Clinical Caseload Research Articles

Clinical Challenges in the Evaluation and Treatment of Individuals with Poststroke Dysphagia

Although reported frequencies vary due to study design, patient characteristics, and method of ascertainment, dysphagia is a commonly encountered morbidity after stroke. Consequently, speech-language pathologists’ clinical caseloads are heavily populated with individuals with poststroke dysphagia. The body of knowledge about swallowing and swallowing disorders has expanded exponentially over the last 3 decades, and speech-language pathologists are increasingly sophisticated in their evaluation and treatment of this patient population. Nevertheless, clinical quandaries persist regarding the management of these individuals. In this article, clinical challenges are discussed, including early detection of dysphagia and aspiration risk, treatment efficacy, refractory dysphagia, and noncompliance with treatment. Research relevant to these issues is reviewed to aid in formulating sound clinical decisions.

The use of probiotics as dietary supplements in dogs

Gastrointestinal microflora are non-pathogenic, naturally occurring ‘beneficial’ bacteria that reside in the gastrointestinal tract and play an important role in physiological functions including enhancing the overall health of the intestinal tract and stimulating a strong immune system. When bacterial populations diminish, their health benefits to the animal may also diminish and this can potentially result in digestive upsets. Intestinal disorders pose a significant clinical caseload in clinical practice and one way to prevent and treat these cases is to support normal digestive function with the addition of synbiotics, which are oral supplements consisting of probiotics (beneficial bacteria) and prebiotics (nondigestable carbohydrates that support the growth of beneficial bacteria).

Changes in Programmatic Outcomes During 7 Years of Scale-up at a Community-Based Antiretroviral Treatment Service in South Africa

To assess sustainability of programmatic outcomes in a community-based antiretroviral therapy (ART) service in South Africa during 7 years of scale-up. Prospective cohort of treatment-naive patients aged ≥ 15 years enrolled between 2002 and 2008. Data were analyzed by calendar period of ART initiation using time-to-event analysis and logistic regression. ART was initiated by 3162 patients (67% women; median age, 34 years) who were followed-up for a median of 2.4 years (interquartile range, 1.2-3.8). After 6 years, the cumulative probability of death and loss to follow-up (LTFU) was 37.4%. The probabilities of transfer-out to another ART service and of virological failure were 21.6% and 23.1%, respectively. Low mortality risk and excellent virological and immunological responses during the first year of ART were not associated with calendar period of ART initiation. In contrast, risk of LTFU and virological failure both increased between successive calendar periods in unadjusted and adjusted analyses. The number of patients per member of clinic staff increased markedly over time. Successful early outcomes (low mortality and good immunological and virological responses) were sustained between sequential calendar periods during 7 years of scale-up. In contrast, the increasing cumulative probabilities of LTFU or virological failure may reflect decreasing capacity to adequately support patients during long-term therapy as clinic caseload escalated.

The Design and Implementation of an Automated System for Logging Clinical Experiences Using an Anesthesia Information Management System

Residents in anesthesia training programs throughout the world are required to document their clinical cases to help ensure that they receive adequate training. Current systems involve self-reporting, are subject to delayed updates and misreported data, and do not provide a practicable method of validation. Anesthesia information management systems (AIMS) are being used increasingly in training programs and are a logical source for verifiable documentation. We hypothesized that case logs generated automatically from an AIMS would be sufficiently accurate to replace the current manual process. We based our analysis on the data reporting requirements of the American College of Graduate Medical Education (ACGME). We conducted a systematic review of ACGME requirements and our AIMS record, and made modifications after identifying data element and attribution issues. We studied 2 methods (parsing of free text procedure descriptions and CPT4 procedure code mapping) to automatically determine ACGME case categories and generated AIMS-based case logs and compared these to assignments made by manual inspection of the anesthesia records. We also assessed under- and overreporting of cases entered manually by our residents into the ACGME website. The parsing and mapping methods assigned cases to a majority of the ACGME categories with accuracies of 95% and 97%, respectively, as compared with determinations made by 2 residents and 1 attending who manually reviewed all procedure descriptions. Comparison of AIMS-based case logs with reports from the ACGME Resident Case Log System website showed that >50% of residents either underreported or overreported their total case counts by at least 5%. The AIMS database is a source of contemporaneous documentation of resident experience that can be queried to generate valid, verifiable case logs. The extent of AIMS adoption by academic anesthesia departments should encourage accreditation organizations to support uploading of AIMS-based case log files to improve accuracy and to decrease the clerical burden on anesthesia residents.

Results of the 2005-2008 Association of Residents in Radiation Oncology Survey of Chief Residents in the United States: Clinical Training and Resident Working Conditions

To document clinical training and resident working conditions reported by chief residents during their residency. During the academic years 2005 to 2006, 2006 to 2007, and 2007 to 2008, the Association of Residents in Radiation Oncology conducted a nationwide survey of all radiation oncology chief residents in the United States. Chi-square statistics were used to assess changes in clinical training and resident working conditions over time. Surveys were completed by representatives from 55 programs (response rate, 71.4%) in 2005 to 2006, 60 programs (75.9%) in 2006 to 2007, and 74 programs (93.7%) in 2007 to 2008. Nearly all chief residents reported receiving adequate clinical experience in commonly treated disease sites, such as breast and genitourinary malignancies; and commonly performed procedures, such as three-dimensional conformal radiotherapy and intensity-modulated radiotherapy. Clinical experience in extracranial stereotactic radiotherapy increased over time (p < 0.001), whereas clinical experience in endovascular brachytherapy (p <0.001) decreased over time. The distribution of gynecologic and prostate brachytherapy cases remained stable, while clinical case load in breast brachytherapy increased (p = 0.006). A small but significant percentage of residents reported receiving inadequate clinical experience in pediatrics, seeing 10 or fewer pediatric cases during the course of residency. Procedures involving higher capital costs, such as particle beam therapy and intraoperative radiotherapy, and infrequent clinical use, such as head and neck brachytherapy, were limited to a minority of institutions. Most residency programs associated with at least one satellite facility have incorporated resident rotations into their clinical training, and the majority of residents at these programs find them valuable experiences. The majority of residents reported working 60 or fewer hours per week on required clinical duties. Trends in clinical training and resident working conditions over 3 years are documented to allow residents and program directors to assess their residency training.

Nurse directors do not have the time to take on a heavy clinical caseload

Why do we constantly try to measure ourselves against our medical colleagues? Simply because some medical directors retain some clinical input does not necessarily mean it is right for us.

Readers panel - Leading by medical example

Should nurse directors manage nursing staff and keep their own clinical caseload? We asked our readers panel

Results from the Cognitive Changes and Retirement among Senior Surgeons Self-Report Survey

The Cognitive Changes and Retirement among Senior Surgeons (CCRASS) study suggested that although subjective cognitive awareness may play a role in surgeons' retirement decisions, self-perceived cognitive decline did not predict objective cognitive performance. This article summarizes results from all participants who completed the survey portion of the CCRASS study. A survey examining subjective cognitive changes, changes in caseload, involvement in new technology, and retirement decisions, was administered to 995 surgeons at annual meetings of the Clinical Congress of the American College of Surgeons between 2001 and 2006. Forty-five percent reported increased caseload volume and 48% reported increased caseload complexity during the previous 5 years. In addition, 75% and 73% denied any recent changes in memory recall or name recognition, respectively. Increasing age was associated with decreases in clinical caseload and complexity. The majority of respondents across all age groups reported active participation in either learning (64%) or contributing (13%) to new technology in the field. Among surgeons with no imminent plans for retirement, 58% reported that a retirement decision will be based on skill level. Increasing age was associated with decreases in caseload and case complexity. But a steady proportion of surgeons, even in the oldest age group, are active in new surgical innovations and challenging cases. Most reported no changes in perceived cognitive abilities. The majority of surgeons who had made no decision to retire reported that their decision will be based on skill level rather than age.

British HIV Association (BHIVA) national cohort outcomes audit of patients commencing antiretrovirals from naïve

The aim of this work was to audit the extent to which routine HIV care in the UK conforms with British HIV Association (BHIVA) guidelines and specifically the proportion of patients starting highly active antiretroviral therapy (HAART) who achieve the outcome of virological suppression below 50 HIV-1 RNA copies/mL within 6 months. A prospective cohort review of adults with HIV infection who started antiretroviral therapy (ART) for the first time between April and September 2006 was carried out using structured questionnaire forms. A total of 1170 adults from 122 clinical sites participated in the review. Of these patients, 699 (59.7%) started ART at CD4 counts <200 cells/microL and 193 (16.5%) had not been tested for HIV drug resistance. Excluding patients with valid reasons for stopping short-term ART, 795 (73.5%) of 1081 patients had an undetectable viral load (VL) at follow-up. Detectable VL was strongly associated with pretreatment CD4 count below 50 cells/microL and pretreatment VL above 100 000 copies/mL, and was not associated with clinic location or case load. About a quarter of patients did not have a VL measurement during the first 6 weeks after starting ART. The majority of patients who initiated ART at sites participating in this UK national audit were managed within the BHIVA guidelines and achieved virological suppression below 50 copies/mL around 6 months after commencing treatment. Poor VL outcomes were associated with very low CD4 cell count and/or high VL at baseline but not with clinic case load or location. There is an urgent need to diagnose patients at an earlier stage of their HIV disease.

Evidence-Based and Clinical Outcome Scores to Facilitate Audit and Feedback for Colorectal Cancer Care

To describe a methodology for surgical audit and feedback based on hospital-level indicators of the quality of colorectal cancer care. Process and outcome indicators were identified from a population-based database (N = 3095 patients treated by 258 surgeons at 130 hospitals across New South Wales between February 1, 2000 and January 31, 2001). Hospitals were ranked on each indicator, with those in the lowest 20th percentile receiving a score of 0 and the remainder receiving a score of 1. Scores for individual indicators were then summed for each hospital and divided by the number of relevant indicators to provide an evidence-based score (EBS) and a clinical outcome score. Ten process and six clinical outcome indicators were identified. Hospital-level summary scores ranged from 0.14 to 1.0 for evidence-based processes and from 0.17 to 1.0 for clinical outcomes. Evidence-based score and clinical outcome score were independent (r = 0.12, P = 0.32). There was a small positive association between evidence-based score and caseload (r = 0.33, P = 0.005) but clinical outcome score and caseload were unrelated (r = 0.11, P = 0.36). Evidence-based score and clinical outcome score address different aspects of quality of care. The wide variability of hospitals' outcome scores and an association of evidence-based score and caseload indicate that simple scores may be useful in audit and feedback.

A case study of occupational therapy managers in NSW: Roles, responsibilities and work satisfaction

Job satisfaction has been shown to affect levels of staff retention and productivity, but few studies have been conducted on the work of occupational therapy managers and their job satisfaction. This study explores the roles and responsibilities of occupational therapy managers who are clinician-managers or manager-administrators, and sources of their work satisfaction. A collective case study involved telephone interviews with 16 occupational therapy managers. Semistructured interview questions were based on an earlier discussion with a separate group of occupational therapy managers. Interview transcripts were analysed for emerging themes. There were no clear differences in the roles and responsibilities of the two types of managers (manager-administrators and clinician-managers); however, manager-administrators tended to be responsible for larger numbers of staff. Managers reported that taking a clinical caseload is often at their own discretion. A common challenge for managers is the balancing of priorities as a clinician and a manager. Managing people was a common source of joy and sometimes a source of frustration. Mediating between staff and senior management and the need for budget control and efficiencies was an important aspect of managers' work, as was their autonomy to make decisions. Occupational therapy managers assume responsibilities consistent with clinician managers across disciplines. The main sources of work satisfaction related to people management particularly when staff were working effectively as a team and there was respect from senior management. Further research will confirm whether there are no obvious differences between clinician-manager and manager-administrators, and whether there are clear differences in work-related frustration across sectors.

P01-155 Audit of pattern of benzodiazepine prescribing in a community mental health team in England

Aims:To audit benzodiazepine prescribing in a Community Mental Health team, with a view to identifying areas for improvement.Methods:All the 245 patient's case notes were audited, from October 2004 to October 2005, of those in the Outpatients Clinic's case load, in North Shields. A semi structured pro-forma was designed. On the basis of the guidelines from Committee on Safety of Medicines (CSM) (1988), DOH Document (1999), DOH Ireland report of benzodiazepine commission (2002), www.benzo.org.uk, Newcastle, North Tyneside and Northumbria NHS Trust Guidelines for hypnotic/anxiolytic use and Lanarkshire PCT guidelines, the standards were finalised. The audit tool looked at demographics, indications of benzodiazepine prescription, co-morbid medical conditions, substance misuse, psychotherapeutic intervention and follow up of patients prescribed benzodiazepines.Results:245 notes were audited. 24% of all patients were on benzodiazepines. Out of those, 56% were women. A third of these patients were between 41-50 year olds, while another third were older than 50years. Co-morbid substance and alcohol dependence was uncommon. The most common diagnoses in these patients were mood disorder (31%), schizophrenia (20%), and personality disorders (12%). Nearly two-third of patients suffered from co-morbid medical conditions. 25% patients had had psychological therapies. None of them were given advice about sleep hygiene and driving.Conclusions:Older women with mood disorders are more likely to be prescribed benzodiazepines longer than recommended. Advice about driving, sleep hygiene, information about side effects and risks was not offered to most patients. Recommendations have been made, with a view to re-auditing and improving services.

Breed differences in canine aggression

Canine aggression poses serious public health and animal welfare concerns. Most of what is understood about breed differences in aggression comes from reports based on bite statistics, behavior clinic caseloads, and experts’ opinions. Information on breed-specific aggressiveness derived from such sources may be misleading due to biases attributable to a disproportionate risk of injury associated with larger and/or more physically powerful breeds and the existence of breed stereotypes. The present study surveyed the owners of more than 30 breeds of dogs using the Canine Behavioral Assessment and Research Questionnaire (C-BARQ), a validated and reliable instrument for assessing dogs’ typical and recent responses to a variety of common stimuli and situations. Two independent data samples (a random sample of breed club members and an online sample) yielded significant differences among breeds in aggression directed toward strangers, owners and dogs (Kruskal–Wallis tests, P < 0.0001). Eight breeds common to both datasets (Dachshund, English Springer Spaniel, Golden Retriever, Labrador Retriever, Poodle, Rottweiler, Shetland Sheepdog and Siberian Husky) ranked similarly, r s = 0.723, P < 0.05; r s = 0.929, P < 0.001; r s = 0.592, P = 0.123, for aggression directed toward strangers, dogs and owners, respectively. Some breeds scored higher than average for aggression directed toward both humans and dogs (e.g., Chihuahuas and Dachshunds) while other breeds scored high only for specific targets (e.g., dog-directed aggression among Akitas and Pit Bull Terriers). In general, aggression was most severe when directed toward other dogs followed by unfamiliar people and household members. Breeds with the greatest percentage of dogs exhibiting serious aggression (bites or bite attempts) toward humans included Dachshunds, Chihuahuas and Jack Russell Terriers (toward strangers and owners); Australian Cattle Dogs (toward strangers); and American Cocker Spaniels and Beagles (toward owners). More than 20% of Akitas, Jack Russell Terriers and Pit Bull Terriers were reported as displaying serious aggression toward unfamiliar dogs. Golden Retrievers, Labradors Retrievers, Bernese Mountain Dogs, Brittany Spaniels, Greyhounds and Whippets were the least aggressive toward both humans and dogs. Among English Springer Spaniels, conformation-bred dogs were more aggressive to humans and dogs than field-bred dogs (stranger aggression: Mann–Whitney U test, z = 3.880, P < 0.0001; owner aggression: z = 2.110, P < 0.05; dog-directed aggression: z = 1.93, P = 0.054), suggesting a genetic influence on the behavior. The opposite pattern was observed for owner-directed aggression among Labrador Retrievers, ( z = 2.18, P < 0.05) indicating that higher levels of aggression are not attributable to breeding for show per se.

The development of expertise in paediatric rehabilitation therapists: The roles of motivation, openness to experience, and types of caseload experience

A transdisciplinary approach was taken to study the nature of variables associated with the development of expertise in 71 paediatric rehabilitation therapists (i.e. physical, occupational, speech, behavioural, and recreational therapists). Six groups of practising therapists were identified based on expertise status (novice, intermediate, and expert, as determined by a multifaceted assessment battery), and their level of clinical experience (10 years or less, more than 10 years). Scores for these six therapist groups were examined on three variables generally considered to be associated with the development of expertise--motivation, openness to experience (as defined by the critical-thinking dispositions of truth-seeking, open-mindedness, and cognitive maturity), and features of their clinical caseload experience (i.e. breadth of experience as measured by number of different client age groups worked with, the complexity of clients' needs, and experience in delivering services to adolescents, school-age children, preschoolers, and infants). Low-experience experts ('young stars') had the highest motivation, truth-seeking, and open-mindedness scores of all groups, the highest percentage of clients with complex service needs, and were more likely to work with adolescents. The major differences between therapists who attain expertise quickly versus those who remain novices after many years of experience appear to be motivation and complexity of work experiences. Implications for supporting the development of expertise in practising therapists are discussed.

Differences in Baseline Characteristics and Outcomes at 1- and 2-Year Follow-up of Cancer Survivors Accrued via Self-Referral versus Cancer Registry in the FRESH START Diet and Exercise Trial

Participant accrual to research studies is a challenge; oftentimes, advertisements are used to supplement cases ascertained through clinic caseloads and cancer registries. It is unknown, however, if cases ascertained through these two sources differ. In this study, we compared self-referred (n = 209) and registry-ascertained (n = 334) participants enrolled in FRESH START, a randomized controlled trial promoting a healthy diet and increased exercise among breast and prostate cancer survivors. The two groups were compared on baseline characteristics, adherence, attrition, and outcomes by study arm. Compared with participants enrolled from registries, self-referrals were significantly younger (54.1 +/- 10.4 versus 58.7 +/- 10.7 years), more likely to have later-stage disease and to have received chemotherapy (40% versus 19%), and more likely to report "fighting spirit" coping styles (50% versus 30%), lower quality-of-life (88.2 +/- 15.1 versus 92.0 +/- 12.9), fewer comorbid conditions (1.87 +/- 1.60 versus 2.24 +/- 1.78), and lower consumption of five or more daily servings of fruits and vegetables (35% versus 45%; P values <0.05). Although no differences in behavior change were observed between self-referred and registry-ascertained cases assigned to the tailored intervention arm, this was not the case within the attention control arm. Among those who received the attention control intervention of standardized materials in the public domain, self-referred versus registry-ascertained participants showed significantly greater increases in exercise at 1-year follow-up and significantly greater increases in fruit and vegetable consumption at both 1- and 2-year follow-up (P values <0.05). Several differences exist between self-referred and registry-ascertained participants, including motivation to respond to standardized educational materials, which appears significantly greater in self-referred populations.

Problem-maintaining circles: Case illustrations of formulations that truly guide therapy

The cognitive behaviour therapy (CBT) emphasis on treatment relevance in assessment, and on evidence-based intervention, has led to an increasing focus on problem maintenance factors (vs. precipitants) in both its models of psychopathology and in its individual case formulations. This article describes the reasons for this growing focus, and presents a generic CBT model based on the functional analysis of “problem-maintaining circles” (PMCs) of causes. Some samples of the profuse literature implicating PMCs in many psychological disorders are presented, and the utility of PMC-based functional analysis, case formulation, or modelling of psychopathology is advanced, not only as a guide to selection of therapeutic interventions, but as an alternative to standard psychiatric diagnosis. A sampling of a taxonomy of such PMCs is presented. And finally, the clinical application of PMC-based functional analysis, case formulation, and treatment selection is illustrated in five case illustrations drawn from a recent clinical caseload.

Soft tissue injuries: principles of biomechanics, physiotherapy and imaging

In the second of this series on soft tissue injury, the principles of biomechanics, physiotherapy and imaging are covered. Although injuries vary immensely in severity and according to location, an...

The Application of Cognitive-Behavioral Therapy for Psychosis in Clinical and Research Settings

This study compared the practice of cognitive-behavioral therapy (CBT) for psychosis across research and routine clinical settings. An observer-rated adherence measure was used to compare the content of 40 therapy sessions of clients with positive psychotic symptoms. Twenty therapist-client dyads came from a research setting in the United Kingdom and 20 from three clinical settings, two in the United Kingdom and one in the United States. In the research setting CBT was provided by research clinical psychologists and trained local therapists. In the clinical settings CBT was part of a case management service by trained therapists. Therapist adherence to CBT for psychosis did not differ between the research and clinical settings. However, clinicians in the research settings scored significantly higher on items for schema work (z=-1.98, p<.05), relapse prevention interventions (z=-2.08, p<.05), and formulating a model of relapse (z=-2.61, p<.01). CBT for psychosis conducted in clinical settings was more strongly characterized by assessment of symptoms and work on coping strategies and less so by relapse prevention and schema-level work. Relapse prevention interventions and schema work could be considered more challenging for therapists to undertake. The findings suggest that therapists working in routine clinical settings are able to establish good therapeutic relationships with people with psychosis and to work on assessing and coping with their psychotic symptoms. However, some therapeutic approaches may be more challenging in this context.

Gatekeeping access to community mental health teams: A qualitative study

BackgroundGatekeeping access to services at the interface with primary care has been identified as one of the key issues that community mental health teams (CMHTs) have to confront. ObjectivesThe aim of this study was to develop a better understanding of the contextual influences that impact upon the outcome of gatekeeping decisions. DesignAn interview-based qualitative study, informed by the philosophy of critical realism. SettingAn urban catchment area in Northern England. ParticipantsTwenty-nine interviews were conducted with gatekeeping clinicians and service managers. MethodA convenience sample of clinicians was initially approached to take part in a series of semi-structured interviews. This was followed up by a purposive sample of clinicians and service managers, as specific contextual influences were identified and explored in detail. The emerging analysis was then subjected to critical scrutiny by a further sample of gatekeeping clinicians. FindingsA clear hierarchy of appropriateness was identified with four dimensions: severity, risk, beneficence and a moral dimension. It was suggested that the salient contextual influences that shaped the hierarchy were: (a) the need to fit in with strategic planning directives, (b) the burden of responsibility that clinicians carried, (c) the high number of referrals and the relatively slow turnover of patients on clinical caseloads, (d) the position of CMHTs in the economy of care and (e) the character of the relationship between clinicians and service managers. ConclusionThe findings from the study support a multi-level view of the gatekeeping process within CMHTs, which takes account of the role that key contextual influences play in shaping the range of options that are available to gatekeeping clinicians.

Review of Gambling problems in youth: Theoretical and applied perspectives.

JEFFREYL. DEREVENSKYand RINA GUPTA (Eds.) Gambling Problems in Youth: Theoretical and Applied Perspectives New York: Kluwer Academic Press, 2004, 264 pages (ISBN 0-306-48585-0, US$65.00 Hardcover) As the public view of gambling in the United States and Canada has evolved over the past couple of decades from sin, to vice, to a benign form of recreation, participation rates have markedly increased. For a minority, gambling has had devastating consequences for themselves and their families, employers, and communities. Its emergence has resulted in addiction researchers and clinicians arguing about which dependence is more harmful - alcoholism or pathological gambling. A persuasive case can be made for both sides but most agree that problem gambling generally shows the more rapid and devastating impact on a family's equilibrium. At the same time, practitioners across North America are starting to see the effects of growing gambling activity on their clinical caseloads. Research into problem gambling is still in its infancy. Despite a general paucity of literature on problem gambling, two recent books, Grant and Potenza's Pathological Gambling: A Clinical Guide to Treatment (American Psychiatric, 2004) and Gambling Problems in Ymitli (the focus of (his review), are significant contributions to the field. Both have joined my list of core texts on problem-gambling behaviour. Derevensky and Gupta are world recognized leaders in youth gambling research and co-directors of the McGiII University Youth Gambling Research and Treatment Clinic and the International Centre for \buth Gambling Problems and High-Risk Behaviours. Their new book specifically addresses gambling problems in youlh, and presents a balanced and comprehensive overview of theory, research, and treatment knowledge. Until recently, little was known about this area, much like the situation that existed some 50 years ago when the concept of juvenile alcoholism was not yet plausible (diagnostic criteria involved a lengthy time span of use, withdrawal, and medical problems associated with use). In a similar fashion, we are only now recognizing the problems associated with this first generation of youth that has been exposed to widespread availability, acceptance, and promotion of gambling. Stinchfield reports that in early adolescence, the prevalence of gambling involvement rivals alcohol use and far exceeds the use of illicit drugs or tobacco. The level of research funding for adolescent gambling has grown quickly over the past 10 years, especially among Canadian provinces, and the resulting knowledge base is expanding rapidly. On a related front, the call for a gold standard for measuring prevalence has led to the development of a new, soon-to-bereleased adolescent gambling screen cooperatively undertaken by a number of publicly funded Canadian research groups. The field is in many ways defined by the dynamics of new research and clinical activities, and the need to be kept current is apparent. Derevensky and Gupta organize their book into seven sections: Prevalence, Correlates and Risk Factors, New Technologies, Measurement Issues, Treatment, Prevention, and Social Policy Issues, comprising a total of 12 well-written chapters. The introductory section is written by Dewey Jacobs, the patriarch of gambling research who suggests that the age of onset for gambling will continue to decrease as more children see their parents and relatives gambling. His chapter deftly predicts the explosive popularity of poker tournaments and celebrity poker on TV, and parent reports of their preteen children playing Texas Hold'em with their friends. An issue that emerges repeatedly is the debate over the actual prevalence of gambling and problem gambling in adolescent populations. Despite the inadequacy of currently available measurement tools, along with fundamental nomenclature and conceptual disagreement, all sides concur that significant numbers of adolescents are harmed by their gambling. …