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.

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.

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.

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.

Using "Markers of Harm" to Track Risky Gambling in Two Cohorts of Online Sports Bettors.

Online gambling poses novel risks for problem gambling, but also unique opportunities to detect and intervene with at-risk users. A consortium of gambling companies recently committed to using nine behavioral "Markers of Harm'' that can be calculated with online user data to estimate risk for gambling-related harm. The current study evaluates these markers in two independent samples of sports bettors, collected ten years apart. We find over a two-year period that most users never had high enough overall risk scores to indicate that they would have received an intervention. This observation is partly due to characteristics of our samples that are associated with lower risk for gambling-related harm, but might also be due to overly high risk thresholds or flaws in the design of some markers. Users with higher average risk scores had more intraindividual variability in risk scores. Younger age and male gender were not associated with higher average risk scores. The most active users were more likely than other users to have ever exceeded risk thresholds. Several risk scores significantly predicted proxies of gambling-related harm (e.g., account closure). Overall, the current Markers of Harm system has some correctable limitations that future risk detection systems should consider adopting.

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.

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.

Alcohol Withdrawal Syndrome in Neurocritical Care Unit: Assessment and Treatment Challenges.

Alcohol withdrawal syndrome (AWS) can range from mild jittery movements, nausea, sweating to more severe symptoms such as seizure and death. Severe AWS can worsen cognitive function, increase hospital length of stay, and in-hospital mortality and morbidity. Due to a lack of reliable history of present illness in many patients with neurological injury as well as similarities in clinical presentation of AWS and some commonly encountered neurological syndromes, the true incidence of AWS in neurocritical care patients remains unknown. This review discusses challenges in the assessment and treatment of AWS in patients with neurological injury, including the utility of different scoring systems such as the Clinical Institute Withdrawal Assessment and the Minnesota Detoxification Scale as well as the reliability of admission alcohol levels in predicting AWS. Treatment strategies such as symptom-based versus fixed dose benzodiazepine therapy and alternative agents such as baclofen, carbamazepine, dexmedetomidine, gabapentin, phenobarbital, ketamine, propofol, and valproic acid are also discussed. Finally, a treatment algorithm considering the neurocritical care patient is proposed to help guide therapy in this setting.

Prognostic Value of a Structural Brain MRI Score in the Acute Phase of Aneurysmal Subarachnoid Hemorrhage: A Pilot Study.

BACKGROUND/OBJECTIVE: Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality despite advances in management. We evaluated the prognostic significance of a qualitative score using brain magnetic resonance imaging (MRI) features obtained early after aSAH. METHODS: Patients with aSAH were enrolled in a prospective observational cohort and underwent brain MRI during their acute hospitalization. MRIs were rated using a scoring system that considers the anatomical location of signal intensity changes on diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) sequences. The relationship between MRI scores and functional outcome defined by modified Rankin scale (mRS) at 6 months was evaluated in uni- and multivariable models. RESULTS: The cohort included 45 aSAH patients (median World Federation of Neurologic Surgeons (IQR) 2 (1-4)) who underwent brain MRI a mean (SD) of 9.0 ± 8.0 days after aSAH. At 6 months after aSAH, 26 patients had achieved a favorable outcome (mRS ≤ 2) while 15 had an unfavorable outcome (mRS > 2). Deep gray nuclei (DGN) score (p = 0.016), cortex + DGN score (p = 0.015), FLAIR score (p = 0.016), DWI score (p = 0.0045), and overall score (p = 0.0081) were significantly lower in patients with favorable outcome compared to those with unfavorable outcome. However, MRI scores were not independent predictors of outcome in multivariable models adjusting for admission Hunt and Hess, Glasgow Coma Scale, or World Federation of Neurologic Surgeons scales. CONCLUSIONS: In this pilot study, a qualitative scoring system using anatomically defined MRI FLAIR and DWI signal abnormalities identified in the acute phase of aSAH was linked to 6-month functional outcome. However, these scores did not add prognostic value to established indices of neurological severity.

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.

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.

Patterns of Daily Fantasy Sport Play: Tackling the Issues.

Daily fantasy sports (DFS), a rapidly growing industry, allows players to create fantasy teams of real-life players and potentially win cash prizes, derived from entry fees. Some stakeholders have expressed concern that DFS's accelerated nature and other features might promote excessive play and related harm. We conducted the first descriptive summary of actual DFS play using records from a cohort of subscribers to a dominant operator, DraftKings. Participants (N = 10,385) initially entered paid National Football League (NFL) contests. Across all participants, players entered a median of two contests per entry day and typically submitted a single entry for each contest they entered. Players paid a median of $87 in entry fees throughout the 2014 NFL season and experienced an overall median net loss of $30.7. However, we identified heavily involved sub-groups of players based on number of contests entered, total entry fees, and net loss. These top 1% groups were less likely to restrict themselves to NFL games, exhibited greater time involvement, but also won a greater percentage of the contests they entered than typical players. Our observations of typical and heavily involved players tend to mirror those generated in previous Internet sports gambling research.

Effects of the Arg9Cys and Arg25Cys mutations on phospholamban's conformational equilibrium in membrane bilayers.

Approximately, 70% of the Ca2+ ion transport into the sarcoplasmic reticulum is catalyzed by the sarcoplasmic reticulum Ca2+-ATPase (SERCA), whose activity is endogenously regulated by phospholamban (PLN). PLN comprises a TM inhibitory region and a cytoplasmic regulatory region that harbors a consensus sequence for cAMP-dependent protein kinase (PKA). The inhibitory region binds the ATPase, reducing its apparent Ca2+ binding affinity. ß-adrenergic stimulation activates PKA, which phosphorylates PLN at Ser 16, reversing its inhibitory function. Mutations and post-translational modifications of PLN may lead to dilated cardiomyopathy (DCM) and heart failure. PLN's cytoplasmic region interconverts between a membrane-associated T state and a membrane-detached R state. The importance of these structural transitions on SERCA regulation is emerging, but the effects of natural occurring mutations and their relevance to the progression of heart disease are unclear. Here we use solid-state NMR spectroscopy to investigate the structural dynamics of two lethal PLN mutations, R9C and R25C, which lead to DCM. We found that the R25C mutant enhances the dynamics of PLN and shifts the conformational equilibrium toward the R state confirmation, whereas the R9C mutant drives the amphipathic cytoplasmic domain toward the membrane-associate state, enriching the T state population. The changes in membrane interactions caused by these mutations may explain the aberrant regulation of SERCA.

Magnetic Resonance Imaging in Aneurysmal Subarachnoid Hemorrhage: Current Evidence and Future Directions.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is associated with an unacceptably high mortality and chronic disability in survivors, underscoring a need to validate new approaches for treatment and prognosis. The use of advanced imaging, magnetic resonance imaging (MRI) in particular, could help address this gap given its versatile capacity to quantitatively evaluate and map changes in brain anatomy, physiology and functional activation. Yet there is uncertainty about the real value of brain MRI in the clinical setting of aSAH. METHODS: In this review, we discuss current and emerging MRI research in aSAH. PubMed was searched from inception to June 2017, and additional studies were then chosen on the basis of relevance to the topics covered in this review. RESULTS: Available studies suggest that brain MRI is a feasible, safe, and valuable testing modality. MRI detects brain abnormalities associated with neurologic examination, outcomes, and aneurysm treatment and thus has the potential to increase knowledge of aSAH pathophysiology as well as to guide management and outcome prediction. Newer pulse sequences have the potential to reveal structural and physiological changes that could also improve management of aSAH. CONCLUSION: Research is needed to confirm the value of MRI-based biomarkers in clinical practice and as endpoints in clinical trials, with the goal of improving outcome for patients with aSAH.

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.

Solution and Solid-State Nuclear Magnetic Resonance Structural Investigations of the Antimicrobial Designer Peptide GL13K in Membranes.

The antimicrobial peptide GL13K encompasses 13 amino acid residues and has been designed and optimized from the salivary protein BPIFA2 to exhibit potent bacteriocidal and anti-biofilm activity against Gram-negative and Gram-positive bacteria as well as anti-lipopolysaccharide activity in vitro and in vivo. Here, the peptide was analyzed in a variety of membrane environments by circular dichroism spectroscopy and by high-resolution multidimensional solution nuclear magnetic resonance (NMR) spectroscopy. Whereas in the absence of membranes a random coil conformation predominates, the peptide adopts a helical structure from residue 5 to 11 in the presence of dodecylphosphocholine micelles. In contrast, a predominantly ß-sheet structure was observed in the presence of lipid bilayers carrying negatively charged phospholipids. Whereas 15N solid-state NMR spectra are indicative of a partial alignment of the peptide 15N-1H vector along the membrane surface, 2H and 31P solid-state NMR spectra indicate that in this configuration the peptide exhibits pronounced disordering activities on the phospholipid membrane, which is possibly related to antimicrobial action. GL13K, thus, undergoes a number of conformational transitions, including a random coil state in solution, a helical structure upon dilution at the surface of zwitterionic membranes, and ß-sheet conformations at high peptide:lipid ratios.

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.

Changing Social Networks Among Homeless Individuals: A Prospective Evaluation of a Job- and Life-Skills Training Program.

Social networks play important roles in mental and physical health among the general population. Building healthier social networks might contribute to the development of self-sufficiency among people struggling to overcome homelessness and substance use disorders. In this study of homeless adults completing a job- and life-skills program (i.e., the Moving Ahead Program at St. Francis House, Boston), we prospectively examined changes in social network quality, size, and composition. Among the sample of participants (n = 150), we observed positive changes in social network quality over time. However, social network size and composition did not change among the full sample. The subset of participants who reported abstaining from alcohol during the months before starting the program reported healthy changes in their social networks; specifically, while completing the program, they re-structured their social networks such that fewer members of their network used alcohol to intoxication. We discuss practical implications of these findings.