, and (iii) LDLR modulates the homeostasis of cholesterol, which itself appears associated with AD. Therefore, we evaluated whether LDLR haplotypes alter the odds of AD by performing an association study examining three LDLR single nucleotide polymorphisms (SNPs) in 118 AD patients and 133 non-AD subjects. LDLR genotypes were obtained by TaqMan allelic discrimination assays. Although individual LDLR SNPs were not associated with AD, analyses of unambiguous haplotypes suggested the hypothesis that the 211 LDLR haplotype was associated with reduced odds of AD. We then evaluated this hypothesis in a second study cohort, i.e., the Religious Orders Study. These results supported the hypothesis that the 211 LDLR haplotype is associated with reduced odds of AD. Moreover, these data suggested further associations between LDLR variants and AD. Thus, LDLR variants appear significantly associated with AD and merit additional study.     

Urban health: a look out our windows.

Approximately 80% of Americans live in cities or immediately adjacent communities. Such urban environments are complex amalgams of people of disparate backgrounds, economic status, and expectations, with extraordinary disparities in health status and outcomes between groups just blocks apart. Urban health as a framing paradigm is of recent vintage and offers a perspective on health and disease that integrates clinical medicine and public health and draws on the social and political sciences to seek understanding of the impact of cities on the health of populations and individuals. Ironically, disparate outcomes and increased mortality among poor minority populations in cities are not primarily related to the consequences of the urban epidemics of drugs and violence but rather are due to the increased prevalence and severity of common diseases such as asthma, cardiovascular disease, diabetes, and kidney disease. Several factors may be responsible for such disparities, including stress, racism, perceptions of deprivation, economic inequalities, and lack of access to quality health care. It is time for leaders in medical education and health care delivery to focus on the populations that surround their institutions in order to study urban health and meet the challenge of caring for all the residents of our cities.     

Conservative long-term treatment of children with eosinophilic esophagitis

BackgroundCurrent treatments of eosinophilic esophagitis (EoE), including restrictive diets or glucocorticoids, provide only transient improvement. Proton pump inhibitor (PPI) use in EoE does not lead to histologic improvement; however, the long-term use of PPI on symptoms and prevention of complications has not been evaluated.ObjectiveTo evaluate the use of PPI as maintenance therapy in children with EoE.MethodsEosinophilic esophagitis was diagnosed based on initial endoscopic biopsies and persistent eosinophilic inflammation despite PPI therapy. Inclusion criteria included diagnosis of EoE and PPI use as primary maintenance treatment. Patients were excluded if they were treated with dietary or glucocorticoid therapy. Histologic evidence of inflammation as well as degree of subepithelial fibrosis at presentation was compared with most recent biopsies while receiving PPI therapy.ResultsThirty-eight patients (30 males and 8 females; average age 6.7 ± 5.4 years) fulfilled inclusion criteria. Duration of follow-up was 3.0 ± 2.4 years. At presentation, vomiting was significantly more frequent in the younger patients, whereas dysphagia occurred more frequently in the older patients. At follow-up, 26 patients were asymptomatic, and the remaining 12 patients' symptoms were significantly improved. No complications of stricture or food impaction were seen. Significant eosinophilic inflammation persisted in 28 patients. No difference in degree of subepithelial fibrosis at diagnosis compared with most recent biopsies. The z-scores of the treated EoE patients significantly improved.ConclusionPatients with EoE treated with PPIs show an improvement in symptoms and z-scores despite persistent eosinophilic inflammation. PPI treatment may be useful maintenance therapy in children with EoE.     

Information and Communication Technology to Support Self-Management of Patients with Mild Acquired Cognitive Impairments: Systematic Review

Background

Mild acquired cognitive impairment (MACI) is a new term used to describe a subgroup of patients with mild cognitive impairment (MCI) who are expected to reach a stable cognitive level over time. This patient group is generally young and have acquired MCI from a head injury or mild stroke. Although the past decade has seen a large amount of research on how to use information and communication technology (ICT) to support self-management of patients with chronic diseases, MACI has not received much attention. Therefore, there is a lack of information about what tools have been created and evaluated that are suitable for self-management of MACI patients, and a lack of clear direction on how best to proceed with ICT tools to support self-management of MACI patients.

Objective

This paper aims to provide direction for further research and development of tools that can support health care professionals in assisting MACI patients with self-management. An overview of studies reporting on the design and/or evaluation of ICT tools for assisting MACI patients in self-management is presented. We also analyze the evidence of benefit provided by these tools, and how their functionality matches MACI patients’ needs to determine areas of interest for further research and development.

Methods

A review of the existing literature about available assistive ICT tools for MACI patients was conducted using 8 different medical, scientific, engineering, and physiotherapy library databases. The functionality of tools was analyzed using an analytical framework based on the International Classification of Functioning, Disability and Health (ICF) and a subset of common and important problems for patients with MACI created by MACI experts in Sweden.

Results

A total of 55 search phrases applied in the 8 databases returned 5969 articles. After review, 7 articles met the inclusion criteria. Most articles reported case reports and exploratory research. Out of the 7 articles, 4 (57%) studies had less than 10 participants, 5 (71%) technologies were memory aids, and 6 studies were mobile technologies. All 7 studies fit the profile for patients with MACI as described by our analytical framework. However, several areas in the framework important for meeting patient needs were not covered by the functionality in any of the ICT tools.

Conclusions

This study shows a lack of ICT tools developed and evaluated for supporting self-management of MACI patients. Our analytical framework was a valuable tool for providing an overview of how the functionality of these tools matched patient needs. There are a number of important areas for MACI patients that are not covered by the functionality of existing tools, such as support for interpersonal interactions and relationships. Further research on ICT tools to support self-management for patients with MACI is needed.