Shallow Value Weighting Predicts Problem Gambling: A Parameter Estimation Analysis Using Cumulative Prospect Theory.

Problem gambling is a non-substance-based addictive disorder that can cause significant distress and dramatic consequences. Despite extensive research in neuroscience and clinical/social psychology, few contributions have been made from formal models of behavioural economics. We apply Cumulative Prospect Theory (CPT) to provide a formal analysis of cognitive distortions in problem gambling. In two experiments, participants made decisions between pairs of gambles and completed a standard gambling assessment. We estimated the parameter values specified by CPT for each participant and used those estimates to predict gambling severity. In Experiment 1, severe gambling behaviour was associated with a shallow valuation curve, a reversal of loss aversion, and decreased influence of subjective value on decisions (i.e., more noise or variability in preference). Experiment 2 replicated the effect of shallow valuation but did not demonstrate reversed loss version or noisier decisions. Neither experiment provided evidence of differences in probability weighting. We explore implications of the findings and conclude that problem gambling at least partially reflects a fundamental distortion to subjective valuation.

Prevalence and clinical correlates of bronchoreversibility in severe emphysema.

Chronic obstructive pulmonary disease (COPD) exhibits airflow obstruction that is not fully reversible. The importance of bronchoreversibility remains controversial. We hypothesised that an emphysematous phenotype of COPD would be associated with decreased bronchoreversibility. 544 patients randomised to the medical arm of the National Emphysema Treatment Trial formed the study group. Participants underwent multiple measurements of bronchoreversibility on a mean of four sessions over 1.91 yrs. They were also characterised by measures of symptoms, quality of life and quantitative measures of emphysema by computed tomography. Mean baseline forced expiratory volume in 1 s (FEV(1)) in this patient population is 24% predicted. 22.2% of patients demonstrated bronchoreversibility on one or more occasions using American Thoracic Society/European Respiratory Society criteria. Few patients (0.37%) had bronchoreversibility on all completed tests. Patients who demonstrated bronchoreversibility were more likely to be male, and have better lung function and less emphysema. 64% of patients demonstrated large (> or =400 mL) changes in forced vital capacity (FVC). In a severe emphysema population, bronchoreversibility as defined by change in FEV(1) is infrequent, varies over time, and is more common in males and those with less severe emphysema. Improvements in FVC, however, were demonstrated in the majority of patients.

Requirement of CD4-positive T cells for cellular recruitment to the lungs of mice in response to a particulate intratracheal antigen.

To determine whether CD4+ T cells participate in the recruitment of other lymphocyte subsets to the lungs, we examined pulmonary immune responses in C57BL/6 mice treated in vivo with the MAb GK1.5, either intact (which depletes CD4+ cells) or as F(ab')2 fragments (which block CD4 molecules). After intratracheal challenge with sheep erythrocytes, antigen-primed mice treated with intact GK1.5 had marked decreases in lymphocytes and macrophages in bronchoalveolar lavage fluid and minimal parenchymal inflammation, compared to primed mice treated with an isotype-matched irrelevant antibody or with no antibody. At 7 d after challenge, flow cytometric analysis showed that numbers of Thy 1.2+ and B220+ cells, but not of CD8+ cells, were markedly decreased in lavage fluid of CD4-depleted mice. Similar suppression of the pulmonary immune response to intratracheal challenge was found in primed mice injected repeatedly with F(ab')2 fragments of GK1.5, which did not deplete CD4+ T cells, and in athymic mice. These findings indicate that, in response to a single intratracheal antigen challenge, recruitment to the lungs of leukocytes other than CD8+ T cells depends largely on CD4+ T cells, possibly because of signals requiring T cell activation via interactions with antigen-presenting cells.

Lung lymphocyte elimination by apoptosis in the murine response to intratracheal particulate antigen.

Pulmonary immune responses are suited to determine mechanisms of lymphocyte elimination, as lung inflammation must be regulated tightly to preserve gas exchange. The self-terminating response of primed C57BL/6 mice to intratracheal challenge with the T cell-dependent Ag sheep erythrocytes (SRBC) was used to test the importance of lung lymphocyte apoptosis in pulmonary immunoregulation. Apoptosis of alveolar and interstitial lymphocytes was demonstrated morphologically, by three independent methods to detect DNA fragmentation, and by surface expression of phosphatidylserine. Apoptotic lymphocytes were exclusively CD4-, CD8-, B220-, but many were CD3+ and Thy 1+. Inhibiting apoptosis by in vivo cyclosporine treatment prolonged lung lymphocyte accumulation following SRBC challenge. Experiments using mice homozygous for the lpr or gld mutations showed that pulmonary lymphocyte apoptosis depended on expression of Fas (CD95) and its ligand (Fas-L). Pulmonary inflammation increased on repeated intratracheal SRBC challenge of lpr/lpr mice, in contrast to the waning response in normal mice. These results confirm that in situ lymphocyte apoptosis contributes to termination of immune responses in nonlymphoid organs, probably because of activation-induced cell death, and may be important in inducing tolerance to repeated antigen exposure.

Essential thrombocythemia and leukemic transformation.

Alkylating agents and 32P have been widely employed in the treatment of patients with essential thrombocythemia (ET). During a four-month period, we observed 3 cases of ET that had transformed into leukemia. Two patients had been treated with uracil mustard: One developed acute myelogenous leukemia 79 months after institution of therapy, and the other patient developed chronic myelomonocytic leukemia 24 months after the start of therapy. The third patient had been treated with busulfan, and ET evolved into myelofibrosis and eventually into acute undifferentiated leukemia with myelofibrosis. The patient who developed acute myelogenous leukemia was asymptomatic at the time of diagnosis of ET but was treated because his platelet count was greater than 1,000,000/mm3. He died 1 month after leukemic transformation, during induction chemotherapy. The other 2 patients presented with symptoms referable to their thrombocythemia. Review of the English literature revealed 12 other definite or probable cases of ET with leukemic transformation, all but 1 having been treated with alkylating agents and/or 32P. We propose that the natural history of ET may be similar to that of polycythemia vera, with evolution into leukemia being an unusual occurrence except in the setting of previous chemotherapy. Therefore, the current practice of treating asymptomatic patients with ET may not be justified, since administration of alkylating agents or 32P may increase the risk of subsequent development of leukemia.

Recovery of biologically active enzymes after HPLC separation.

The mass and activity recovery of eight different enzymes (two monomeric, six oligomeric) with molecular masses between 25,000 and 240,000 daltons were tested after HPLC separation on three different HPLC instruments (two with stainless steel and one with titanium flow paths). Most of the tested proteins are known to be sensitive to heavy metal ions. Eight wide pore, ion-exchange columns, two size-exclusion columns and two hydrophobic-interaction columns were used. Both stainless steel and glass column hardware were used in all three separation modes. The elution times were between 8 and 12 minutes. In almost all cases, the activity recovery was between 90% and 100% compared with a control sample incubated in the chromatographic elution buffer for the same time at the same temperature. A severe activity loss (about 30%) was observed with only one ion-exchange column and one enzyme. Neither the column hardware nor the material of the HPLC equipment had any negative effect on the activity recovery of the enzymes tested.

Cutaneous cytomegalovirus vasculitis: an unusual clinical presentation of a common opportunistic pathogen.

A case of cutaneous leukocytoclastic cytomegalovirus (CMV) vasculitis arising in a man with acute myelogenous leukemia is described. An antemortem biopsy specimen of ulcerated skin and an open lung biopsy specimen showed leukocytoclastic vasculitis and nonspecific diffuse interstitial pneumonitis, respectively, neither tissue demonstrating viral infection. Autopsy material revealed CMV vasculitis with typical intranuclear inclusions identified in enlarged endothelial cells associated with thrombus formation and luminal narrowing, in addition to florid CMV pneumonitis. This case represents an unusual although clinically relevant expression of a common opportunistic pathogen.

Primary pulmonary hypertension and human immunodeficiency virus infection in a non-hemophiliac man.

We describe clinical and postmortem findings in a 44-year-old man with pulmonary hypertension and infection with the human immunodeficiency virus (HIV-1). Plexogenic angiopathy and veno-occlusive lesions were present, in addition to a mild, patchy pulmonary interstitial lymphoid infiltrate. The clinical data for 14 previously reported cases of HIV-associated primary pulmonary hypertension are summarized. We speculate that these vascular changes may be due to damage from a specific immune response to HIV.

Helium-oxygen gas therapy. Use and availability for the emergency treatment of inoperable airway obstruction.

Inoperable obstruction of the upper airway due to extrinsic malignancy may present as respiratory failure. We treated such a patient for 48 hours with 80 percent: 20 percent helium-oxygen delivered by a nonrebreathing mask while chemotherapy and radiation therapy reduced the tumor size. The need for intubation, mechanical ventilation, and high risk surgical intervention was avoided through the use of this gas therapy. We then surveyed San Francisco Bay area hospitals and found that fewer than one half could provide this potentially lifesaving gas therapy in an emergency situation. Physiologic basis of helium-oxygen gas therapy is reviewed and recommendations made for its use and availability.

Lung volume reduction surgery alters management of pulmonary nodules in patients with severe COPD.

OBJECTIVE: To examine the role of lung volume reduction surgery (LVRS) in expanding the treatment options for patients with single pulmonary nodules and emphysema. METHODS: Retrospective review of all patients undergoing LVRS at the University of Michigan between January 1995 and June 1996. Those undergoing simultaneous LVRS and resection of a suspected pulmonary malignancy formed the study group and underwent history and physical examination, pulmonary function tests, chest radiography, and high-resolution CT of the chest. If heterogeneous emphysema was found, cardiac imaging and single-photon emission CT perfusion lung scanning were performed. All study patients participated in pulmonary rehabilitation preoperatively. Age- and sex-matched patients who had undergone standard lobectomy for removal of pulmonary malignancy during the same period formed the control group. RESULTS: Of 75 patients who underwent LVRS, 11 had simultaneous resection of a pulmonary nodule. In 10 patients, the nodules were radiographically apparent with 1 demonstrating central calcification. Histologic evaluation revealed six granulomas, two hamartomas, and three neoplastic lesions (one adenocarcinoma, one squamous cell, and one large cell carcinoma). Preoperative FEV1 was 26.18+/-2.49% predicted in the LVRS group and 81.36+/-6.07% predicted (p=0.000001) in the control group, and the FVC was 65.27+/-5.17% predicted vs 92.18+/-5.53% predicted (p=0.002). Two LVRS patients had a PaCO2 >45 mm Hg while 11 exhibited oxygen desaturation during a 6-min walk test. Postoperative complications occurred in two LVRS patients and three control patients. The mean length of stay in the LVRS group (7.55+/-1.10 days) was not different than in the control group (8.81+/-1.56 days). Three months after LVRS and simultaneous nodule resection, FEV1 rose by 47%, FVC by 25%, and all study patients noted less dyspnea as measured by transitional dyspnea index. CONCLUSIONS: Simultaneous LVRS and resection of a suspected bronchogenic carcinoma is feasible and associated with minimal morbidity and significantly improved pulmonary function and dyspnea.

Preoperative echocardiographic evaluation of patients referred for lung volume reduction surgery.

BACKGROUND: The most efficient preoperative assessment for lung volume reduction surgery (LVRS) in patients with advanced emphysema is undefined. This study analyzed the preoperative assessment of patients by surface echocardiography (without and with dobutamine infusion), the results of which were used to exclude patients with significant pre-existing cardiac disease, a contraindication to LVRS, from the surgery. SETTING: A university-based, tertiary care referral center. METHODS: Patients with emphysema who met initial LVRS screening criteria underwent resting and stress surface echocardiography with Doppler imaging. Patients were evaluated prospectively for perioperative cardiac complications. RESULTS: Between July 1994 and December 1996, 503 candidates for LVRS were evaluated. Of these, 207 patients (81.8%) who had echocardiography performed at our institution formed the primary study group. Images were adequate for the analysis of chamber sizes and function in 206 patients (99.5%) undergoing resting echocardiography, and the images were adequate for wall motion analysis in 172 of 174 patients (98.9%) undergoing functional testing. Right heart abnormalities were common (40.1%). Significant pulmonary hypertension (> 35 mm Hg) was uncommon (5 patients, 5.4%) among the 92 patients who subsequently underwent right heart catheterization. Occult ischemia, left ventricular dysfunction, and valvular abnormalities also were uncommon. Thus, although Doppler imaging estimates of right ventricular systolic pressure were imperfect, echocardiographic findings of normal right heart anatomy and function excluded significant pulmonary hypertension. Ninety patients (43%) eventually underwent LVRS (70 bilateral and 20 unilateral). A total of 13 perioperative cardiac events occurred in 10 patients, 6 of whom had undergone preoperative echocardiography. No patient suffered acute myocardial infarction or cardiac death. CONCLUSIONS: Despite potential limitations due to severe obstructive lung disease, surface echocardiographic imaging is a feasible, noninvasive tool in this patient population to identify patients with evidence of cor pulmonale that suggests pulmonary hypertension. The routine use of surface resting and stress echocardiography for preoperative screening obviates the need for invasive right heart catheterization in many patients and results in a low incidence of significant perioperative cardiac complications.

The sensitivity of high-resolution CT in detecting idiopathic pulmonary fibrosis proved by open lung biopsy. A prospective study.

OBJECTIVES: To assess the sensitivity of high-resolution chest computed tomography (HRCT) in detecting idiopathic pulmonary fibrosis proved by biopsy specimen. To determine the degree of physiologic and pathologic abnormalities in patients with idiopathic pulmonary fibrosis who have a false-negative HRCT. DESIGN: Prospective 2-year study. SETTING: Tertiary care university hospital. PATIENTS: All patients with dyspnea and suspected interstitial lung disease referred to the University of Michigan for enrollment in the Idiopathic Pulmonary Fibrosis Specialized Center of Research (SCOR) protocol were included; 25 underwent open lung biopsy and formed the final study group. MEASUREMENTS: All patients underwent physiologic (pulmonary function, gas exchange, and exercise testing), radiologic (chest x-ray film and HRCT), and pathologic assessments (bronchoscopic and open lung biopsy). The results of HRCT were prospectively compared with results of standard pulmonary function tests, cardiopulmonary exercise testing, and open lung biopsy. RESULTS: Of 25 patients who had both HRCT and open lung biopsy, 3 patients (12%) had HRCTs that demonstrated no evidence of interstitial lung disease. These three patients had less severe disease based on clinical, radiographic, and physiologic (CRP) scores, gas exchange abnormalities, and pathologic scoring of open lung biopsy specimens, compared with those with an abnormal HRCT. CONCLUSION: We conclude that in the evaluation of patients with dyspnea and abnormal results of pulmonary function studies, a normal HRCT does not exclude early and clinically significant interstitial lung disease. In our patient population, physiologic testing was more sensitive than HRCT in detecting mild abnormalities in patients with idiopathic pulmonary fibrosis proved by biopsy specimen.

Short-term and long-term outcomes after bilateral lung volume reduction surgery : prediction by quantitative CT.

OBJECTIVES: To evaluate selection criteria and duration of benefit for patients undergoing lung volume reduction surgery (LVRS). METHODS: Eighty-nine consecutive patients with severe emphysema who underwent bilateral LVRS were prospectively followed up for up to 3 years. Patients underwent preoperative pulmonary function testing, 6-min walk, chest CT, and answered a baseline dyspnea questionnaire. CT scans in 65 patients were analyzed for emphysema extent and distribution using the percentage of emphysema in the lung, percentage of normal lower lung, and the CT emphysema ratio (CTR, an index of the craniocaudal distribution of emphysema). All patients underwent at least 6 weeks of pulmonary rehabilitation prior to surgery. Outcome measures were FEV(1), 6-min walk distance, and transitional dyspnea index (TDI). RESULTS: Compared to baseline, FEV(1) was significantly increased at 3, 6, 12, 18, 24, and 36 months after surgery (p < or = 0.008). The 6-min walk distance increased from 871 feet (baseline) to 1,110 feet (3 months), 1,214 feet (6 months), 1,326 feet (12 months), 1,342 feet (18 months), 1,371 feet (24 months), and 1,390 feet (36 months) after surgery. Despite a decline in FEV(1) over time, 6-min walk distance was preserved. Dyspnea as measured by TDI improved at 3, 6, 12, 18, 24, and 36 months after surgery. A high CTR was the best predictor of a 12% increase over baseline and an absolute increase of 200 mL in FEV(1), although with a low area under the receiver operating characteristic curve. In addition, the sensitivity and negative predictive value of the CTR were limited. No radiographic or physiologic predictor was able to consistently predict a successful increase in walk distance or TDI. CONCLUSION: LVRS improves pulmonary function, decreases dyspnea, and enhances exercise capacity in many patients with severe emphysema, although improvement wanes 36 months after surgery.

Weight gain after lung volume reduction surgery is not correlated with improvement in pulmonary mechanics.

STUDY OBJECTIVES: Malnutrition and low body weight are common in patients with emphysema. Previous work has demonstrated correlation between severity of airflow obstruction and body weight. Lung volume reduction surgery (LVRS) is a recent advance in the treatment of patients with severe emphysema that results in improved pulmonary function. We formed the hypothesis that improved lung mechanics after LVRS would result in body weight gain. DESIGN: Retrospective chart review. PATIENTS: All patients who underwent bilateral LVRS for severe emphysema at the University of Michigan between January 1995 and April 1996 were eligible for the study. MEASUREMENTS AND RESULTS: Pulmonary function and body weight were measured preoperatively and at 3, 6, and 12 months postoperatively for patients who underwent bilateral LVRS between January 1995 and April 1996. The average weight gain in 38 patients returning for 12 months of follow-up was 3.8 +/- 0.9 kg, or 6.2% of the preoperative weight. Women gained significantly more weight than men (9.2 vs 2.2%, respectively) at 1 year. Interestingly, there was no correlation between change in weight and postoperative change in FEV(1), FVC, residual volume (RV), total lung capacity (TLC), or RV/TLC at 12 months. However, there was a statistically significant correlation between weight gained and improvement in diffusion of carbon monoxide measured 12 months postoperatively. CONCLUSIONS: This study shows that patients with severe emphysema gain weight after LVRS. These changes were independent of changes in pulmonary mechanics but may be a result of improved gas exchange. These findings provide further information about benefits of LVRS in patients with advance emphysema that are beyond simple changes in pulmonary function.

The longitudinal study of chronic sarcoidosis.

Although spontaneous remissions are frequent in sarcoidosis, chronic persistent disabling disease is also observed. This feature seems more frequent and more severe in black patients, as has been previously reported (10). The more extensive and severe the initial disease manifestations, the more likely it is that the disease will continue. Corticosteroids are usually beneficial and complications are infrequent. Delayed or interrupted treatment seems to allow progression or irreversible disease or both. Patient compliance is an obvious important factor. Relapses are frequent as treatment is withdrawn but are usually at least partially reversible. Some deterioration is observed with repeated relapses. Low dose daily prednisone (5-15 mg) seems to prevent relapses. Patient compliance is facilitated with daily treatment rather than alternate day therapy. Prolonged treatment for 10 to 15 or more years is often required. Chloroquine is particularly helpful in skin and mucosal disease. The necessity for long-term thoughtful management is obvious.

Disseminated Curvularia infection. Additional therapeutic and clinical considerations with evidence of medical cure.

A previously reported case of cerebral infection due to Curvularia lunata is more fully described. Medical cure was apparently achieved after 30 months' treatment with amphotericin B. Success was achieved only when the drug was given in a dose of 40 mg, three times per week, and was continued for six months after enhanced computed tomographic scans no longer showed cerebral lesions. Immunologic studies suggested the infection was accompanied by an unexplained defect in cell-mediated immunity.

Deaths among former psychiatric inpatients in an outreach case management program.

OBJECTIVE: The mortality rate of discharged psychiatric inpatients has long been known to be higher than that of persons in the general population. This study assessed the effectiveness of outreach case management in reducing the mortality rate of recently discharged psychiatric inpatients in New York City. METHODS: A sample of 292 patients discharged from an inpatient psychiatry service at an urban general hospital were randomly assigned either to an intervention group (N = 147), which received intensive outreach case management for periods ranging from 15 to 52 months after discharge, or to a control group (N = 145), which received standard aftercare services. Both groups were offered and received regular aftercare and other services during the study period. Both groups were followed for comparable periods of time to determine their rate of mortality. RESULTS: The overall mortality rate for the total group of 292 patients was 7.2 percent, 2.25 times higher than among persons in the general population matched for age, sex, and race. The mortality rates for the intervention group and the control group were 7.5 percent and 6.9 percent, respectively, not a significant difference. CONCLUSIONS: Discharged psychiatric inpatients who received outreach case management did not have a lower mortality rate than similar patients who did not receive this intervention.

Effects of diagnosis, demographic characteristics, and case management on rehospitalization.

OBJECTIVES: A randomized controlled study was conducted to assess the effects of case management and patients' characteristics on the use of inpatient psychiatric services. METHODS: Inpatients discharged from Harlem Hospital Center in 1984-1985 were randomly assigned to an outreach case management team or standard aftercare. Analysis of variance was used to assess the main effects and two- and three-way interaction effects of treatment status, gender, age, substance abuse, and diagnosis on the number of days of psychiatric rehospitalization in state and city community hospitals. RESULTS: In the follow-up period, 75 of the 146 patients in the case management group (51.4 percent) and 51 of the 143 patients in the control group (35.7 percent) were rehospitalized for psychiatric care. On average, patients spent 31.1 days in city hospitals and 26.6 days in state hospitals. Members of the case management team spent a mean total of 18.1 hours a month in direct and indirect care for each patient. They spent most time with substance-abusing older women. Significant three-way interaction effects were found between treatment status and diagnosis and gender, diagnosis and age, and diagnosis and substance abuse on the number of days patients spent rehospitalized for psychiatric care in city and state hospitals. CONCLUSIONS: It is unlikely that case management intervention will reduce rehospitalization rates unless appropriate and effective outpatient and community services are available. Effective surveillance of patient populations by case managers frequently results in rehospitalization as the only treatment alternative if other options for meeting the needs and resolving the crises of patients are not available.

Does outreach case management improve patients' quality of life?

OBJECTIVE: This study examined whether enhancing standard aftercare with an outreach case management intervention would improve patients' quality of life. METHODS: A sample of 292 patients discharged from an inpatient psychiatry service at an urban general hospital were randomly assigned either to an intervention group (N = 147), which received outreach case management services in addition to standard aftercare service, or to a control group (N = 145), which received only standard aftercare services. The follow-up period was 15 to 52 months. Individuals in both groups were reinterviewed by an independent research team about 21.6 months after discharge. The groups were compared using 39 measures of quality of life. The interviews elicited information about patients' physical well-being and competence in performing activities of daily living; their emotional well-being as shown in emotional expressiveness, sadness, suicidal thoughts, and substance abuse; and their interpersonal relationships, living arrangements, friendships, income maintenance, and employment. RESULTS: No difference was found between the groups on any of the quality-of-life variables. CONCLUSIONS: Outreach case management was not associated with improved quality of life.

Oral mucosa pigment changes in heavy drinkers and smokers.

The preliminary observation that heavy drinking and smoking produced oral mucosal changes consisting of splotchy areas of depigmentation surrounded by hyperpigmentation was tested. The study population was comprised of 52 patients from an alcohol detoxification ward, who were compared with 54 patients from psychiatric inpatient and day hospital services. Structured interviewing was developed for both samples of patients who met either diagnostic criteria for alcohol abuse or dependence, or criteria for alcoholism on the Short Form of the Michigan Alcohol Screening Test, and were identified as nonsmokers or as those who smoked one to three or more packs of cigarettes a day. Photographs of the inner surface of the lips, oral mucosa, and gingivae independently were rated for severity of oral pigment change by two raters blind to a patient's alcohol or smoking history. This study demonstrates that reported observable oral pigment changes identify patients who are heavy smokers and drinkers, and may be a useful diagnostic sign.