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Virtual visits are a telehealth service where patients and providers communicate in real-time using audio and/or video technology. Setting up a virtual visit is complex and may pose challenges for some autistic adults. We conducted semi-structured interviews with autistic adults ( n = 7), family members of autistic adults ( n = 12), and clinic personnel ( n = 6) from one US-based clinic and used thematic analysis to identify factors affecting usability of virtual visits. We found virtual visit preparation involves multiple contacts between clinic personnel and patients or family members via a variety of channels and usability was affected by technology considerations, logistical considerations, and expectations for visits. Participants said technological experience and using the patient portal enhanced usability, but technological issues could increase anxiety. Clinic personnel reported time constraints created logistical barriers to virtual visits; streamlining the process before the visit via the patient portal may improve the usability of virtual visits for autistic adults, family members, and clinic personnel. Participants also reported unclear expectations for virtual visits reduced usability and recommended reminders, instructional videos, and estimated wait-times to clarify expectations. While our findings are based on a single clinic, they may help inform usability improvement efforts in other clinics offering virtual visits for autistic adults. Lay abstract Real-time telehealth visits, called “virtual visits,” are live video chats between patients and healthcare professionals. There are lots of steps involved in setting up a virtual visit, which may be difficult for some autistic adults. We interviewed 7 autistic adults, 12 family members of autistic adults, and 6 clinic staff from one clinic in the United States. Our goal was to understand their experiences with virtual visits and see how we can make virtual visits easier to use. We re-read text from the interviews to organize experiences and advice that was shared into topics. We found that autistic adults (or their family members) had to connect with clinic staff many times by phone or online over several days to set up a virtual visit. Participants said that having more experience with technology and using the online patient portal made virtual visits easier to use. But, having issues with technology before the visit could make autistic adults and family members anxious. Clinic staff said it was hard for them to meet the needs of people who were using virtual visits and those who were being seen in person at the clinic. Participants recommended reducing the number of calls between staff and autistic adults or family members using the online patient portal instead. Participants also recommended reminder messages, instruction videos, and approximate wait-times to help autistic adults and family members know what to expect for the virtual visit. Our results are based on peoples’ experiences at one clinic, but could help other clinics make virtual visits easier to use for autistic adults and their family members.

We previously found that autistic adults who received care through a primary care embedded specialized clinic, called the Center for Autism Services and Transition (CAST), had higher satisfaction, continuity of care, and preventive care use than national samples of autistic adults.Examine the impact of CAST on healthcare utilization and expenditures.Retrospective study of medical billing data.CAST patients (N = 490) were propensity score matched to Medicare-enrolled autistic adults (N = 980) and privately insured autistic adults (N = 980) using demographic characteristics. The median age of subjects was 21 years, 79% were male, and the median duration of observation was 2.2 years.We quantified expenditures and utilization for primary care; emergency department (ED) visits; inpatient hospitalizations; mental health admissions; and outpatient visits.CAST patients had the highest primary care utilization and expenditures. However, CAST patients had significantly lower expenditures than Medicare-enrolled autistic adults for mental health admissions ($1074 vs $1903), outpatient visits ($1671 vs $2979), and total expenditures ($5893 vs $6987), as well as 57% fewer inpatient hospitalizations. Compared to privately insured autistic adults, CAST patients had significantly lower expenditures for mental health admissions ($1074 vs $1362), inpatient hospitalizations ($3851 vs $4513), and outpatient visits ($1671 vs $6070), as well as 16% fewer inpatient hospitalizations, 24% fewer ED visits, and 50% fewer outpatient visits. On average, CAST patients had more ED visits, mental health admissions, and outpatient visits than Medicare-enrolled autistic adults and more mental health admissions than privately insured autistic adults.Although CAST patients had greater primary care utilization and expenditures, our findings suggest embedding specialized clinics within broader primary care settings could be an alternative to current standards of care and may reduce expenditures and healthcare utilization in other areas, particularly relative to standard care for privately insured autistic adults.

Current primary care models are inadequate for adults on the autism spectrum. The Center for Autism Services and Transition (CAST) clinic was developed in 2014 using feedback from parents of adults on the autism spectrum and patient-centered medical home principles. We evaluated the reach of CAST's services. As of January 2021, 858 patients were seen in CAST. Many continue to receive primary care from the CAST clinic. The program has undergone staffing changes but continues to accept new patients. We have added services such as "happy visits," pre-procedure videos, and telehealth visits. CAST provides one example of how to improve primary care for adults on the autism spectrum. More research is needed to assess the effectiveness of the CAST model.

BACKGROUND: While in some studies, the patient-centered medical home has been linked with increased receipt of preventive services among other populations, there is a paucity of literature testing the effectiveness of medical homes in serving the healthcare needs of autistic adults. OBJECTIVE: To compare the receipt of preventive services by patients at a patient-centered medical home specifically designed for autistic adults (called the Center for Autism Services and Transition “CAST”) to US national samples of autistic adults with private insurance or Medicare. DESIGN: Retrospective study of medical billing data. SAMPLE: The study sample included CAST patients (N = 490) who were propensity score matched to Medicare-enrolled autistic adults (N = 980) and privately insured autistic adults (N = 980) using demographic characteristics. The median age of subjects was 21 years old, 79% were male, and the median duration of observation was 2.2 years. MAIN MEASURES: The primary outcome measure was the receipt of any preventive service, as defined by the Medicare Learning Network and AAPC (formerly the American Academy of Professional Coders). Secondary outcome measures included receipt of specific preventive service types (i.e., general health and wellness services, screenings, counseling and therapies, vaccinations, and sexual/reproductive health services). KEY RESULTS: CAST patients had significantly greater odds of receiving any preventive service than Medicare-enrolled (OR = 10.3; 95% CI = 7.6–13.9) and privately insured (OR = 3.1; 95% CI = 2.3–4.2) autistic adults. CAST patients were also significantly more likely to receive screenings and vaccinations than either Medicare beneficiaries (screenings OR = 20.3; 95% CI = 14.7–28.0; vaccinations OR = 5.5; 95% CI = 4.3–7.0) or privately insured beneficiaries (screenings OR = 2.0; 95% CI = 1.6–2.5; vaccinations OR = 3.3; 95% CI = 2.6–4.1). CONCLUSIONS: Autistic adults receiving care through CAST were significantly more likely to recieve preventive care services than national samples of autistic adults. Future comparative effectiveness trials are needed to rigorously assess the impact of primary care-based initiatives to improve care for autistic adults. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06513-7.

Autistic adults experience barriers to primary care, including distant/inaccessible clinics, sensory stressors, and communication barriers with providers. Synchronous telehealth visits, termed “virtual visits,” may be a way to minimize these barriers. We investigated the advantages and disadvantages of primary care virtual visits using a phenomenological approach. We interviewed autistic adults ( n = 7) and caregivers of autistic adults ( n = 12) from one primary care clinic. Using thematic analysis, we identified three advantages to virtual visits: (1) increased patient comfort from avoiding travel to the clinic, crowded waiting rooms, and other sensory stressors; (2) increased safety by avoiding physical contact with others who may be sick; and (3) similar or better patient–provider communication than in-person visits. Disadvantages included the following: (1) Internet instability and other technological issues, (2) the inability to receive hands-on care from the provider, and (3) reduced patient engagement due to environmental distractions. Virtual visits may minimize barriers to care for autistic adults by reducing travel time, exposure to sensory stressors, and barriers to communication with the provider. While we recognize that virtual visits may not be appropriate for all patients or in all situations, they may be a promising model of health care delivery for autistic adults. Lay abstract Autistic adults face many barriers to receiving quality primary health care like clinics that are far away and sensory sensitivities. Real-time telehealth visits, called “virtual visits,” are live video chats between the patient and provider. Virtual visits may minimize barriers to care for autistic adults. We wanted to describe advantages and disadvantages of using virtual visits for delivering primary health care for autistic adults. We interviewed 7 autistic adults and 12 caregivers of autistic adults who receive primary care through one clinic. Autistic adults and caregivers said advantages to virtual visits were that (1) patients were more comfortable at home, (2) patients could get health care while avoiding physical contact with other people during the pandemic, and (3) virtual visits were similar to or better than in-person visits. The disadvantages included that (1) there could be technology problems like grainy video, (2) the doctor could not physically examine the patient (e.g. look in ears), and (3) patients sometimes participated less in the virtual visit than they would in person. Virtual visits may be beneficial for autistic adults by eliminating travel to the clinic and avoiding stressful sensory stimuli. We recognize that virtual visits may not work for all patients or in all situations. However, our study shows that primary care virtual visits may be beneficial for autistic adults during and beyond the pandemic.

BACKGROUND: Autistic adults have complex physical and mental healthcare needs that necessitate specialized approaches to healthcare. One promising approach is to embed providers with specialized training or specialty clinics for autistic adults within general primary care facilities. We previously found that autistic adults who received their healthcare through one specialty clinic designed with and for autistic adults had better continuity of care and more preventive service utilization than national samples of autistic adults. OBJECTIVE: To characterize factors that increased or decreased satisfaction with healthcare received through a specialty clinic for autistic adults. METHODS: We conducted 30–60-minute semi-structured interviews with autistic adults (N=9) and parents of autistic adults (N=12). We conducted an inductive thematic analysis, using a phenomenological approach. RESULTS: Factors that increased participants’ satisfaction included: (1) receiving personalized care from the provider; (2) spending quality time with the provider; and (3) having strong, positive patient-provider relationships. Factors that decreased participants’ satisfaction included: (1) lack of access to services due to scarcity of trained providers; (2) difficulty at times communicating with the provider; and (3) system-level barriers such as policies, practices, or procedures. CONCLUSION: Our findings highlight the importance of providers using personalized approaches to care that meet patients’ sensory and communication needs and spending quality time with patients to establish strong, positive patient-provider relationships. Our findings also underscore the critical scarcity of healthcare providers who are trained to deliver care for the growing population of autistic adults.

Seuli Bose-Brill,1 Jinming Xing,2 Debra J Barnette,1,2 Christopher Hanks1 1Internal Medicine and Pediatrics at Grandview, Wexner Medical Center, 2Department of Practice and Science, College of Pharmacy, The Ohio State University, Columbus, OH, USA Abstract: Adolescents with autism have higher rates of anxiety than the general adolescent population. They often struggle to express psychological symptoms verbally where their symptoms may manifest as withdrawal and agitation. Adolescent patients with autism have higher rates of polypharmacy and high-risk psychiatric medication use (eg, atypical antipsychotics) than other patients with psychiatric illness. Primary care pediatricians are at the front lines of psychiatric management for patients with autism. Yet, they have inadequate access to pediatric psychiatry for complex medication management. Pharmacogenomic testing can provide personalized drug metabolism profiles for a majority of psychotropic medications. Primary care based pharmacogenomic testing for adolescents with autism on one or more psychiatric medications may help individualize and optimize complex medication regimens, while promoting drug safety. Keywords: autism, pharmacogenomic, pharmacogenetic, pharmacotherapy, anxiety, depression, psychiatry, pediatrics

Little has been reported about how to improve health care access and delivery for adolescents and adults with autism spectrum disorder. To understand the contributions to the health disparities in the autism spectrum disorder population, we conducted two independent research approaches to learn about current medical needs. A retrospective chart review was performed to evaluate medical comorbidities and medication use. A focus group was also created to address barriers faced in providing medical care. Of 126 charts reviewed, 49% (n = 62) had intellectual disability, 49% (n = 62) had attention-deficit hyperactivity disorder, 52% (n = 65) had anxiety, 41% (n = 52) had obesity, 31% (n = 39) with a history of aggressive behavior, 31% (n = 31) had depression, 22% (n = 28) had seizures, and 9% (n = 11) had hypertension. A Medical Regimen Complexity Index score was determined to examine medication use trends in the autism spectrum disorder population. Medical Regimen Complexity Index scores were significantly higher for patients with intellectual disability, patients with seizures, and patients with a history of aggressive behavior. Both the focus group and our pre-visit assessment identified the waiting room and waiting time as barriers to care. Understanding the comorbidities, polypharmacy, and medical barriers should provide a better understanding of the current health care access and delivery needs of adolescents and adults with autism spectrum disorder.

BACKGROUND Adults with autism spectrum disorder (ASD) frequently experience polypharmacy. However, there is limited understanding of how to quantify medication complexity in this vulnerable population. OBJECTIVES This study examined medication administration difficulty using the Medication Regimen Complexity Index (MRCI) tool in adolescents and adults with ASD. The outcomes compared the mean total MRCI score with the medication count, described MRCI contributions for over-the-counter medication (OTC), and compared MRCI scores by patient characteristics. METHODS This was a retrospective chart review of patients aged 7-45 years (mean = 20.1) enrolled in a primary care ASD transitions program. Each patient's listed medications were counted and then scored using the validated MRCI tool. RESULTS For the 142 patients studied, mean total MRCI was 14.6 ± 14.6 (range 0-89) and mean medication count was 6.3 ± 5.4 (range 0-38). For patients on 0-4 medications (66 of 142; 46.5%), the mean MRCI was 5.5 ± 4.2, 5-9 medications (50 of 142; 35.2%) the mean MRCI was 15.2 ± 6.8, and 10-38 medications (26 of 142; 18.3%) the mean MRCI was 36.5 ± 18.9 (p

Youth with special health care needs (YSHCN) experience health care disparities and often need additional support to receive optimal medical care, particularly in adolescence as they prepare to transition to adult care. Many medical practices struggle to address their needs. Here, we discuss approaches to improve medical care in office-based settings for YSHCN. Office visits can be optimized by training staff in developmentally appropriate care and ensuring that the physical office space facilitates care. Participating in previsit preparation, including managing patient registries of YSHCN, engaging in regular team huddles, and incorporating previsit planning, can improve preparation and ensure that important needs are not overlooked. Additionally, approaches to improve patient and medical provider comfort with office visits with YSHCN, including approaches to measuring vital signs, examining patients, and communicating with patients with various disabilities, are reviewed. Finally, we discuss methods of supporting adolescents with special health care needs in developing self-management skills that will allow them to be better prepared to enter adult health care settings when appropriate. Although YSHCN can present challenges to medical teams, their care can be improved by developing office-based changes and processes to support improved care for these patients. This may help overcome the health care disparities they experience and increase comfort for all members of the medical team.

Breathing complaints are common in athletes. Studies have suggested that the prevalence of asthma and exercise-induced bronchoconstriction (EIB) is higher in elite athletes than the general population. Vocal cord dysfunction (VCD) may mimic asthma and EIB as a cause of dyspnea in athletes. However, the majority of studies to date have primarily relied on symptoms to diagnose VCD, and there are limited data on coexistence of asthma, EIB, and/or VCD. It is well established that symptoms alone are inadequate to accurately diagnose EIB and VCD. Our goal was to define via objective testing the prevalence of asthma, EIB, VCD alone, or in combination in a cohort of athletes with respiratory complaints.A retrospective chart review was done of 148 consecutive athletes (collegiate, middle school, high school, and recreational) referred to a tertiary care center's asthma center for evaluation of respiratory complaints with exercise. An evaluation including medical history, physical examination, and objective testing including pulmonary function testing (PFT), eucapnic voluntary hyperventilation, and video laryngostroboscopy, were performed.The most common symptom was dyspnea on exertion (96%), with1% complaining of either hoarseness or stridor. The most common diagnosis prior to referral was asthma (40%). Only 16% had PFTs prior to referral. Following evaluation by a pulmonologist, 52% were diagnosed with EIB, 17% with asthma, and 70% with VCD. Of those diagnosed with asthma before our evaluation, the diagnosis of asthma was confirmed, with PFTs in only 19 of 59 (32%) athletes based on our testing. Vocal cord dysfunction was more common in females and in adolescent athletes. Coexistence of multiple disorders was common, such as EIB and asthma (8%), EIB and VCD (31%), and VCD and asthma (6%).Asthma and EIB are common etiologies of dyspnea in athletes, both competitive and recreational. However, VCD is also common and can coexist with either asthma or EIB. Vocal cord dysfunction may contribute to exercise-related respiratory symptoms more frequently in middle school- and high school-aged athletes than in college athletes. Effective treatment of dyspnea requires appropriate identification and treatment of all disorders. Classic symptoms of stridor and/or hoarseness are often not present in athletes with VCD. Accurate diagnosis of asthma, EIB, and VCD requires objective testing and can prevent exposure of patients to medications that are ineffective and have potential adverse side effects. Furthermore, there is need for increased awareness of VCD as a common cause of respiratory complaints in athletes, either as a single diagnosis or in combination with EIB, especially in females, as well as middle school and high school athletes.

Activator of G protein Signaling 1 (AGS1) and Ras homologue enriched in striatum (Rhes) define a new group of Ras-like monomeric G proteins whose signaling properties and physiological roles are just beginning to be understood. Previous results suggest that AGS1 and Rhes exhibit distinct preferences for heterotrimeric G proteins, with AGS1 selectively influencing Gαi and Rhes selectively influencing Gαs. Here, we demonstrate that AGS1 and Rhes trigger nearly identical modulation of N-type Ca2+channels (CaV2.2) by selectively altering Gαi-dependent signaling. Whole-cell currents were recorded from HEK293 cells expressing CaV2.2 and Gαi- or Gαs-coupled receptors. AGS1 and Rhes reduced basal current densities and triggered tonic voltage-dependent (VD) inhibition of CaV2.2. Additionally, each protein attenuated agonist-initiated channel inhibition through Gαi-coupled receptors without reducing channel inhibition through a Gαs-coupled receptor. The above effects of AGS1 and Rhes were blocked by pertussis toxin (PTX) or by expression of a Gβγ-sequestering peptide (masGRK3ct). Transfection with HRas, KRas2, Rap1A-G12V, Rap2B, Rheb2, or Gem failed to duplicate the effects of AGS1 and Rhes on CaV2.2. Our data provide the first demonstration that AGS1 and Rhes exhibit similar if not identical signaling properties since both trigger tonic Gβγ signaling and both attenuate receptor-initiated signaling by the Gβγ subunits of PTX-sensitive G proteins. These results are consistent with the possibility that AGS1 and Rhes modulate Ca2+influx through CaV2.2 channels under more physiological conditions and thereby influence Ca2+-dependent events such as neurosecretion.

There is no other sport that has come under greater scrutiny surrounding the incidence and treatment of concussion than football, and there is no other professional sports league that has experienced more intense focus of its handling of concussions than the National Football League (NFL). The NFL has received significant criticism of their management of concussion in players from both the popular press and the medical community. However, those working with active NFL players have changed their assessment and treatment of these injuries as the knowledge of concussions has evolved over time. We review the current approach to the management of concussions in the professional football player.

There is no other sport that has come under greater scrutiny surrounding the incidence and treatment of concussion than football, and there is no other professional sports league that has experienced more intense focus of its handling of concussions than the National Football League (NFL). The NFL has received significant criticism of their management of concussion in players from both the popular press and the medical community. However, those working with active NFL players have changed their assessment and treatment of these injuries as the knowledge of concussions has evolved over time. We review the current approach to the management of concussions in the professional football player.

Using data on non-presidential-year elections for governor and U.S. Senators in eight southern states over the period 1922– 1990, we provide a rational-choice-inspired model of the factors that should be expected to affect the relative levels of turnout in primaries as compared to general elections. Both V.O. Key and Anthony Downs have argued that voters will be more likely to participate in the elections in which they can most expect to be decisive. V.O. Key (1949) proposed that when general elections are usually lop-sided because of one-party dominance of a state's politics the primary of the dominant party of the state should have a higher turnout than the general election. Downs argued that turnout should be higher in competitive elections. Our modelling combines these ideas. We use as our dependent variable the ratio of primary to general election turnout in each year. We posit that this ratio will increase (1) the greater the degree of within-party competition in the primary (especially that within the dominant party of a state, if there is one), and (2) the weaker the degree of between party competition in the general election. In addition to election-specific effects, we also posit long-run effects, such that the ratio for the offices of governor and U.S. Senator will be affected not merely by the degrees of competition within and between parties specific to any given election, but also by the long-run trends in party competition. This hypothesis leads us to expect that, (3) in the South, with the rise of the Republican party, the ratio of primary to general election turnout should decline over time. All of our expectations about the links between turnout and competition are strongly supported. We argue that rational choice models of turnout perform quite well when we view them in a comparative statics perspective, rather than using them to make predictions about who will and who will not vote in any given election.

∗To whom correspondence should be addressed. E-mail: brett@biology.usu.edu.Activator of G protein Signaling 1 (AGS1) and Ras homologue enriched in striatum (Rhes) define a new group of Ras-like monomeric G proteins whose signaling properties and physiological roles are just beginning to be understood. Previous results suggest that AGS1 and Rhes exhibit distinct preferences for heterotrimeric G proteins, with AGS1 selectively influencing Gαi and Rhes selectively influencing Gαs. Here, we demonstrate that AGS1 and Rhes trigger nearly identical modulation of N-type Ca2+ channels (CaV2.2) by selectively altering Gαi-dependent signaling. Whole-cell currents were recorded from HEK293 cells expressing CaV2.2 and Gαi- or Gαs-coupled receptors. AGS1 and Rhes reduced basal current densities and triggered tonic voltage-dependent (VD) inhibition of CaV2.2. Furthermore, each protein attenuated agonist-initiated channel inhibition through Gαi-coupled receptors without reducing channel inhibition through a Gαs-coupled receptor. The above effects of AGS1 and Rhes were blocked by pertussis toxin (PTX) or by expression of a Gβγ-sequestering peptide (masGRK3ct). Transfection with HRas, KRas2, Rap1A-G12V, Rap2B, Rheb2 or Gem failed to mimic the effects of AGS1 and Rhes on CaV2.2. Our data provide the first demonstration that AGS1 and Rhes exhibit similar if not identical signaling properties since both trigger tonic Gβγ signaling and both attenuate receptor-initiated signaling by the Gβγ subunits of PTX-sensitive G proteins. These results are consistent with the possibility that AGS1 and Rhes modulate Ca2+ influx through CaV2.2 channels under more physiological conditions and thereby influence Ca2+-dependent events such as neurosecretion.

Oxford House was established in 1798 as a supply depot for the Hudson's Bay Company. Over the next thirty years, a symbiotic relationship developed between the HBC and the local Cree population which grew up around the post. This relationship then slowly shifted from one based upon mutual dependence to an association dominated by the traders. Due to this dependence, the Cree changed from semi-nomadic, big-game hunters and gatherers to territorially restricted trappers. Oxford House, Manitoba, is located at the northeast end of Oxford Lake on the Hayes River system. The Hayes River drains a region of boreal forest on the Canadian Shield southeast of the Nelson River and north of Lake Winnipeg in northern Manitoba, and flows to the northeast emptying into Hudson Bay at York Factory, five miles south of the Nelson River. The Hayes River played a significant role in the European fur trade to the southwest of Hudson Bay from the end of the 17th century until the late 19th century when the advent of the transcontinental railroad and steamboats on Lake Winnipeg eclipsed the route from the Bay. During that time the smaller less turbulent Hayes was consistently preferred by traders and Indians alike, over the larger rapid ridden Nelson River. Trade was carried out via ships from Europe which brought goods to the depot at York Factory on Hudson's Bay. Supplies were then moved inland via the Hayes and Echmamish Rivers to the Upper Nelson River, then across Lake Winnipeg to the Saskatchewan River and on to the west. Oxford House was established in 1798 as a depot to facilitate this movement of goods inland and not as a post intended to draw a large Indian trade (Hanks 1980:54). The formation and growth of the Oxford House Band was the result of the depot requiring natives to provide provisions and labor for transporting goods to and from the interior. The historic resettlement of the Cree near Oxford House can be traced to the period following the establishment of the HBC post in 1798. Initially the settlement was not intended as a trading post, but rather as a supply depot for maintaining the HBC western trade. According to William Sinclair, the first factor at Oxford House at the time the post was established, the region had long since been trapped out by the "Home Guard Cree" from York Factory. As a result, Sinclair notes that although there were few Indians living in the region when the post was established, it was ideally suited for the purpose of supplying the inland trade (PAM, HBCA, B. 239/b/66, fo. 107). Therefore, the Oxford House Band is the result of the historic late 18th and early 19th century interaction between the fur trade and native groups and was not an in situ development of the aboriginal population.