Do measures of social support and social distress share general factors associated with suicidal ideation and attempts?

INTRODUCTION: Aspects of social relationships have variably been associated with suicidal ideation (SI) and suicide attempts (SAs). This study assessed whether social support and social distress measures have general factors versus measure-specific factors that are associated with suicide risk. METHODS: Adults (N = 455, 60.0% female), admitted to psychiatric inpatient units following a recent suicide attempt or active SI, completed assessments of social support (emotional support, instrumental support, friendship, perceived support from significant others, friends, family) and social distress (loneliness, perceived rejection, perceived burdensomeness, thwarted belongingness). Bifactor modeling examined general and specific factors of social support and distress in relation to SI (week prior to hospitalization, via the Beck Scale for SI) and SAs (past 30 days, via the Columbia Suicide Severity Rating Scale). RESULTS: SI was significantly associated with the general social support (B = -1.51), the general social distress (B = 1.67), and the specific perceived burdensomeness (B = 1.57) factors. SAs were significantly associated with the specific Perceived Rejection (OR = 1.05) and Thwarted Belongingness (OR = 0.91) factors. CONCLUSION: General social support and social distress were associated with SI but not recent SAs. Specific social distress factors were also related to SI and SAs controlling for general social distress, suggesting areas for future interventions.

A comparison of self-reported risk and protective factors and the death implicit association test in the prediction of future suicide attempts in adolescent emergency department patients.

BACKGROUND: Concerns have been raised about the utility of self-report assessments in predicting future suicide attempts. Clinicians in pediatric emergency departments (EDs) often are required to assess suicidal risk. The Death Implicit Association Test (IAT) is an alternative to self-report assessment of suicidal risk that may have utility in ED settings. METHODS: A total of 1679 adolescents recruited from 13 pediatric emergency rooms in the Pediatric Emergency Care Applied Research Network were assessed using a self-report survey of risk and protective factors for a suicide attempt, and the IAT, and then followed up 3 months later to determine if an attempt had occurred. The accuracy of prediction was compared between self-reports and the IAT using the area under the curve (AUC) with respect to receiver operator characteristics. RESULTS: A few self-report variables, namely, current and past suicide ideation, past suicidal behavior, total negative life events, and school or social connectedness, predicted an attempt at 3 months with an AUC of 0.87 [95% confidence interval (CI), 0.84-0.90] in the entire sample, and AUC = 0.91, (95% CI 0.85-0.95) for those who presented without reported suicidal ideation. The IAT did not add significantly to the predictive power of selected self-report variables. The IAT alone was modestly predictive of 3-month attempts in the overall sample ((AUC = 0.59, 95% CI 0.52-0.65) and was a better predictor in patients who were non-suicidal at baseline (AUC = 0.67, 95% CI 0.55-0.79). CONCLUSIONS: In pediatric EDs, a small set of self-reported items predicted suicide attempts within 3 months more accurately than did the IAT.

Predicting short-term suicidal thoughts in adolescents using machine learning: developing decision tools to identify daily level risk after hospitalization.

BACKGROUND: Mobile technology offers unique opportunities for monitoring short-term suicide risk in daily life. In this study of suicidal adolescent inpatients, theoretically informed risk factors were assessed daily following discharge to predict near-term suicidal ideation and inform decision algorithms for identifying elevations in daily level risk, with implications for real-time suicide-focused interventions. METHODS: Adolescents (N = 78; 67.9% female) completed brief surveys texted daily for 4 weeks after discharge (n = 1621 observations). Using multi-level classification and regression trees (CARTSs) with repeated 5-fold cross-validation, we tested (a) a simple prediction model incorporating previous-day scores for each of 10 risk factors, and (b) a more complex model incorporating, for each of these factors, a time-varying person-specific mean over prior days together with deviation from that mean. Models also incorporated missingness and contextual (study week, day of the week) indicators. The outcome was the presence/absence of next-day suicidal ideation. RESULTS: The best-performing model (cross-validated AUC = 0.86) was a complex model that included ideation duration, hopelessness, burdensomeness, and self-efficacy to refrain from suicidal action. An equivalent model that excluded ideation duration had acceptable overall performance (cross-validated AUC = 0.78). Models incorporating only previous-day scores, with and without ideation duration (cross-validated AUC of 0.82 and 0.75, respectively), showed relatively weaker performance. CONCLUSIONS: Results suggest that specific combinations of dynamic risk factors assessed in adolescents' daily life have promising utility in predicting next-day suicidal thoughts. Findings represent an important step in the development of decision tools identifying short-term risk as well as guiding timely interventions sensitive to proximal elevations in suicide risk in daily life.

A hepatitis C elimination model in healthcare for the homeless organization: A novel reflexive laboratory algorithm and equity assessment.

BACKGROUND: Reaching World Health Organization hepatitis C (HCV) elimination targets requires diagnosis and treatment of people who use drugs (PWUD) with direct acting antivirals (DAAs). PWUD experience challenges engaging in HCV treatment, including needing multiple provider and laboratory appointments. Women, minoritized racial communities, and homeless individuals are less likely to complete treatment. METHODS: We implemented a streamlined opt-out HCV screening and linkage-to-care program in two healthcare for the homeless clinics and a medically supported withdrawal center. Front-line staff initiated a single-order reflex laboratory bundle combining screening, confirmation, and pre-treatment laboratory evaluation from a single blood draw. Multinomial logistic regression models identified characteristics influencing movement through each stage of the HCV treatment cascade. Multiple logistic regression models identified patient characteristics associated with HCV care cascade progression and Cox proportional hazards models assessed time to initiation of DAAs. RESULTS: Of 11,035 clients engaged in services between May 2017 and March 2020, 3,607 (32.7%) were screened. Of those screened, 1,020 (28.3%) were HCV PCR positive. Of those with detectable RNA, 712 (69.8%) initiated treatment and 670 (94.1%) completed treatment. Of those initiating treatment, 407 (57.2%) achieved SVR12. There were eight treatment failures and six reinfections. In the unadjusted model, the bundle intervention was associated with increased care cascade progression, and in the survival analysis, decreased time to initiation; these differences were attenuated in the adjusted model. Women were less likely to complete treatment and SVR12 labs than men. Homelessness increased likelihood of screening and diagnosis but was negatively associated with completing SVR12 labs. Presence of opioid and stimulant use disorder diagnoses predicted increased care cascade progression. CONCLUSIONS: The laboratory bundle and referral pathways improved treatment initiation, time to initiation, and movement across the cascade. Despite overall population improvements, women and homeless individuals experienced important gaps across the HCV care cascade.

Short-term associations between nonsuicidal and suicidal thoughts and behaviors: A daily diary study with high-risk adolescents.

BACKGROUND: In this daily dairy study of adolescents at elevated suicide risk, we examined proximal associations between nonsuicidal self-injury (NSSI) and suicidal thoughts as well as behaviors. We also investigated the prominence of the anti-suicide function underlying NSSI engagement, relative to intrapersonal and interpersonal motives. METHODS: Seventy-eight adolescents (67.9% female; ages 13-17) hospitalized due to suicide risk completed daily surveys assessing NSSI and suicidal thoughts for four weeks after discharge (n=1621 observations). Suicidal behavior (actual, aborted, interrupted suicide attempts) was assessed at 1-month follow-up. RESULTS: Over and above lifetime NSSI, adolescents who generally experienced more enduring (OR=2.54, p=<.001) and intense (OR=1.87, p=.002) suicidal ideation were more likely to engage in NSSI on a given day. Moreover, NSSI likelihood increased when adolescents experienced more enduring (OR=1.99, p<.001) and intense (OR=1.66, p<.001) ideation relative to their typical levels. This pattern was consistent for those with recent NSSI. The anti-suicide function of NSSI was frequently endorsed at hospitalization and when NSSI occurred daily (65.6% of the time), alongside the intrapersonal-negative motive (to avoid aversive states). Exploratory analyses suggest adolescents with suicidal behavior within the month after discharge experienced higher NSSI levels reported daily over the same period (Hedge's g=1.26, p=<.001). LIMITATIONS: Daily-level associations were examined concurrently and generalizability of results is limited by sample characteristics. CONCLUSIONS: The notable proximal associations between NSSI and suicidal thoughts and behaviors, as well as the prominence of the anti-suicide function, point to the importance of intervention efforts targeting these intersecting phenomena among adolescents at elevated suicide risk.

Daily patterns in nonsuicidal self-injury and coping among recently hospitalized youth at risk for suicide.

Among adolescents at high suicide risk, using a daily diary design, this study examined: (1) the co-occurrence between nonsuicidal self-injury (NSSI) and suicidal ideation, (2) the link between NSSI and coping, and (3) endorsement of using NSSI to cope with suicidal ideation (anti-suicide function). Thirty-four adolescents hospitalized due to suicide risk (76% female; ages 13-17) responded to daily surveys for four weeks after discharge (n = 650 observations). NSSI was positively associated with suicidal ideation at the between- (i.e. relative to others) and within-person (relative to adolescents' own average) levels of analysis. When NSSI and suicidal thoughts co-occurred, adolescents used NSSI to cope with thoughts of suicide on nearly all occasions. While adolescents did not use less adaptive coping when they engaged in NSSI (i.e. within-person), youth who utilized more coping strategies in general (i.e. between-person) had lower probability of NSSI. The probability of NSSI also decreased when adolescents perceived coping to be helpful and for youth who generally tended to perceive coping as helpful. Findings offer fine-grained insights about the intersection of NSSI, suicidal thoughts, and coping among high-risk adolescents, adding to the body of research highlighting the benefit of broadening adolescents' coping strategies as well as assessing their perceived utility.

Motivational Interviewing-Enhanced Safety Planning for Adolescents at High Suicide Risk: A Pilot Randomized Controlled Trial.

This pilot randomized controlled trial examined the feasibility and acceptability of a motivational interview (MI)-enhanced safety planning intervention (MI-SafeCope) for teens hospitalized due to suicide risk and explored proximal outcomes (possible mechanisms of change). Participants were 36 hospitalized adolescents (ages 13-17; 78.8% female) with last-week suicidal ideation and/or past-month suicide attempts. Adolescents were randomized to MI-SafeCope, a three-component intervention (individual and family sessions, postdischarge call), or to treatment as usual. Primary outcomes were feasibility and acceptability. We also explored differences in proximal outcomes assessed at 2 weeks, 1 month, and 3 months (family connectedness, motivation for safety plan use, parental motivation to encourage safety plan use), as well as daily for 4 weeks (self-efficacy, coping behavior, safety plan use). Participation and retention rates and intervention satisfaction ratings indicate feasibility and acceptability. Mixed-effects models of daily assessments indicated, for the MI-SafeCope group, significantly higher self-efficacy to refrain from suicidal action (B = 1.15, p = .030), greater reliance on self to cope with suicidal ideation (B = 1.56, p = .042), and higher likelihood of safety plan use to manage suicidal thoughts (B = 0.25, p = .004). Parents in the MI-SafeCope group reported higher motivation to encourage safety plan use (B = 1.04, p = .031). Safety planning incorporating MI is feasible and acceptable with hospitalized teens. Preliminary findings suggest that MI strategies may be promising in maintaining adherence to safety plans, increasing self-efficacy and coping, and in fostering parents' motivation to encourage safety plan use. Our study also highlights the benefit of daily-level assessment of individuals' response to suicide-specific interventions.

Ecological assessment of daily suicidal thoughts and attempts among suicidal teens after psychiatric hospitalization: Lessons about feasibility and acceptability.

Despite its potential to yield information about the dynamic course of suicidal ideation/behavior in individuals' natural environment, Ecological Momentary Assessment (EMA) has been strikingly underutilized among suicidal teens. This study reports on feasibility and acceptability of ecological assessment of daily suicide risk-related outcomes ("daily diaries," a special case of EMA) among adolescent inpatients in the critical post-discharge period. Thirty-four adolescents (76% female; ages 13-17) responded to daily electronic surveys for four weeks after discharge. Survey adherence was 69% (n = 650 days) and decreased each week. Adherence was half as likely among adolescents without attempt history (OR = 0.50, CI = 0.27-0.95). Mid- and end-point study responses indicated high acceptability of daily diaries. Most adolescents reported no change or more positive change in their thoughts/mood after daily surveys. Suicidal ideation was reported on 24.4% (n = 159) of the days. In the month post discharge, more teens reported suicidal thoughts using daily surveys (70.6%) compared to end-of-study assessment (45.2%) (Chi-square = 4.24, p = .039). Two participants (5.9%) reported an attempt. Ideation frequency and duration varied across time, suggesting utility of frequent assessments in this context. EMA data collection with high-risk adolescents offers a feasible approach to examining real-time suicidal ideation/behavior, yielding nuanced information that is critical to advancing suicide prevention efforts.

Endothelial cells on an aged subendothelial matrix display heterogeneous strain profiles in silico.

Within the artery intima, endothelial cells respond to mechanical cues and changes in subendothelial matrix stiffness. Recently, we found that the aging subendothelial matrix stiffens heterogeneously and that stiffness heterogeneities are present on the scale of one cell length. However, the impacts of these complex mechanical micro-heterogeneities on endothelial cells have not been fully understood. Here, we simulate the effects of matrices that mimic young and aged vessels on single- and multi-cell endothelial cell models and examine the resulting cell basal strain profiles. Although there are limitations to the model which prohibit the prediction of intracellular strain distributions in alive cells, this model does introduce mechanical complexities to the subendothelial matrix material. More heterogeneous basal strain distributions are present in the single- and multi-cell models on the matrix mimicking an aged artery over those exhibited on the young artery. Overall, our data indicate that increased heterogeneous strain profiles in endothelial cells are displayed in silico when there is an increased presence of microscale arterial mechanical heterogeneities in the matrix.

Synthesis, characterization and cytotoxicity of photo-crosslinked maleic chitosan-polyethylene glycol diacrylate hybrid hydrogels.

Synthetic hydrogels are important biomaterials for many biomedical applications and hydrogels produced via photo-gelation have shown particular promise. In this paper, we describe a new family of biodegradable hybrid hydrogels fabricated in aqueous solution via long wavelength UV photo-crosslinking using maleic chitosan and polyethylene glycol diacrylate (PEGDA) as precursors. The maleic chitosan precursor was prepared by a simple one-step chemical modification of chitosan, with high yields, and characterized by Fourier transform infrared spectroscopy, (1)H NMR and (13)C NMR. Maleic chitosan and PEGDA precursors at a wide range of weight feed ratios were mixed in aqueous solution and directly photo-crosslinked for 10 min under a long wavelength UV light (365 nm) using 4-(2-hydroxyethoxy) phenyl-(2-hydroxy-2-propyl) ketone (Irgacure 2959) as photoinitiator. It was observed that as the weight feed ratio of maleic chitosan to PEGDA decreased the pore sizes of the hydrogel samples decreased, thereby increasing the densities of the hydrogel networks and producing a lower swelling ratio and a higher compressive modulus. The molecular weight of PEGDA had a similar effect. Preliminary cell cytotoxicity tests of both the maleic chitosan precursor and maleic chitosan/PEGDA hydrogels, based on the MTT assay and live-dead assay, respectively, showed that these new chitosan-based biodegradable biomaterials were relatively non-toxic to bovine aortic endothelial cells at low dosages.

Intervention research with persons at high risk for suicidality: safety and ethical considerations.

There is a critical need for studies designed to reduce suicidality. Individuals at high risk for suicidality deserve safe and effective treatments, just as do other individuals with mental disorders who do not experience suicidality. Points for consideration regarding safety and monitoring procedures are offered to help researchers who conduct treatment trials with individuals who have mental disorders and investigators specifically interested in developing treatments to reduce suicidality. Issues such as study design, increased monitoring and supervision, research clinician competencies, and liability concerns are addressed. Points to consider in planning an intervention trial, a checklist of informed consent issues, and a list of relevant active federal regulations are provided.

Serotonin dysregulation in adolescents with major depression: hormone response to meta-chlorophenylpiperazine (mCPP) infusion.

This study examined central serotonin disturbance, as reflected by neuroendocrine hormones, among adolescents with major depression. Prolactin, cortisol, and growth hormone were measured following the infusion of a serotonin agonist, meta-chlorophenylpiperazine (mCPP). Twelve (M=6, F=6) medication-free adolescents with major depression (MDD) were compared with 12 (M=6, F=6) matched normal control subjects, ranging in age from 13 to 17 years. Baseline evaluations and a battery of laboratory tests were completed. mCPP, 0.1 mg/kg i. v., was administered in a placebo-controlled design. Analyses of the neuroendocrine hormones revealed that the depressed group had a higher baseline prolactin level and an augmented prolactin response to mCPP challenge than did the control group. The depressed group experienced a sharper baseline-cortisol decline between 08.00 and 11.00 h, and compared to control subjects they displayed an augmented response to the challenge. The depressed group reported more side effects than the control group during saline infusion, but not during mCPP infusion. Findings suggest that depressed adolescents have an elevated baseline prolactin level, and also experience enhanced prolactin and cortisol responses to the serotonergic challenge. These preliminary findings will be confirmed during our ongoing study.

Major histocompatibility complex phenotypes influence serum testosterone concentration.

OBJECTIVES: (a) To confirm our earlier observation that the phenotype HLA-DR4,7 occurs with higher frequency in male patients with rheumatoid arthritis (RA) than in female patients. (b) To test the hypothesis that DR7 is associated with low normal serum testosterone (Te) levels in healthy males; this might explain the increased frequency of DR4,7 in male patients since there appears to be a relationship between low serum Te and RA. (c) To characterize the association between HLA alleles and serum Te concentration in healthy males. METHODS: An additional 82 Newfoundland (NF) RA patients were HLA-DR typed and, combined with our earlier data and data from the 11th International Histocompatibility Workshop, gave HLA-DR and sex information on 373 RA patients. Ninety-four healthy NF males were typed for HLA, the microsatellite marker TNFa (located close to the tumour necrosis factor alpha gene) and complement factor B (BF). An additional 38 males were included, selected partly based on their HLA-B type. RESULTS: We confirmed our earlier finding of a higher frequency of HLA-DR4,7 in male RA patients compared with female RA patients (P<0.01). Contrary to our expectations we found that DR7 was associated with higher than mean values of Te as were B5, B27, DR1, TNFa7 and BF F positivity. Conversely, low Te concentrations were found in men with B15, DR2, DR5, TNFa5 and who were BF F negative. In 28 male 'early-onset' RA patients we did not find an increased frequency of HLA alleles associated with low Te levels as compared with the frequency in 41 'late-onset' patients, suggesting that if low Te level is a risk factor and is present before onset of RA then the level cannot be explained by an association between Te level and major histocompatibility complex (MHC) phenotype. CONCLUSION: This study indicates that a man's MHC phenotype may influence his serum Te concentration, but the relationship of this, if any, to the pathogenesis of RA remains an area of speculation.

Release of vasoactive cytokines by antibody-enhanced dengue virus infection of a human mast cell/basophil line.

We report here the first demonstration of dengue virus infection and vasoactive cytokine response of a cell of the mast cell/basophil lineage. Infection of KU812 cells was dependent on dengue-specific antibody and gave rise to infectious virions. This antibody-enhanced dengue virus infection triggered a four- to fivefold increase in the release of interleukin-1beta (IL-1beta) and a modest increase for IL-6 but not for an alternate cytokine, granulocyte-macrophage colony-stimulating factor. The results suggest a potential role for mast cells/basophils in the pathogenesis of dengue virus-induced disease.

Anxiety contributes to suicidality in depressed adolescents.

Several studies have suggested a positive association between anxiety symptoms and suicidality in adults. However, relatively little is known about this topic in adolescents. To investigate this issue, we examined a group of adolescents admitted to our psychiatric inpatient unit. Fifty-six adolescents (mean age = 14.8 +/- 1.4; females = 34, males = 22; race = 95% Caucasians) participated in the study. Diagnoses were made using the DSM-III-R criteria and a diagnostic interview. Anxiety was found to significantly correlate with depression (r = .60; P = < .05) and suicidality (r = .72; P < .05). A multiple regression analysis revealed that anxiety and depression together accounted for more than half (55%) of the variance in suicidal ideation [F(2,46) = 28.4; P < .0001]. In addition, anxiety had an independent ability to predict suicidality (t = 5.01; P < .0001). Self-rated but not clinician-rated suicidality was positively correlated with both anxiety and depression. Clinical and research implications of these findings are discussed.

DNA fusion vaccines against B-cell tumors.

The ability of naked DNA to induce immune responses against encoded antigen has been clearly demonstrated for infectious diseases (1). In many cases, the induced immunity is able to protect against infection, and can approach the efficacy of exogenous antigen (2).

Factors associated with victimization of personnel in emergency departments.

OBJECTIVE: The purpose of this study was to identify the incidence of ED personnel victimization in Central Florida and examine its relationship to victims' reports of 3 factors: characteristics of the patient/perpetrator, characteristics of the personnel victimized, and characteristics of the ED environment. METHODS: Data were collected anonymously in a mail survey using 37 items from Mahoney's Emergency Department Victimization Questionnaire (EDVQ) and a demographic questionnaire. Chi square, Spearman's rank correlation coefficient, and Pearson's product moment correlation were used to describe frequencies, incidence, and their relationships to the variables studied. A sample of 226 of the 600 direct care personnel (37%) from 18 of the 19 hospital emergency departments in a tri-county area (95%) participated. RESULTS: The incidence of physical assault was reported to be 42% during the past year and 72% during the respondents' careers. Alcohol use was associated with incidence (1-tailed Pearson; P =.001). Verbal abuse was significantly higher on day shift (P =.043). The most desired environmental variable was 24-hour security attendants, available to 51.8% of the respondents. More than a fourth of the subjects reported that they had completed no coursework or had no continuing education in violence prevention. DISCUSSION: Respondents reported avoiding identification on duty, underreporting, postvictimization staff turnover, dissatisfaction with security, and the desire for every security provision listed. The goals of reducing the fears and victimization of ED personnel should become a priority within the health care system.

Manipulation of pathogen-derived genes to influence antigen presentation via DNA vaccines.

To gain insight into the routes of presentation of pathogen sequences via DNA vaccines, we have compared the abilities of sequences encoding fragment C of tetanus toxin (FrC) and influenza A virus nucleoprotein (NP) to induce antibody or cytotoxic T-cell (CTL) responses in vivo. Strong antibody and CTL responses were induced against FrC targeted to the endoplasmic reticulum (ER) and both were reduced by removal of the leader sequence. In contrast, targeting of NP to the ER generated only a modest antibody response, likely due to misfolding in this site. Removal of the leader sequence led to anti-NP antibodies via cross-priming. For NP, induction of CTLs was not influenced by the leader sequence. Exogenous FrC or NP delivered as proteins were unable to induce CTLs. Routes to induction of optimal immune responses via DNA evidently differ according to the nature of the encoded pathogen sequence. Understanding processing pathways for pathogen sequences should assist rational design of DNA vaccines.

Incorporating fun into the business of serious work: the use of humor in group process.

Incorporating formal humor and creative play into group process improves the outcome of serious work. This article discusses the use of humor and play in a traditionally serious setting. On-the-job playfulness improves communication, creativity, problem solving, and team building, thereby increasing productivity and satisfaction.