Improving Emergency Department Care for Suicidality in Autism: Perspectives from Autistic Youth, Caregivers, and Clinicians.

ABSTRACT: Purpose: Emergency department (ED) visits for suicidal ideation and self-harm are more prevalent in autistic than non-autistic youth. However, providers are typically offered insufficient guidance for addressing suicide risk in autistic youth, likely impacting confidence and care. METHODS: In this pilot study, we conducted semi-structured interviews with 17 key members of the autism community (i.e., autistic youth with a history of suicidality, caregivers of autistic youth with a history of suicidality, autism specialist clinicians, ED clinicians) to inform the development of recommendations for modifying ED care for autistic patients, with a focus on suicide risk screening and management. RESULTS: Participants reported on challenges they encountered receiving or providing care and/or recommendations for improving care. Participant perspectives were aligned, and four main categories emerged: accounting for autism features, connection and youth engagement in care, caregiver and family involvement, and service system issues. CONCLUSION: As research continues in the development of autism-specific suicide risk assessment tools and management strategies, it is essential we better equip providers to address suicide risk in autistic patients, particularly in ED settings.

Assessing and Managing Suicide Risk in Autistic Youth: Findings from a Clinician Survey in a Pediatric Psychiatric Emergency Setting.

Suicidal thoughts and behaviors (STB) and emergency department (ED) utilization are prevalent in autistic youth. The current study surveyed clinicians in a pediatric psychiatric ED to examine differences in attitudes on suicide-related care for autistic and non-autistic patient populations. While clinicians rated addressing STB in ASD as important and adaptations to care as necessary, less than half identified ASD as a suicide risk factor and confidence ratings were significantly lower for autistic patients. Previous ASD training predicted confidence and accounted for approximately 25% of the variance in confidence scores. Findings highlight the urgency to develop and disseminate ED clinician training, and address the lack of validated assessment tools, adapted suicide prevention practices, and evidence-based treatments for STB in autistic youth.

Animal-derived medications: cultural considerations and available alternatives.

CONTEXT: Cultural competency is a cornerstone of patient-centered health care. Religious doctrines may define appropriate consumption or use of certain animals and forbid use of others. Many medications contain ingredients that are animal-derived; these medications may be unacceptable to individual patients within the context of their religious beliefs and lifestyle choices. Knowledge of animal-derived medications as a component of cultural competency can facilitate a dialogue that shifts focus from the group to the individual, away from cultural competency toward cultural humility, and away from a paternalistic provider/patient dynamic toward one of partnership. OBJECTIVES: To explore how animal-derived drug components may impact medication selection and acceptability from the perspective of patients, physicians, and religious leaders as evidenced by studies that explore the question via survey or questionnaire. A secondary objective is to use the context of animal-derived drug products as a component of cultural competency to build a framework supporting the development of cultural humility. METHODS: A systematic search was performed in the PubMed, CINAHL, Cochrane, and ProQuest databases using combinations of the following terms: "medication selection," "medication," "adherence," "pharmaceutical preparations," "religion and medicine," "religion," "animal," "dietary," "porcine," and "bovine." Studies that reported using surveys or questionnaires to examine patient, physician, or religious leader perspective on animal-derived medications published in English between 1990 and 2020 were included. Review articles, opinion pieces, case reports, surveys of persons other than patients, religious leaders, or physicians, and studies published in languages other than English were excluded. Three authors independently reviewed articles to extract information pertaining to perspectives on animal-based medication ingredients. RESULTS: Eight studies meeting the described criteria were found that queried beliefs or knowledge of patients, religious leaders, or physicians regarding medications and medical products of biologic origin. Those studies are described in full in this review. CONCLUSIONS: Knowledge of animal-derived ingredients may help open conversations with patients around spiritual history and cultural competency, particularly for those patients belonging to religious sects with doctrines that define appropriate use of human- or animal-derived products. Further formal study is needed to explore more fully the extent to which religious beliefs may impact selection of animal- or human-derived medications. Guidelines developed from this knowledge may aid in identifying individual patients with whom the discussion may be particularly relevant. More studies are needed to quantify and qualify beliefs regarding animal-derived medication constituents.

Influence of experimental history on nicotine self-administration in squirrel monkeys.

RATIONALE: Methods for establishing robust long-term self-administration of intravenous (i.v.) nicotine, the primary psychoactive agent in tobacco, are not well-established in laboratory animals. OBJECTIVE: Here, we examine the use of a fading procedure to establish robust and consistent i.v. nicotine self-administration under second-order schedule conditions in squirrel monkeys. METHODS: First, self-administration behavior was developed in two groups of male squirrel monkeys using a second-order fixed-interval 5-min schedule with fixed-ratio 5 units (FI 5-min (FR5: S)). Comparable performances were maintained by i.v. cocaine (0.032 mg/kg/injection (inj); group A, n = 3) and the combination of food delivery (20-30 % condensed milk) and 0.01 mg/kg/inj i.v. nicotine (group B, n = 3). Subsequently, the concentration of condensed milk was gradually reduced to zero in the second group and self-administration behavior was maintained by i.v. nicotine alone. Next, self-administration of a range of doses of i.v. nicotine (0.001-0.032 mg/kg/inj) and, in additional experiments, the minor tobacco alkaloid anatabine (0.01-0.18 mg/kg/inj) was studied in both groups. RESULTS: Results show that nicotine and anatabine had reinforcing effects in both groups. However, optimal doses of nicotine and anatabine maintained significantly higher rates of i.v. self-administration behavior in subjects trained with the fading procedure than in subjects provided with a history of cocaine-maintained responding. CONCLUSION: These results illustrate conditions under which robust i.v. nicotine self-administration can be established in squirrel monkeys and the influence of prior experimental history in the expression of reinforcing effects of nicotine and anatabine.

Challenges in researching violence affecting health service delivery in complex security environments.

Complex security environments are characterized by violence (including, but not limited to "armed conflict" in the legal sense), poverty, environmental disasters and poor governance. Violence directly affecting health service delivery in complex security environments includes attacks on individuals (e.g. doctors, nurses, administrators, security guards, ambulance drivers and translators), obstructions (e.g. ambulances being stopped at checkpoints), discrimination (e.g. staff being pressured to treat one patient instead of another), attacks on and misappropriation of health facilities and property (e.g. vandalism, theft and ambulance theft by armed groups), and the criminalization of health workers. This paper examines the challenges associated with researching the context, scope and nature of violence directly affecting health service delivery in these environments. With a focus on data collection, it considers how these challenges affect researchers' ability to analyze the drivers of violence and impact of violence. This paper presents key findings from two research workshops organized in 2014 and 2015 which convened researchers and practitioners in the fields of health and humanitarian aid delivery and policy, and draws upon an analysis of organizational efforts to address violence affecting healthcare delivery and eleven in-depth interviews with representatives of organizations working in complex security environments. Despite the urgency and impact of violence affecting healthcare delivery, there is an overall lack of research that is of health-specific, publically accessible and comparable, as well as a lack of gender-disaggregated data, data on perpetrator motives and an assessment of the 'knock-on' effects of violence. These gaps limit analysis and, by extension, the ability of organizations operating in complex security environments to effectively manage the security of their staff and facilities and to deliver health services. Increased research collaboration among aid organizations, researchers and multilateral organizations, such as the WHO, is needed to address these challenges.

Trace amine associated receptor 1 modulates behavioral effects of ethanol.

BACKGROUND: Few treatment options for alcohol use disorders (AUDs) exist and more are critically needed. Here, we assessed whether trace amine associated receptor 1 (TAAR1), a modulator of brain monoamine systems, is involved in the behavioral and reinforcement-related effects of ethanol and whether it could potentially serve as a therapeutic target. METHODS: Wild-type (WT) and TAAR1 knockout (KO) mice (75% C57J/BL6 and 25% 129S1/Sv background) were compared in tests of ethanol consumption (two-bottle choice [TBC]), motor impairment (loss of righting reflex, [LORR], locomotor activity) and ethanol clearance (blood ethanol level [BEL]). RESULTS: As compared with WT mice, KO mice displayed (1) significantly greater preference for and consumption of ethanol in a TBC paradigm (3%-11% vol/vol escalating over 10 weeks), with no significant difference observed in TBC with sucrose (1%-3%); (2) significantly greater sedative-like effects of acute ethanol (2.0 or 2.5 g/kg, intraperitoneal [i.p.]) manifested as LORR observed at a lower dose and for longer time, with similar BELs and rates of ethanol clearance; and (3) lower cumulative locomotor activity over 60 minutes in response to an acute ethanol challenge (1.0-2.5 g/kg, i.p.). CONCLUSIONS: The present findings are the first to implicate TAAR1 in the behavioral and reinforcement-related effects of ethanol and raise the question of whether specific drugs that target TAAR1 could potentially reduce alcohol consumption in humans with AUDs.

Augmentation of methamphetamine-induced behaviors in transgenic mice lacking the trace amine-associated receptor 1.

The trace amine-associated receptor 1 (TAAR1) is a G protein-coupled receptor that is functionally activated by amphetamine-based psychostimulants, including amphetamine, methamphetamine and MDMA. Previous studies have shown that in transgenic mice lacking the TAAR1 gene (TAAR1 knockout; KO) a single injection of amphetamine can produce enhanced behavioral responses compared to responses evoked in wild-type (WT) mice. Further, the psychostimulant effects of cocaine can be diminished by selective activation of TAAR1. These findings suggest that TAAR1 might be implicated in the rewarding properties of psychostimulants. To investigate the role of TAAR1 in the rewarding effects of drugs of abuse, the psychomotor stimulating effects of amphetamine and methamphetamine and the conditioned rewarding effects of methamphetamine and morphine were compared between WT and TAAR1 KO mice. In locomotor activity studies, both single and repeated exposure to d-amphetamine or methamphetamine generated significantly higher levels of total distance traveled in TAAR1 KO mice compared to WT mice. In conditioned place preference (CPP) studies, TAAR1 KO mice acquired methamphetamine-induced CPP earlier than WT mice and retained CPP longer during extinction training. In morphine-induced CPP, both WT and KO genotypes displayed similar levels of CPP. Results from locomotor activity studies suggest that TAAR1 may have a modulatory role in the behavioral sensitization to amphetamine-based psychostimulants. That methamphetamine-but not morphine-induced CPP was augmented in TAAR1 KO mice suggests a selective role of TAAR1 in the conditioned reinforcing effects of methamphetamine. Collectively, these findings provide support for a regulatory role of TAAR1 in methamphetamine signaling.