Gambling disorder and substance-related disorders: Similarities and differences

Gambling disorder (GD) has important similarities with substance use disorders (SUDs) in terms of both diagnostic criteria and underlying mechanisms of action. With regard to diagnostic criteria, only craving is not present as a formal criterion in DSM-5 GD, and chasing losses is not present in SUDs. All other major diagnostic criteria such as loss of control over gambling, tolerance, withdrawal, and negative consequences due to gambling overlap with those of SUD. With regard to underlying mechanisms and vulnerability factors, higher impulsivity, abnormalities in decision-making, deficient executive functions, and related fronto-striatal brain circuitry abnormalities are related to the development and course of both SUD and GD. However, there are also differences between GD and SUD. In gambling, cognitive factors such as risk-taking and decision-making are intrinsically related to the addictive behavior itself, whereas in SUD these effects can also be associated with the pharmacological effect or the neurotoxicity related to (chronic) substance use. Moreover misperceptions with regard to gambling, the experience and interpretation of near misses, and the processing of (potential) rewards and losses influence the experience of gambling, which is not true for SUD. Importantly, these aspects also differ between disordered gamblers and non-problematic gamblers and are thus unique for GD and consitute a risk for relapse. Both shared and unique mechanisms are relevant as targets for the treatment of GD. This chapter concludes with a discussion on novel treatment methods that target some of the working mechanisms shared by GD and SUDs

Mortality after surgery in Europe: a 7 day cohort study

Background: Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfirmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe.Methods: We did this 7 day cohort study between April 4 and April 11, 2011. We collected data describing consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery in 498 hospitals across 28 European nations. Patients were followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Secondary outcome measures were duration of hospital stay and admission to critical care. We used χ² and Fisher’s exact tests to compare categorical variables and the t test or the Mann-Whitney U test to compare continuous variables. Significance was set at p<0·05. We constructed multilevel logistic regression models to adjust for the differences in mortality rates between countries.Findings: We included 46 539 patients, of whom 1855 (4%) died before hospital discharge. 3599 (8%) patients were admitted to critical care after surgery with a median length of stay of 1·2 days (IQR 0·9–3·6). 1358 (73%) patients who died were not admitted to critical care at any stage after surgery. Crude mortality rates varied widely between countries (from 1·2% [95% CI 0·0–3·0] for Iceland to 21·5% [16·9–26·2] for Latvia). After adjustment for confounding variables, important differences remained between countries when compared with the UK, the country with the largest dataset (OR range from 0·44 [95% CI 0·19 1·05; p=0·06] for Finland to 6·92 [2·37–20·27; p=0·0004] for Poland).Interpretation: The mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated. Variations in mortality between countries suggest the need for national and international strategies to improve care for this group of patients.Funding: European Society of Intensive Care Medicine, European Society of Anaesthesiology