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Motivational characteristics such as excitement-seeking are key components of models of addiction, including problem gambling. Previous studies have established associations between excitement-seeking and problem gambling in youth. However, these studies have employed dimensional psychological assessments which are unlikely to be routinely administered. Other approaches to conceptualize excitement-seeking could be of value. In the present study, we employed a single question (What are the reasons that you gamble?) to identify adolescents who reported excitement-seeking motivation for gambling. Cross-sectional data from 2030 adolescent gamblers who participated in a Connecticut high-school survey were examined. Gambling perceptions and correlates of problem-gambling severity were examined relative to excitement-seeking and non-excitement-seeking gambling. Gambling perceptions were more permissive and at-risk/problem gambling was more frequent among adolescents with excitement-seeking gambling versus non-excitement-seeking gambling. A weaker relationship between problem-gambling severity and moderate and heavy alcohol use was observed for excitement-seeking versus non-excitement-seeking gambling. Excitement-seeking gambling is associated with more permissive gambling-related attitudes and riskier gambling behaviors and may account for some variance in adolescent risk of heavy alcohol use. A single question may provide important information for identifying adolescents who are at elevated risk of problem gambling and associated negative outcomes, although the utility of the question in specific settings warrants direct examination, especially given the observed high prevalence of excitement-seeking motivations for gambling.

Background and aims A recent call to action highlighted the need to understand the relationship between problem gambling, violence, and health/functioning. As weapon-carrying and gambling behaviors are prevalent in adolescents, this study systematically examined relationships between weapon-carrying status and measures of problem gambling severity and gambling perceptions and attitudes, as well as how weapon-carrying status moderated relationships between problem gambling severity and measures of health/functioning and gambling behavior. Methods Participants were 2,301 Connecticut high-school adolescents. χ2 and logistic regression models were conducted. Results Weapon-carriers reported greater problem gambling severity, more permissive gambling perceptions, greater parental approval of gambling, and more family gambling concerns, compared to non-weapon-carriers. At-risk/problem gambling was more strongly associated with family, peers, and adult gambling partners among non-weapon-carriers (vs. weapon-carriers) and with machine gambling among weapon-carriers (vs. non-weapon-carriers). Discussion and conclusions Greater problem gambling severity and more permissive gambling perceptions and perceived parental approval of gambling in weapon-carrying adolescents suggest that parent–child relationships are important to be considered in prevention efforts. The moderated relationship by weapon-carrying status between problem gambling severity and gambling partners suggests a problem gambling risk group that may be less linked to gambling with traditional social support groups, and this group may benefit from targeted interventions.

Gambling is prevalent among adolescents and adolescents are vulnerable to experiencing gambling-related problems. Although problem gambling and suicidal behavior have been linked in adults and self-injurious behaviors may predict future suicidality, prior studies have not investigated relationships between problem-gambling severity and self-injurious behavior in adolescents. Data from 2234 Connecticut high-school students were analyzed in chi-square tests and logistic regression models to examine self-injurious behaviors in relation to at-risk/problem gambling with respect to sociodemographic characteristics, gambling attitudes and perceptions, and extracurricular and health measures. Individuals who engaged in self-injurious behavior (versus those who did not) reported more permissive views towards gambling and were more likely to exhibit at-risk/problem gambling. Stronger relationships between problem-gambling severity and gambling in casinos (OR 4.85, 95%CI 1.94, 12.12) and non-strategic gambling (1.92, 95%CI 1.01, 3.66) were observed in adolescents who acknowledged engagement in self-injurious behavior versus those who did not. Links between self-injurious behaviors and more permissive gambling attitudes and perceptions and at-risk/problem gambling suggest the need for improved interventions targeting co-occurring self-injurious behaviors and gambling. Stronger relationships between problem-gambling severity and casino and non-strategic gambling among adolescents with self-injurious behaviors suggest adolescents with self-injurious behavior may engage in specific forms of gambling as maladaptive coping strategies to alleviate suffering. Prevention and treatment approaches targeting distress management and improving adaptive coping skills may be important for targeting self-injurious behaviors in adolescents with at-risk/problem gambling.

The study systematically examined the relative relationships between perceived family and peer gambling and adolescent at-risk/problem gambling and binge-drinking. It also determined the likelihood of at-risk/problem gambling and binge-drinking as a function of the number of different social groups with perceived gambling. A multi-site high-school survey assessed gambling, alcohol use, presence of perceived excessive peer gambling (peer excess-PE), and family gambling prompting concern (family concern-FC) in 2750 high-school students. Adolescents were separately stratified into: (1) low-risk, at-risk, and problem/pathological gambling groups; and, (2) non-binge-drinking, low-frequency-binge-drinking, and high-frequency-binge-drinking groups. Multinomial logistic regression showed that relative to each other, FC and PE were associated with greater likelihoods of at-risk and problem/pathological gambling. However, only FC was associated with binge-drinking. Logistic regression revealed that adolescents who endorsed either FC or PE alone, compared to no endorsement, were more likely to have at-risk and problem/pathological gambling, relative to low-risk gambling. Adolescents who endorsed both FC and PE, compared to PE alone, were more likely to have problem/pathological gambling relative to low-risk and at-risk gambling. Relative to non-binge-drinking adolescents, those who endorsed both FC and PE were more likely to have low- and high-frequency-binge-drinking compared to FC alone or PE alone, respectively. Family and peer gambling individually contribute to adolescent at-risk/problem gambling and binge-drinking. Strategies that target adolescents as well as their closely affiliated family and peer members may be an important step towards prevention of harm-associated levels of gambling and alcohol use in youths.

This study examined adolescent gambling on school grounds (GS+) and how such behavior was associated with gambling-related attitudes. Further, we examined whether GS+ moderated associations between at-risk problem-gambling (ARPG) and gambling behaviors related to gambling partners.Participants were 1988 high-school students who completed survey materials. Demographic, perceptions, attitudes, and gambling variables were stratified by problem-gambling severity (ARPG versus recreational gambling) and GS+ status. Chi-square and adjusted logistic regression models were used to examine relationships among study variables.Nearly 40% (39.58%) of students reported past-year GS+, with 12.91% of GS+ students, relative to 2.63% of those who did not report gambling on school grounds (GS-), meeting DSM-IV criteria for pathological gambling (p0.0001). In comparison to GS- students, GS+ students were more likely to report poorer academic achievement and more permissive attitudes towards gambling behaviors. Weaker links in GS+ students, in comparison with GS-, students, were observed between problem-gambling severity and gambling with family members (interaction odds ratio (IOR)=0.60; 95% CI=0.39-0.92) and gambling with friends (IOR=0.21; 95% CI=0.11-0.39).GS+ is common and associated with pathological gambling and more permissive attitudes towards gambling. The finding that GS+ (relative to GS-) youth show differences in how problem-gambling is related to gambling partners (friends and family) warrants further investigation regarding whether and how peer and familial interactions might be improved to diminish youth problem-gambling severity. The high frequency of GS+ and its relationship with ARPG highlights a need for school administrators and personnel to consider interventions that target school-based gambling.

Management of patients with early stages of osteonecrosis of the femoral head remains controversial. Uniform use of an effective method of evaluation and classification, including both stage and lesion size, would allow for comparison and would significantly improve treatment of patients. There is no consensus on how best to determine lesion size. The purpose of this study was to evaluate and compare accuracy and ease of use of different techniques for determining the size of femoral head lesions. Twenty-five hips with stages I or II osteonecrosis were evaluated with radiographs and MRI. 3-D MRI measurements of lesion size were used as the standard against which to compare visual estimates and angular measurements: necrotic angle of Kerboul, index of necrosis, and adjusted index of necrosis. 3-D measurements (necrotic volume) showed regular progression from 2.2 to 59.2% of the femoral head. There was a rough correlation with angular measurements; index of necrosis was closer than the necrotic angle. Visual estimates from serial MRI images were as accurate as angular measurements. Simple visual estimates of lesion size from serial MRI images are reasonably accurate and are satisfactory for clinical use. Angular measurements provide some indication of prognosis and treatment; however, they have limited accuracy, with considerable variability between techniques. 3-D MRI volumetric measurements are the most accurate. Using current techniques and software, they are easier to use, requiring similar time and effort to angular measurements. They should be considered for clinical research and publications when the most accurate measurements are required.

OBJECTIVES:: To identify subtypes of adolescent gamblers based on the 10 Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for pathological gambling and the 9 Diagnostic and Statistical Manual of Mental Disorders, fifth edition criteria for gambling disorder and to examine associations between identified subtypes with gambling, other risk behaviors, and health/functioning characteristics. METHODS:: Using cross-sectional survey data from 10 high schools in Connecticut (N = 3901), we conducted latent class analysis to classify adolescents who reported past-year gambling into gambling groups on the basis of items from the Massachusetts Gambling Screen. Adolescents also completed questions assessing demographic information, substance use (cigarette, marijuana, alcohol, and other drugs), gambling behaviors (relating to gambling formats, locations, motivations, and urges), and health/functioning characteristics (eg, extracurricular activities, mood, aggression, and body mass index). RESULTS:: The optimal solution consisted of 4 classes that we termed low-risk gambling (86.4%), at-risk chasing gambling (7.6%), at-risk negative consequences gambling (3.7%), and problem gambling (PrG) (2.3%). At-risk and PrG classes were associated with greater negative functioning and more gambling behaviors. Different patterns of associations between at-risk and PrG classes were also identified. CONCLUSIONS:: Adolescent gambling classifies into 4 classes, which are differentially associated with demographic, gambling patterns, risk behaviors, and health/functioning characteristics. Early identification and interventions for adolescent gamblers should be sensitive to the heterogeneity of gambling subtypes. Language: en

Elevated levels of both pathological gambling (PG) and problem shopping (PS) have been reported among adolescents, and each is associated with a range of other negative health/functioning measures. However, relationships between PS and PG, particularly during adolescence, are not well understood. In this study, we explored the relationship between different levels of problem-gambling severity and health/functioning characteristics, gambling-related social experiences, gambling behaviors and motivations among adolescents with and without at-risk/problematic shopping (ARPS). Survey data from Connecticut high school students (n=2,100) were analyzed using bivariate analyses and logistic regression modeling. Although at-risk/problematic gambling (ARPG) was not increased among adolescents with ARPS, adolescents with ARPG (versus non-gamblers) were more likely to report having experienced a growing tension or anxiety that could only be relieved by shopping and missing other obligations due to shopping. In comparison to the non-ARPS group, a smaller proportion of respondents in the ARPS group reported paid part-time employment, whereas a greater proportion of respondents reported excessive gambling by peers and feeling concerned over the gambling of a close family member. In general, similar associations between problem-gambling severity and measures of health/functioning and gambling-related behaviors and motivations were observed across ARPS and non-ARPS adolescents. However, associations were weaker among ARPS adolescents for several variables: engagement in extracurricular activities, alcohol and caffeine use and gambling for financial reasons. These findings suggest a complex relationship between problem-gambling severity and ARPS. They highlight the importance of considering co-occurring risk behaviors such as ARPS when treating adolescents with at-risk/problem gambling.

Background and aims: Gambling is common in adolescents and at-risk and problem/pathological gambling (ARPG) is associated with adverse measures of health and functioning in this population. Although ARPG commonly co-occurs with marijuana use, little is known how marijuana use influences the relationship between problem-gambling severity and health- and gambling-related measures. Methods: Survey data from 2,252 Connecticut high school students were analyzed using chi-square and logistic regression analyses. Results: ARPG was found more frequently in adolescents with lifetime marijuana use than in adolescents denying marijuana use. Marijuana use was associated with more severe and a higher frequency of gambling-related behaviors and different motivations for gambling. Multiple health/functioning impairments were differentially associated with problem-gambling severity amongst adolescents with and without marijuana use. Significant marijuana-use-by-problem-gambling-severity-group interactions were observed for low-average grades (OR = 0.39, 95% CI = [0.20, 0.77]), cigarette smoking (OR = 0.38, 95% CI = [0.17, 0.83]), current alcohol use (OR = 0.36, 95% CI = [0.14, 0.91]), and gambling with friends (OR = 0.47, 95% CI = [0.28, 0.77]). In all cases, weaker associations between problem-gambling severity and health/functioning correlates were observed in the marijuana-use group as compared to the marijuana-non-use group. Conclusions: Some academic, substance use, and social factors related to problem-gambling severity may be partially accounted for by a relationship with marijuana use. Identifying specific factors that underlie the relationships between specific attitudes and behaviors with gambling problems and marijuana use may help improve intervention strategies.

Management of patients with osteonecrosis of the hip remains controversial and challenging. Because the prognosis and treatment are determined in large part by the stage and extent of the disease, it is important to use a reliable and efficient method for evaluation and staging. The objective of this study was to determine how musculoskeletal (MSK) radiologists evaluate osteonecrosis and whether this evaluation is adequate. A 12-part questionnaire was designed to determine how MSK radiologists evaluate patients with osteonecrosis of the femoral head (ONFH). This was sent to 888 members of the Society of Skeletal Radiology. One hundred and twenty-one members responded to essentially all questions. Patients were evaluated using plain radiographs and MRI. All agreed that it is clinically important to determine the extent of necrosis and joint involvement, and 115 (95 %) stated that this should be part of the radiologists’ evaluation. However, only 55 (46 %) said that in practice they used a specific system of classification, and most of these used the Ficat and Arlet classification, which does not indicate the extent of involvement. One hundred and seven (88 %) respondents included a simple visual estimate of the extent of involvement, and a small number added a specific measurement of lesion size. The majority indicated that they were infrequently consulted about which imaging studies should be obtained. Although radiologists recognize the clinical importance of determining the extent of necrosis and joint involvement in patients with ONFH, in practice the methods used to evaluate these patients often do not accomplish this satisfactorily. The use of an effective classification, which includes both stage and extent of involvement, should be stressed, as it will lead to improved treatment of patients with ON. Physicians who order imaging studies for patients with ON should be encouraged to consult routinely with their radiology colleagues regarding which studies to request, as well as on the interpretation of these studies.

Studies of Asian-American adults have found high estimates of problematic gambling. However, little is known about gambling behaviors and associated measures among Asian-American adolescents. This study examined gambling perceptions and behaviors and health/functioning characteristics stratified by problem-gambling severity and Asian-American and Caucasian race using cross-sectional survey data of 121 Asian-American and 1,659 Caucasian high-school students. Asian-American and Caucasian adolescents significantly differed on problem-gambling severity, with Asian-American adolescents more often reporting not gambling (24.8% vs. 16.4%), but when they did report gambling, they showed higher levels of at-risk/problem gambling (30.6% vs. 26.4%). Parental approval or disapproval of adolescent gambling also significantly differed between races, with Asian-American adolescents more likely to perceive both parental disapproval (50.0% vs. 38.2%) and approval (19.3% vs. 9.6%) of gambling. Asian-American adolescents were also more likely to express concern about gambling among close family members (25.2% vs. 11.6%). Among Asian-American adolescents, stronger associations were observed between at-risk/problem gambling and smoking cigarettes (interaction odds ratio=12.6). In summary, differences in problem-gambling severity and gambling perceptions indicate possible cultural differences in familial attitudes towards gambling. Stronger links between cigarette smoking and risky/problematic gambling amongst Asian-American adolescents suggest that prevention and treatment efforts targeting youth addictions consider cultural differences.

Instant (scratch) lottery ticket gambling is popular among adolescents. Prior research has not determined whether adolescents' gambling behavior and attitudes toward gambling are influenced by the receipt of scratch lottery tickets as gifts.Cross-sectional survey data from 2,002 Connecticut high school students with past-year gambling were analyzed using bivariate approaches and logistic regression analyses. Interactions between gambling-problem severity and lottery-gift status were examined in relation to multiple outcomes.Adolescents who received a scratch lottery ticket as a gift compared with those who did not were more likely to report features of problem gambling, buy scratch lottery tickets for themselves, and buy and receive other types of lottery tickets; they were also less likely to report parental disapproval of gambling and to see gambling prevention efforts as important. Later (≥15 years) age-at-gambling-onset was inversely linked to gambling-problem severity in the lottery gift group (odds ratio [OR] = .38) but not in the nongift group (OR = .91), yielding a significant severity by gift status interaction. Other academic, health, and gambling-related correlates of gambling-problem severity were similar in the gift and nongift groups.For adolescents, the receipt of scratch lottery tickets as gifts during childhood or adolescence was associated with risky/problematic gambling and with gambling-related attitudes, behaviors, and views suggesting greater gambling acceptability. The extent to which the receipt of scratch lottery tickets may promote gambling behaviors and the development of gambling problems warrants consideration. Education, prevention, and treatment strategies should incorporate findings relating to receipt of gambling products by underage individuals.

It is well recognised that to evaluate a patient with osteonecrosis of the femoral head (ONFH) adequately, it is necessary that the size of the infarct and the extent of femoral head joint involvement be indicated, in addition to the type or stage of the pathological process. The purpose of this study was to determine whether patients with ONFH are being evaluated adequately in studies published during the past 25 years and to see if any trends can be identified. Articles describing treatment of patients with ONFH, published between 1985 and 2011, were reviewed to determine the methods used to indicate the type and extent of pathology present on radiographs and magnetic resonance imaging (MRI) studies. The classification systems cited were identified and divided between those which indicated only the stage and those which indicated both stage and extent of involvement. In 208 studies published between 1985 and 2011, specific classification systems were cited 237 times. During this period, non-quantitative systems, which only indicate stage, were cited 139 times (59 %) and quantitative systems, which indicate both stage and extent of involvement were cited 77 times (32 %). Between 2006 and 2011, non-quantitative systems were cited 30 times (48 %) and quantitative systems were cited 27 times (44 %). During the past 25 years there has been a trend towards the use of more comprehensive and effective methods of evaluating patients with ONFH. However, during the past five years, approximately half of the published studies continued to use limited, non-quantitative methods of evaluation. This should be brought to the attention of the orthopaedic community. Future investigations and publications on ONFH should employ comprehensive methods of classification which include not only the stage of disease but also measurements of the size of the necrotic segment and the extent of femoral head and joint involvement.

In adults, different levels of gambling problem severity are differentially associated with measures of health and general functioning, gambling behaviors, and gambling-related motivations. Here we present data from a survey of 2,484 Connecticut high school students, and investigate the data stratifying by gambling problem severity based on DSM-IV criteria for pathological gambling. Problem/pathological gambling was associated with a range of negative functions; for example, poor academic performance, substance use, dysphoria/depression, and aggression. These findings suggest a need for improved interventions related to adolescent gambling and a need for additional research into the relationship (eg, mediating factors) between gambling and risk and protective behaviors.

Characteristics of black and white callers to a gambling helpline for southern New England were examined for racial differences.Logistic regression analyses were performed on data from 2000-2003 from 1,627 callers (9% blacks and 91% whites).Black callers were more likely than white callers to be female and less likely to have a post-high school education. After control for gender and education, race-related differences for multiple variables were observed. Black callers were more likely than white callers to report longer durations of gambling problems and less likely to report problems with casino slot machines, depression secondary to gambling, daily tobacco use, and mental health treatment. High proportions of both groups reported psychiatric problems related to gambling, including depression and suicidality.Race-related differences in gambling behaviors, psychiatric problems, and mental health and substance abuse treatment among problem gamblers may inform program planning and outreach efforts.

SUMMARY— The bacteriostatic activity of onion homogenates in making standard plate counts as reported in the literature was confirmed. It was found that potassium sulfite counteracts this activity. The sulfite must be added to the blending solution instead of to the petri plate. Five-tenths percent sulfite is sufficient and the concentration may be as high as 1.6%. Variety of onion did not appear to be a factor. This treatment was of value with both laboratory and commercially dehydrated onions. Coliform organisms were not inhibited by sulfite. It is recommended that all standard plate counts of onion be made with 0.5% K2SO8, in the blending solution.

Summary:This section is designed to give the reader a concise overview of a complicated subject to serve as a background to the main theme of this issue: how to treat nontraumatic osteonecrosis (ON) of the adult hip. It reviews the etiology and pathogenesis of ON, the clinical picture, and the impor

Osteonecrosis of femoral head is a rare but disabling condition that usually results in progressive femoral head collapse and secondary arthritis necessitating total hip arthroplasty if not treated appropriately in early stages. However, early diagnosis is challenging as the onset of disease is insidious and the symptoms and signs are usually minimal and nonspecific until it becomes advanced. Of several diagnostic modalities, magnetic resonance imaging (MRI) is considered the imaging method of choice with the highest sensitivity and specificity, while detection of potential risk factors is very important as well. Many investigators have developed several different classification systems; however, there still is controversy regarding the optimal classification system. Diagnostic methods and the evolution of different classification systems will be reviewed in this paper.

Background and aims Smoking is associated with more severe/extensive gambling in adults. The purpose of this study was to examine relationships between smoking and gambling in adolescents. Methods Analyses utilized survey data from 1591 Connecticut high-school students. Adolescents were classified by gambling (Low-Risk Gambling [LRG], At Risk/Problem Gambling [ARPG]) and smoking (current smoker, non-smoker). The main effects of smoking and the smoking-by-gambling interactions were examined for gambling behaviors (e.g., type, location), and gambling attitudes. Data were analyzed using chi-square and logistic regression; the latter controlled for gender, race/ethnicity, grade, and family structure. Results For APRG adolescents, smoking was associated with greater online, school, and casino gambling; gambling due to anxiety and pressure; greater time spent gambling; early gambling onset; perceived parental approval of gambling; and decreased importance of measures to prevent teen gambling. For LRG adolescents, smoking was associated with non-strategic gambling (e.g., lottery gambling); school gambling; gambling in response to anxiety; gambling for financial reasons; greater time spent gambling; and decreased importance of measures to prevent teen gambling. Stronger relationships were found between smoking and casino gambling, gambling due to pressure, earlier onset of gambling, and parental perceptions of gambling for ARPG versus LRG adolescents. Discussion Smoking is associated with more extensive gambling for both low- and high-risk adolescent gamblers. Conclusion Smoking may be a marker of more severe gambling behaviors in adolescents and important to consider in gambling prevention and intervention efforts with youth.

Background: Several studies have documented that the size of the osteonecrotic lesion in the femoral head is an essential parameter in determining prognosis and treatment. There are several methods currently available to measure lesion size, but no general agreement as to which is most useful. In the present study, three different radiographic methods for determining lesion size were evaluated and compared. Methods: Anteroposterior and lateral radiographs of forty-two hips with osteonecrosis were examined. The extent of osteonecrotic involvement of the femoral head was determined through the use of three different methods: the volume of necrosis by quantitative digital image analysis, and the angular measurements described by Kerboul et al. and Koo and Kim. Graphs were constructed to demonstrate these relationships. Results: Volumetric measurement appeared to be the most reliable. There was only a rough correlation with angular measurements. Several sources of error were noted when simple angular measurements of irregular, three-dimensional lesions were used. The Kerboul method routinely overestimated lesion size and designated 81% of the lesions as “large.” The modified Koo and Kim method provided a more even distribution of lesion size and correlated with volumetric measurements in 74% of hips (thirty-one of forty-two hips). Conclusions: Quantitative volumetric measurements appear to be the most reliable method to measure the true size of a three-dimensional osteonecrotic lesion of the femoral head. Volumetric measurement is more accurate than angular measurement and can be performed easily with modern technology. Angular measurements, although somewhat simpler to use than volumetric measurements, may provide only a rough estimate of lesion size, partly due to the considerable differences in outline or location of the necrotic segments. Nevertheless, determination of lesion size must be part of a comprehensive system of staging of this disease, which includes the evaluation of other parameters, such as the extent and degree of articular surface involvement and the status of the hip joint and the acetabulum. Level of Evidence: Diagnostic Level III. See Instructions to Authors on [jbjs.org][1] for a complete description of levels of evidence. [1]: http://jbjs.org

Multiple classification systems for osteonecrosis of the hip have been developed to assist physicians in the diagnosis and treatment of this potentially debilitating disorder. The purpose of this analysis was to delineate the classification systems utilized in reports published since 1985 and, through a comparison of the most commonly used systems, to identify consistent factors that would allow for cross-publication comparisons to be made.We performed a PubMed search for reports of outcome studies concerning treatment methods for osteonecrosis of the hip. All studies of reported outcomes with greater than ten patients were included in the analysis. Various classification systems were tabulated to determine usage frequencies. The four most commonly used systems were then analyzed to determine common factors used for classification.One hundred and fifty-seven studies were available for analysis. Sixteen major classification systems that made use of more than one radiographic factor were identified, and nine of these systems had one to five modifications reported throughout the literature. Additionally, eleven other systems made use of single factors obtained from either magnetic resonance imaging or anatomic data. The review revealed that four classification systems accounted for greater than 85.4% of the reported studies. Parameters for these four systems were stratified to allow for uniformity of patient or study evaluation.This analysis of the reported classification systems for osteonecrosis of the femoral head revealed several similarities between the most commonly used systems. An analysis of patients can be made with any of the four major systems if specific data are collected according to various magnetic resonance imaging and radiographic findings. This approach will allow for easier comparison of studies across different centers.Prognostic Level III. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Early treatment of osteonecrosis of the femoral head yields better results than late treatment. Because osteonecrosis frequently is bilateral, it often is advisable to treat both hips simultaneously. Core decompression is one of the more common methods of treatment; however the safety of doing simultaneous bilateral core decompression has been questioned. We sought to evaluate the safety and effectiveness of simultaneous bilateral core decompression compared with unilateral core decompression. One hundred ninety-three patients (276 hips) who had core decompression with bone grafting were followed up for 24 to 145 months. One hundred twenty-four procedures were unilateral and 152 were bilateral. Patients were evaluated by change in Harris hip score, radiographic progression, postoperative complications, and conversion to total hip arthroplasty. Total hip arthroplasty was required in 56 of 124 (45%) of hips in the unilateral, and 48 of 152 (32%) of hips in the bilateral group. Postoperative complications were similar. In the unilateral group there were two major and nine minor complications; in the bilateral group there were three major and 10 minor complications. When bilateral core decompression is indicated, it can be done simultaneously on both hips, allowing earlier treatment of the contralateral hip without risk of increased complications and possibly with a better outcome. It requires only one hospitalization and decreases recovery time compared with two separate procedures. Therefore, it provides advantages over procedures that cannot be done simultaneously on both hips.Therapeutic study, Level IV (case series-no common or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Problem gamblers often attribute suicidal ideation or attempts to their gambling. Logistic regression analyses were applied to data from problem gamblers (N = 986) calling a helpline. Problem gamblers reporting gambling-related suicidality (n = 252; 25.6%) were more likely than those denying it (n = 734; 74.4%) to acknowledge family, financial, legal, and mental and substance-related problems. Of problem gamblers acknowledging gambling-related suicidality, those reporting gambling-related suicide attempts (n = 53; 21.5%) were more likely than those denying them (n = 193; 78.5%) to acknowledge gambling-related illegal behaviors, mental health and substance abuse treatment, and family histories of alcohol problems, and were less likely to report prior gambling treatment. The findings suggest that increased gambling severity is associated with gambling-related suicidality. Language: en

Because evidence supports phenomenological, clinical, and epidemiological links between pathological gambling and addictive behaviors, understanding the relationship of compulsive sexual behavior (CSB) to pathological gambling may prove helpful in treating individuals with co-occurring addictions. This study investigates the sexual behaviors of 225 adults (mean age ± SD = 47.3 ± 11.0 years; n = 120 [53, 3] females) who met criteria for pathological gambling. Forty-four (19.6%) subjects met criteria for co-occurring CSB. The symptoms of CSB preceded the onset of pathological gambling symptoms in 31 (70.5%) subjects. Men were more likely to have CSB (X 2 = 4.74; df = 1; p = 0.029). CSB in pathological gamblers appears common, and gamblers should be screened for a co-occurring sexual addiction.

The psychometric properties of a clinician-administered, DSM-IV-based, structured clinical interview for pathological gambling (SCI-PG) were examined. Seventy-two consecutive subjects requesting treatment for gambling problems were administered the SCI-PG. Reliability and validity were determined. Classification accuracy was examined using longitudinal course of illness. The SCI-PG demonstrated excellent inter-rater and test-retest reliability. Concurrent validity was observed with the South Oaks Gambling Screen (SOGS). Discriminant validity was observed with measures of anxiety and depression. The SCI-PG demonstrated both high sensitivity and specificity based on longitudinal assessment. The SCI-PG demonstrated excellent reliability and validity in diagnosing PG in subjects presenting with gambling problems. These findings require replication in other groups to examine their generalizability.

It generally is accepted that without specific treatment 70-80% of hips with clinically diagnosed osteonecrosis will progress to collapse. However, there are conflicting reports regarding the relationship between pain and outcome before femoral head collapse. Some surgeons are reluctant to operate on patients with asymptomatic or minimally symptomatic hips, assuming that these patients have a better prognosis than patients with pain. This study reviewed the outcome of 328 hips in 235 patients with nontraumatic osteonecrosis, all treated with core decompression and grafting. The preoperative stage, the extent of necrosis, and the Harris pain scores were correlated with the clinical and radiographic outcomes. Mean followup was 46 months. Patients with hips treated surgically did better as a group than patients with hips treated without surgery. A direct correlation was found between outcome and the stage and size of the necrotic lesion. Hips that had femoral head collapse were more painful than hips that did not have collapse and had a poorer outcome. Before collapse, outcome was correlated with the size of the necrotic lesion but there was no correlation with the preoperative pain level. These findings, although limited to patients with hips which had core decompression and grafting, support the observations of investigators who reported that most asymptomatic hips with osteonecrosis would progress without specific treatment. They also may apply to hips which have other forms of prophylactic treatment. Although several factors must be considered in determining the optimum treatment of hips with early stages of osteonecrosis, prophylactic treatment should not be withheld specifically because of the absence or paucity of pain.

Few studies have examined the smoking behaviors of problem gamblers. A high proportion of problem gamblers calling a gambling helpline reported daily tobacco smoking (43.1%). Problem gamblers reporting daily tobacco smoking more frequently acknowledged depression and suicidality secondary to gambling, gambling-related arrests, alcohol and drug use problems, mental health treatment, and problems with casino slot machine gambling. The findings substantiate the relationship in problem gamblers between tobacco smoking and psychiatric symptomatology, particularly other substance use problems. The high proportion of callers reporting daily tobacco smoking highlights the need for enhanced smoking cessation efforts in problem gamblers.

Background: In an effort to decrease the rate of aseptic loosening, certain cemented femoral components were designed to have a roughened or textured surface with a methylmethacrylate precoating. Reports differ as to whether this step has increased or decreased the rate of failure. This study was designed to evaluate this issue. Methods: Five hundred and fourteen hips treated with a cemented Harris Precoat stem (Zimmer, Warsaw, Indiana) were evaluated clinically and radiographically and compared with 254 hips treated with an uncoated Harris Design-2 stem (Howmedica, East Rutherford, New Jersey). Prostheses that had been removed at revision were examined. The cementing and surgical techniques were identical and the population demographics were similar for these two groups. Results: The mean durations of follow-up were 8.4 and 13.5 years for the Precoat and uncoated Design-2 stems, respectively. At those times, at least forty-nine (9.5%) of the 514 Precoat components and at least ten (3.9%) of the 254 uncoated Design-2 stems had failed (p = 0.006). Five Precoat stems fractured, and no uncoated Design-2 stems fractured. Component failure was associated with use in young, active, heavy men with a diagnosis of avascular necrosis and generally with the use of smaller components. The cementing technique was satisfactory in the majority of the patients, and there were no qualitative differences in cementing technique between the hips that failed and those that did not. The mechanisms of failure of the Precoat prostheses included bone-cement loosening, focal osteolysis, stem fracture, and prosthesis-cement debonding. Fractures of smaller components occurred as a result of fatigue failure and were associated with good distal fixation but proximal stem loosening. Conclusions: The rate of failure of roughened, precoated, cemented femoral components was considerably higher and occurred earlier than that of femoral components that were neither textured nor precoated with methylmethacrylate. Younger patients with avascular necrosis had a higher risk of failure; however, this factor alone did not completely explain the differences in outcome between these two components. The causes of aseptic loosening are multifactorial and may be related to component design and size as well as to precoating and surface finish.

The management of osteonecrosis (ON) remains one of the more perplexing problems facing the orthopedic surgeon. There is still much to be learned about the etiology, pathophysiology, and management of this condition. Because prognosis and treatment are determined in large part by the stage of the disease, it is important to use a reliable and efficient method of evaluation and staging. The uniform use of such a system of classification would also enable us to compare the effectiveness of various methods of treatment and determine the best method of management for different stages of osteonecrosis.

Background The study examined in adolescents how alcohol-drinking frequency relates to gambling-related attitudes and behaviors and perceptions of both problem-gambling prevention strategies and adult (including parental) behaviors/attitudes. Methods A survey assessing alcohol, gambling, and health and functioning measures in 1609 high school students. Students were stratified into low-frequency/nondrinking and high-frequency-drinking groups, and into low-risk and at-risk/problematic gambling groups. Results High-frequency drinking was associated with at-risk/problematic gambling (χ2(1, N = 1842) = 49.22, P < .0001). High-frequency-drinking versus low-frequency/nondrinking adolescents exhibited more permissive attitudes towards gambling (e.g., less likely to report multiple problem-gambling prevention efforts to be important). At-risk problematic gamblers exhibited more severe drinking patterns and greater likelihood of acknowledging parental approval of drinking (χ2(1, N = 1842) = 31.58, P < .0001). Problem-gambling severity was more strongly related to gambling with adults among high-frequency-drinking adolescents (odds ratio [OR] = 3.17, 95% confidence interval [95% CI] = [1.97, 5.09]) versus low-frequency/nondrinking (OR = 1.86, 95% CI = [0.61, 2.68]) adolescents (interaction OR = 1.78, 95% CI = [1.05, 3.02]). Conclusions Interrelationships between problematic drinking and gambling in youth may relate to more permissive attitudes across these domains. Stronger links between at-risk/problem gambling and gambling with adults in the high-frequency-drinking group raises the possibility that interventions targeting adults may help mitigate youth gambling and drinking.

Osteonecrosis, also known as avascular necrosis, ischemic necrosis, and aseptic necrosis, is not a specific disease entity. It is rather a condition in which a circumscribed area of bone becomes necrotic as a result of the loss of its blood supply. The most common cause is trauma, a displaced fracture or dislocation which results in a mechanical injury to the local vessels. However, many etiologic factors unrelated to trauma have also been identified. The femoral head is the region most often affected, but the proximal humerus, femoral condyles, and small bones of the hands and feet may also be involved. Despite considerable progress in the study of this condition, there is still much to be learned about its etiology, pathogenesis, and treatment.

The characteristics of male and female gamblers utilizing a gambling helpline were examined to identify gender-related differences.The authors performed logistic regression analyses on data obtained in 1998-1999 from callers to a gambling helpline serving southern New England.Of the 562 phone calls used in the analyses, 349 (62.1%) were from male callers and 213 (37.9%) from female callers. Gender-related differences were observed in reported patterns of gambling, gambling-related problems, borrowing and indebtedness, legal problems, suicidality, and treatment for mental health and gambling problems. Male gamblers were more likely than female gamblers to report problems with strategic or "face-to-face" forms of gambling, e.g., blackjack or poker. Female gamblers were more likely to report problems with nonstrategic, less interpersonally interactive forms of gambling, e.g., slot machines or bingo. Female gamblers were more likely to report receiving nongambling-related mental health treatment. Male gamblers were more likely to report a drug problem or an arrest related to gambling. High rates of debt and psychiatric symptoms related to gambling, including anxiety and depression, were observed in both groups.Individuals with gambling disorders have gender-related differences in underlying motivations to gamble and in problems generated by excessive gambling. Different strategies may be necessary to maximize treatment efficacy for men and for women with gambling problems.

Summary:Recent advances in diagnostic imaging, especially in magnetic resonance imaging, have enabled early diagnosis of osteonecrosis, before radiographic changes and femoral head collapse. This is of clinical importance because it allows prompt institution of prophylactic treatment, thus improving

When an arthroplasty is needed to treat osteonecrosis of the femoral head, the use of a component that replaces or resurfaces only the femoral head is often considered as an alternative to total hip replacement if the acetabulum appears radiographically normal. However, the long-term results of the use of endoprostheses have often been poor, secondary in part to progressive degeneration of the acetabular cartilage and to protrusio acetabuli. To help to explain these observations, we examined the acetabular cartilage in forty-one hips in which a primary total hip replacement had been performed because of osteonecrosis of the femoral head in association with a radiographically normal acetabulum. The cartilage in the superior, weight-bearing region of the acetabulum was grossly abnormal in forty of the forty-one hips and it was histologically abnormal in all thirty-three hips that were so evaluated. In all but one hip, gross degeneration of the cartilage was apparent, involving less than 20 percent of the acetabulum; the degeneration was graded as mild (superficial fibrillation and slight irregularity of the surface) in sixteen hips, moderate (moderate fibrillation, alteration in color and consistency, and thinning of cartilage without complete erosion to bone) in twenty hips, and severe (marked fibrillation, alteration in color and consistency, and marked thinning of cartilage with areas of complete erosion to bone) in four hips. These observations emphasize the fact that radiographs cannot demonstrate early degeneration of cartilage and that, by the time that an arthroplasty is needed, degenerative changes are already present in the acetabular cartilage of a high percentage of hips with osteonecrosis, even when radiographs of the acetabulum show no abnormalities. These findings should be kept in mind when a decision is being made regarding which type of arthroplasty should be done in a patient who has osteonecrosis of the femoral head and regarding when to do the procedure.

SUMMARY— Eight different storage conditions were applied. The storage variables were air temperature, air movement and initial bruising of the onions. Storage time was three weeks. Standard plate count and percent spoiled onions were combined into an expression termed the microbial quotient. Moving air at 34°F was the best storage condition and even bruised onions kept well. At room temperature bruised onions showed a greatly increased microbial quotient. Statistical analysis showed that air temperature and bruising were highly significant factors.

Postoperative dislocation remains one of the most frequent complications following total hip replacement. In this report, a case is presented that illustrates two potential concerns with postoperative dislocation and subsequent closed reduction. The first complication presented in this report is entrapment of a closed drainage system tube in the joint space following closed reduction. The second complication, transfer of metallic debris to a ceramic femoral head from contact with an acetabular shell during closed reduction, was documented by analysis of a femoral head using scanning electron microscopy and energy dispersive x-ray spectrometry. This report emphasizes the need for the surgeon to express caution when relocating a dislocated hip, particularly when a closed drainage system is used postoperatively.

Background and aims: Perceived parental permissiveness toward gambling may relate to adolescents’ engagement in various risky behaviors. To examine this possibility, we analyzed data from a high-school based risk-behavior survey to assess relationships between perceived parental permissiveness toward gambling and adolescent gambling behavior, substance use and related problems. We also evaluated predictions that relationships between perceived parental permissiveness toward gambling and risky behaviors would be particularly strong amongst adolescents reporting high sensation-seeking or impulsivity. Methods: High-school students (n = 2,805) provided data on risky behaviors, perceived parental permissiveness toward gambling, impulsivity and sensation-seeking. Bivariate and logistic regression analyses were conducted to examine relationships with gambling and alcohol, cigarette and marijuana use. Results: Perceived parental permissiveness toward gambling related significantly to adolescent gambling, all substance-use behaviors as well as alcohol and drug problems. There were significant parental-permissiveness-by-sensation-seeking interactions in multiple models. Relationships between perceived parental permissiveness toward gambling and alcohol-use frequency were particularly strong among those with high sensation-seeking. This relationship also applied to gambling and heavy cigarette smoking, albeit to a lesser extent. Impulsivity related strongly to drug problems among those who perceived their parents to be more and less permissive toward gambling. Discussion and conclusions: These findings support the relevance of perceived parental permissiveness toward gambling to adolescent risky behaviors. Parenting perceived as less permissive toward gambling appeared to have protective effects on gambling, alcohol and cigarette use, even among those with high sensation-seeking. Reducing parental permissiveness toward gambling may be a valuable intervention goal, particularly for parents of sensation-seeking adolescents.

With the popularity of Internet use among adolescents, there is concern that some youth may display problematic or addictive patterns of Internet use. Although excessive patterns of Internet use was considered for inclusion in the DSM-5 with pathological gambling and substance-use disorders in a category of addictive disorders, it was determined that more research was needed on Internet-use behaviors before such actions be further considered and possibly undertaken. The present study is the first to investigate whether at-risk/problematic Internet use (ARPIU) may moderate the strength of association between problem-gambling severity and gambling-related characteristics and health and well-being measures in adolescents. Survey data from 1884 Connecticut high-school student stratified by Internet use (ARPIU vs. non-ARPIU) were examined in bivariate analyses and logistic regression models. Gambling-related characteristics and health and well-being measures were mostly positively associated with problem-gambling severity in both Internet use groups. Interaction odds ratio revealed that the strength of the associations between problem-gambling severity and marijuana, alcohol and caffeine use were stronger amongst the non-ARPIU compared to the ARPIU group, suggesting that the relationships between these substance use behaviors and problem gambling may be partially accounted for by ARPIU. Future studies should examine the extent to which preventative interventions targeting both problematic Internet use and problem gambling may synergistically benefit measures of health and reduce risk-taking behaviors in adolescence.

This study compares the benefits of aspirin and warfarin prophylactic agents for patients with thromboembolic disease after total joint arthroplasty. It is a prospective randomized study of 388 patients having total hip or total knee surgery. All consecutive patients having total hip or total knee surgery were entered into this study and evaluated with preoperative and postoperative ventilation perfusion scans and a postoperative venogram. The aspirin and warfarin treatment groups were compared by size and location of venographically revealed clots and changes in ventilation perfusion scans. The results showed that there was no difference in the size or location of deep venous thrombosis in the aspirin or warfarin treatment groups. The venogram was negative in 44.5% of patients; 28.8% had small ++calf clots, 16% had large calf clots, 3.9% had popliteal clots, and 6.7% had femoral clots. Patients with total knee replacement had a 2.6 times greater incidence of calf deep venous thrombosis than patients with total hip replacement. There was no difference between the aspirin and warfarin groups in the incidence of changes in ventilation perfusion scans (18.9%). There was no difference between the 2 groups in bleeding complications. The results suggest that aspirin and warfarin are equivalent in prophylaxis against thromboembolic disease, as determined by prevention of venographic changes or changes in ventilation perfusion scans.

Much of the current confusion and contradiction on the treatment of avascular necrosis of the femoral head is caused by the lack of an agreed efficient, quantitative system for evaluation and staging. We have used a new system to evaluate over 1000 hips with avascular necrosis during a period of 12 years; it has proved to be very valuable. The system is based on the sequence of pathological events known to take place. It allows accurate quantification in both early and later stages, does not use older, invasive diagnostic procedures, and incorporates the newer techniques of bone scanning and MRI. Clinical records of pain and reduced function are not a specific part of the system, although they help to determine treatment and outcome. Hips are first placed into one of seven stages from 0 to VI, based upon the type of radiological change. The extent of involvement is then measured. This allows more accurate evaluation of progression or resolution and better comparison of different methods of management. The system also helps to provide a prognosis and to decide on the best available method of treatment.

Despite advances in the treatment of fractures and dislocations of the hip, avascular necrosis (AVN) remains one of the two most frequent complications encountered. To understand the pathogenesis and treatment of this condition, this article describes the circulation to the femoral head. The reported incidence of AVN varies considerably with different studies, but overall it is much higher in displaced than in undisplaced intracapsular fractures. The clinical picture and prognosis are discussed in this article, and the measures for early diagnosis are reviewed. A quantitative system for evaluation and staging that helps in establishing a prognosis and determining treatment is described. Specific measures for management are reviewed. Although ideally the treatment goal is to preserve the femoral head, for most patients who sustain posttraumatic AVN, treatment will be symptomatic until such time as pain and disability justify arthroplasty. At the point, the majority of patients will undergo total hip replacement that yields gratifying and durable results.

Nontraumatic avascular necrosis of the femoral head in the adult is being diagnosed with increasing frequency. Predisposing factors can be identified in approximately 80% of the cases and help lead to an early diagnosis. In most instances the diagnosis will be confirmed by good quality anteroposterior and lateral radiographs of the hip. If these are nondiagnostic, magnetic resonance imaging studies should be performed. These are currently extremely sensitive and specific for the diagnosis of avascular necrosis. Except in the case of a very small asymptomatic lesion, conservative or nonoperative management is ineffective in most cases, and early prophylactic surgery should be performed to prevent collapse of the femoral head. The use of an effective, quantitative method for evaluation and staging will help to determine the prognosis and the specific method of treatment. Prophylactic procedures include core decompression, various types of osteotomies, and bone grafting procedures. Use of a fibular graft with microvascular anastomosis is technically demanding, but is producing gratifying results in the hands of a limited number of investigators. If the hip disease has progressed to the point of significant collapse with pain and disability, prophylactic procedures are generally of little avail. Patients should be treated symptomatically until such time as arthroplasty is required. Although modified cup arthroplasties are receiving renewed attention, most patients will undergo either endoprosthetic replacement or total hip replacement. Results with total hip replacement are generally more consistent and more durable than with an endoprosthesis, and this is currently the treatment of choice in most instances when arthroplasty is required.

In adults, different levels of gambling problem severity are differentially associated with measures of health and general functioning, gambling behaviors, and gambling-related motivations. Here we present data from a survey of 2,484 Connecticut high school students, and investigate the data stratifying by gambling problem severity based on DSM-IV criteria for pathological gambling. Problem/pathological gambling was associated with a range of negative functions; for example, poor academic performance, substance use, dysphoria/depression, and aggression. These findings suggest a need for improved interventions related to adolescent gambling and a need for additional research into the relationship (eg, mediating factors) between gambling and risk and protective behaviors.

Until recently, the couple relationship has been relatively neglected in both clinical reports and systematic research in the compulsive gambling literature. This article suggests the need for family and intergenerational assessment as well as early interventions within the couple system. The following treatment issues are discussed: multiple addictions; finances; control and power; anger; sexuality; and emotional intimacy. Overcoming deficits in intimacy is viewed as central to couples recovery.