Suicide and Life Insurance.

Much has been written about the history of suicide and, notably, about societies that condemned both the act and the actor, resulting in a perpetuation of suicide being stigmatized in many cultures. One aspect of this perceived stigmatization involves exclusionary clauses in life insurance policies that reject paying benefits to survivor-beneficiaries of the decedent if the decedent has died by suicide within a prescribed time frame. From the perspective of the individual, life insurance is designed to protect the estate of a decedent from a significant financial burden. From the insurer's perspective, there are essentially 2 reasons for having a suicide exclusion clause: limiting risk and preventing or discouraging fraud. This column examines these rationales in light of the estimated few suicides that do occur during exclusionary clause time frames. Observations are made about the effect of these clauses on those impacted by the loss of a loved one who died by suicide within the exclusionary time frame. An examination of the perspectives of both the life insurance industry and the impacted survivors of suicide decedents raises questions about what are reasonable and appropriate exclusionary clause time frames that protect both the insurer and survivor-beneficiaries. The forensic expert consulting on such cases should be cognizant of these competing perspectives and engage in therapeutic assessment whenever possible, identifying opportunities to promote thoughtful suicide postvention.

An examination of housing interventions among youth experiencing homelessness: an investigation into racial/ethnic and sexual minority status.

OBJECTIVES: The purpose of this study is to explore main and interaction effects of minority and multiple minority statuses on exits from homelessness and the stability of homelessness exits overtime. METHODS: This study utilized the Homeless Management Information System administrative data of 10 922 youth experiencing homelessness collected from a convenience sample of 16 geographically diverse communities across the USA between 2015-17. Using multinomial logistic regression analyses and logistic regression, main effects and interaction effects of racial/ethnic minority identity and sexual/gender minority identity were examined on various homelessness exits (n = 9957) and housing sustainability (n = 5836). RESULTS: Black youth, relative to White youth, were disproportionately exiting homelessness through incarceration (P < 0.001). Black and Latinx youth were less likely to successfully self-resolve their homelessness (both P < 0.05). Black heterosexual and Black and Latinx non-heterosexual youth were most frequently lost to the homeless system (all P < 0.01). Black youth, relative to White youth, were approximately half as likely to remain stably housed after returning to family (P < 0.01). CONCLUSIONS: With respect to housing exits and exit stability, Black and Latinx heterosexual youth are consistently at a disadvantage. Homelessness/housing systems and programs need to conduct a deeper investigation into how they implement and develop equitable outreach and engagement practices.

Hospital-Based Suicides: Challenging Existing Myths.

Myths are widely held and often based on false beliefs. To improve patient safety and speed the translation of research to clinical practice, we highlight and then debunk 10 common myths regarding the assessment, treatment, and management of hospitalized patients at risk for suicide. Myths regarding hospital-based suicides are examined and empirical evidence that counters each myth is offered. Ten common myths regarding hospital-based suicides are found to be untrue or unsupported based on existing empirical evidence. Rethinking common beliefs and practices that lack empirical support and seeking alternatives based on research evidence is consistent with an emphasis on evidence-based practices leading to improved patient care and protection.

Can elective surgery for mandibular and zygomatic complex fractures reduce overall hospital stay without compromising outcomes? Analysis of administrative datasets by the GIRFT programme.

When patients attend the emergency department with facial fractures that require surgery and are immediately admitted, surgery can be delayed as theatre time is prioritised for other more urgent patients. One solution is to send the patient home and admit them as an elective patient at a later date. The aim of this study was to investigate the outcomes of patients admitted directly and those seen as elective patients following fracture of the mandible or zygomatic complex. Data were taken from the hospital episodes statistics (HES) dataset for 2011-2018, and all hospital admissions for mandibular and zygomatic complex fractures within the National Health Service (NHS) in England were extracted. Patients were categorised as those admitted on attendance at the emergency department and given definitive treatment during the admission, and those not admitted on attendance at the emergency department but discharged home and seen as elective admissions within 30 days of attendance. Data were available for 39 606 patients. For both types of fracture there was substantial variation between NHS trusts in the proportion of patients admitted electively and the proportion admitted directly as emergencies. Elective admission was independently associated with shorter overall stay and lower emergency readmission rates. We found no evidence that delays to definitive surgery through elective admission had a negative impact on emergency readmission rates. Patients admitted electively had a significantly shorter hospital stay.

Variability of TSNA in U.S. Tobacco and Moist Smokeless Tobacco Products.

Tobacco-specific nitrosamines (TSNAs) have been of concern to the public health community for decades and their reduction through agricultural practices, plant breeding, and tobacco processing has also been a decades-long industry effort. Despite those efforts, TSNAs, though lower, continue to be constituents of concern in tobacco products. This paper examines the TSNA levels of dark air-cured, dark fire-cured, and burley tobaccos purchased in the United States by U.S. Smokeless Tobacco Company LLC (USSTC) and of nine finished USSTC moist smokeless tobacco products. TSNA values of the incoming purchased tobaccos and the finished products showed considerable variability. For the incoming tobaccos, the coefficient of variation was generally more than 100 % for each tobacco type and for each of the measured TSNAs. The relative TSNA variability of the finished tobacco products was also considerable, averaging approximately 25 %. It was also found that the measured values for the finished products averaged well above the proposed FDA NNN proposed product standard of 1.0 µg/g dry weight. Because of the large variability in NNN values, products would have to average well below FDA's proposed product standard to be consistently compliant.

Suicide Prevention in the Americas.

The Americas encompass the entirety of the continents of North America and South America, representing 49 countries. Together, they make up most of Earth's western hemisphere. The population is over 1 billion (2006 figure), with over 65 % living in one of the three most populated countries (the United States, Brazil, and Mexico). The Americas have low-, middle-, and high-income countries. Data from this region have not been readily and consistently available. There are several English-speaking Caribbean nations and countries in South America that have not had updated information. This chapter will focus on suicide prevention within North America (United States and Canada), some countries in the Caribbean region, and some countries in South America. Guyana, Suriname, and Trinidad and Tobago have severe issues with pesticide suicide, with average rates of 44.2 (global rank 1); 27.8 (global rank 5) and 13.0 (global rank 41) per 100,000 respectively. Jamaica, however, had one of the lowest rates: 1.2 per 100,000 (global rank 166). General, regional, and country-specific prevention proposals are suggested, highlighting intersectoral, private collaboration, attention to at-risk persons, substance abuse and mental health interventions, training, and reducing access to lethal means.

Near Term Suicide Risk Assessment: A Commentary on the Clinical Relevance of Protective Factors.

In this article we examine the clinical relevance of protective factors to the assessment and formulation of near-term risk of death by suicide. Contrary to current clinical belief and practice, we posit that there is no evidence base to support these factors as mitigating or buffering risk for suicide for the individual patient, especially in the near-term assessment of that suicide risk. We show that evidence-based protective factors derive from population-based studies and, applicably, have relevance to public health promotion/primary prevention and are significant in informing treatment/secondary prevention, but they lack evidence to support their often-proposed role in mitigating or buffering risk for suicide on an individual basis, especially when applied to the assessment of near-term risk of suicide. Accordingly, we argue for the need for empirical study of the role protective factors may or may not play in the formulation of a patient's risk for suicide and, in the interim, for clinical caution in assuming that protective factors have any significant buffering effect on a patient's level of near-term risk.

From Yielding to Shear Jamming in a Cohesive Frictional Suspension.

Simulations are used to study the steady shear rheology of dense suspensions of frictional particles exhibiting discontinuous shear thickening and shear jamming, in which finite-range cohesive interactions result in a yield stress. We develop a constitutive model that combines yielding behavior and shear thinning at low stress with the frictional shear thickening at high stresses, in good agreement with the simulation results. This work shows that there is a distinct difference between solids below the yield stress and in the shear-jammed state, as the two occur at widely separated stress levels, with an intermediate region of stress in which the material is flowable.

The effect of anodal/cathodal biphasic electrical stimulation on insulin release.

We studied the effects of electrical stimulation on insulin release from rat insulinoma (INS-1) cells. The anodal/cathodal biphasic stimulation (ACBPS) electrical waveform resulted in a voltage- and stimulation duration-dependent increase in insulin release. ACBPS elicited insulin release both in the presence and absence of glucose. Basal and ACBPS-induced insulin secretion could be inhibited by mitochondrial poisons and calcium channel blockers, indicating that insulin release was dependent on adenosine triphosphate (ATP) and the influx of calcium. ACBPS parameters that released insulin caused no detectable plasma membrane damage or cytotoxicity, although temporary morphological changes could be observed immediately after ACBPS. ACBPS did not alter the plasma membrane transmembrane potential but did cause pronounced uptake of MitoTracker Red into the mitochondrial membrane, indicating an increased mitochondrial membrane potential. While the ATP:ADP ratio after ACBPS did not change, the guanosine triphosphate (GTP) levels increased and increased GTP levels have previously been associated with insulin release in INS-1 cells. These results provide evidence that ACBPS can have significant biological effects on cells. In the case of INS-1 cells, ACBPS promotes insulin release without causing cytotoxicity.

The Potential Perils of a Suicide-specific Diagnosis.

The clinical and scientific challenges inherent in treating and investigating suicide warrant novel approaches to this public health issue of paramount importance. The implementation of suicide-specific diagnoses has been proposed as one possible way to address this problem and was described in the first column of this special 2-part series. This second column explores potential unintended consequences related to such proposed diagnoses and alternative solutions that might afford greater benefits. The idea of suicide-specific diagnoses represents a novel approach, and one worthy of further discussion and consideration; the debate featured in this series represents a joint effort to advance the dialogue about suicide and to promote innovation.

Effects of biphasic and monophasic electrical stimulation on mitochondrial dynamics, cell apoptosis, and cell proliferation.

Currently, electrical stimulation (ES) is used to induce changes in various tissues and cellular processes, but its effects on mitochondrial dynamics and mechanisms are unknown. The aim of this study was to compare the effects of monophasic and biphasic, anodal, and cathodal ES on apoptosis, proliferation, and mitochondrial dynamics in neuroblastoma SH-SY5Y cells. Cells were cultured and treated with ES. Alamar blue assay was performed to measure cell proliferation. The proteins expression of apoptotic-related proteins Bcl-2 associated X (Bax), B cell lymphoma 2 (Bcl-2), optic-atrophy-1 (OPA1), mitofusin2 (Mfn2), phosphorylated dynamin-related protein 1 at serine 616 (p-DRP1), and total dynamin-related protein 1 (Total-DRP1) were also determined. The results showed that monophasic anodal and biphasic anodal/cathodal (Bi Anod) ES for 1 hr at 125 pulses per minute (2.0 Hz) produced the most significant increase in cell proliferation. In addition, monophasic anodal and Bi Anod ES treated cells displayed a significant increase in the levels of anti-apoptotic protein Bcl-2, whereas the Bax levels were not changed. Moreover, the levels of Mfn2 were increased in the cells treated by Bi Anod, and OPA1 was increased by monophasic anodal and Bi Anod ES, indicating increased mitochondrial fusion in these ES-treated cells. However, the levels of mitochondrial fission indicated by DRP1 remained unchanged compared with non-stimulated cells. These findings were confirmed through visualization of mitochondria using Mitotracker Deep Red, demonstrating that monophasic anodal and Bi Anod ES could induce pro-survival effects in SH-SY5Y cells through increasing cell proliferation and mitochondrial fusion. Future research is needed to validate these findings for the clinical application of monophasic anodal and Bi Anod ES.