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To assess whether a shorter length of stay (LOS) is associated with a higher risk of readmission among newborns with neonatal abstinence syndrome (NAS) and examine the risk, causes, and characteristics associated with readmissions among newborns with NAS, using a longitudinally linked population-based database.Our study sample included full-term singletons with NAS (n = 4,547) and without NAS (n = 327,836), born in Massachusetts during 2011-2017. We used log-binomial regression models to estimate the crude risk ratios (cRRs) and adjusted RRs with 95% confidence intervals (CI) of the association between LOS and readmissions, controlling for maternal age, race/ethnicity, education, marital status, insurance, method of delivery, birthweight, adequacy of prenatal care, smoking, and abnormal conditions of newborn.Compared with infants without NAS, infants with NAS had a non-significantly higher risk of readmission within 2-42 days (2.8% vs. 2.5%; p = 0.17) and a significantly higher risk of readmission within 43-182 days (2.7% vs. 1.8%; p 0.001). The risk of readmission within 2-42 days was significantly higher among infants with NAS with a LOS of 0-6 days compared to a LOS of 14-20 days (reference group) (aRR: 2.1; 95% CI: 1.2-3.5). No significant differences in readmission rates between 43 and 182 days were observed across LOS categories.Among infants with NAS, a LOS of 0-6 days was associated with a significantly higher risk of readmission within 2-42 days of discharge compared to a longer LOS.

Purpose of review Mothers with substance use disorders are often referred for parenting support, though commonly available programs may miss the mark for families impacted by addiction. This may be related to a lack of attention to children's emotional needs, mothers' histories of adversity, and the neurobiological differences seen in mothers with addictions. We review the implications of addiction, adversity, and attachment for parenting interventions. We then describe Mothering from the Inside Out (MIO), an evidence-based parenting intervention designed specifically for mothers with addictions. Recent findings Evidence from clinical trials suggests that MIO improves outcomes for two generations: both mothers with addictions and their children. Recent trials demonstrate that MIO may be delivered effectively by community-based clinicians and may be beneficial for parents with other chronic stressors. Summary Addressing addiction, adversity, and attachment simultaneously may have a positive synergistic effect. Future research should study the implementation of MIO in real-world settings and examine the impact of MIO on maternal neurobiology.

CONTEXT Racial/ethnic inequities are well documented in both maternal-infant health and substance use disorder treatment outcomes. OBJECTIVE To systematically review research on maternal-infant dyads affected by opioid use disorder (OUD) to evaluate for racial/ethnic disparities in health utilization or outcomes and critically assess the reporting and inclusion of race/ethnicity data. DATA SOURCES Peer-reviewed literature in MEDLINE, Embase, and Web of Science from 2000 to 2020. STUDY SELECTION Research reporting health utilization and outcomes data on dyads affected by OUD during pregnancy through the infant’s first birthday. DATA EXTRACTION We extracted data on race/ethnicity, study exposures/outcomes, how race/ethnicity data were analyzed, how authors discussed findings associated with race/ethnicity, and whether racism was mentioned as an explanation for findings. RESULTS Of 2023 articles reviewed, 152 quantitative and 17 qualitative studies were included. Among quantitative studies, 66% examined infant outcomes (n = 101). Three articles explicitly focused on evaluating racial/ethnic differences among dyads. Among quantitative studies, 112 mentioned race/ethnicity, 63 performed analyses assessing for differences between exposure groups, 27 identified racial/ethnic differences, 22 adjusted outcomes for race/ethnicity in multivariable analyses, and 11 presented adjusted models stratified by race/ethnicity. None of the qualitative studies addressed the role that race, ethnicity, or racism may have had on the presented themes. CONCLUSIONS Few studies were designed to evaluate racial/ethnic inequities among maternal-infant dyads affected by OUD. Data on race/ethnicity have been poorly reported in this literature. To achieve health equity across perinatal OUD, researchers should prioritize the inclusion of marginalized groups to better address the role that structural racism plays.

There has been a considerable number of reports on Hg concentrations in Arctic mammals since the last Arctic Monitoring and Assessment Programme (AMAP) effort to review biological effects of the exposure to mercury (Hg) in Arctic biota in 2010 and 2018. Here, we provide an update on the state of the knowledge of health risk associated with Hg concentrations in Arctic marine and terrestrial mammal species. Using available population-specific data post-2000, our ultimate goal is to provide an updated evidence-based estimate of the risk for adverse health effects from Hg exposure in Arctic mammal species at the individual and population level. Tissue residues of Hg in 13 species across the Arctic were classified into five risk categories (from No risk to Severe risk) based on critical tissue concentrations derived from experimental studies on harp seals and mink. Exposure to Hg lead to low or no risk for health effects in most populations of marine and terrestrial mammals, however, subpopulations of polar bears, pilot whales, narwhals, beluga and hooded seals are highly exposed in geographic hotspots raising concern for Hg-induced toxicological effects. About 6% of a total of 3500 individuals, across different marine mammal species, age groups and regions, are at high or severe risk of health effects from Hg exposure. The corresponding figure for the 12 terrestrial species, regions and age groups was as low as 0.3% of a total of 731 individuals analyzed for their Hg loads. Temporal analyses indicated that the proportion of polar bears at low or moderate risk has increased in East/West Greenland and Western Hudson Bay, respectively. However, there remain numerous knowledge gaps to improve risk assessments of Hg exposure in Arctic mammalian species, including the establishment of improved concentration thresholds and upscaling to the assessment of population-level effects.

Can the international conservation agreement protect these bears?

OBJECTIVE To identify factors associated with referral and enrollment in early intervention (EI) for infants with neonatal abstinence syndrome (NAS). METHODS We conducted a retrospective cohort study of 256 infants born with NAS (2006-2013) at a tertiary care hospital in (Springfield), Massachusetts, linking maternal-infant birth hospitalization records with Department of Public Health EI records. We calculated the percent of infants retained at each step in the EI enrollment process over the first 3 years of life. We conducted separate multivariable logistic regression analyses to identify factors associated with EI referral and enrollment. RESULTS Among mothers, 82% received medication-assisted treatment at delivery, 36% endorsed illicit drug use during pregnancy, and 76% retained custody of their child at discharge. Among infants, 77% were referred to EI and 48% were enrolled in services. Of infants discharged to biological parents, 81% were referred to EI versus 66% of infants discharged to foster care (p ≤ 0.05); this difference persisted in multivariable analysis [adjusted odds ratio, 2.30; 95% confidence interval (CI), 1.09-4.86]. Infants in the highest tertile for length of stay had 2.70 times the odds of EI enrollment (95% CI, 1.37-5.31). CONCLUSION Fewer than half of the eligible infants with NAS were enrolled in EI services. Discharge to a biological parent and longer hospital stay had the strongest associations with EI referral and enrollment, respectively. Efforts to improve EI referral rates during the birth hospitalization, particularly among infants discharged into foster care, and close follow-up for infants with shorter hospital stays would enhance the developmental supports for this vulnerable population.

BACKGROUND: Increasing rates of maternal opioid use disorder has led to greater number of opioid exposed newborns (OENs). Maternal enrollment in medication for opioid use disorder (MOUD) program improves short term neonatal outcomes. This study aimed at assessing neurobehavioral outcomes for OENs. METHODS: Retrospective observational cohort study of OENs between Jul 2006 and Dec 2018. Two study groups were identified as initiation of medication for opioid use disorder (MOUD) prior to diagnoses of pregnancy or after. Primary outcome variables were enrollment in and duration of EI services. Secondary outcome variable was diagnoses of a behavioral and/or developmental disorder (BDD) during the study period. RESULTS: Of 242 infants, 113 were enrolled in EI and BDD diagnoses data was available for all infants [age range 6 to 12 years], 82% infants had exposure to maternal MOUD, while 18% were exposed to either maternal prescription non-MOUD opioids or illicit opioids. Maternal MOUD initiation prior to pregnancy was associated with improved short term outcomes for OENs. Almost a third of infants were diagnosed with a BDD with no differences between the two study groups. CONCLUSION: Early initiation of maternal MOUD improved short term outcomes and discharge disposition for OENs. Prolonged in-utero exposure to opioids presents a potential for negative impact on neurodevelopmental and behavioral outcomes. These risks must be considered to increase access and adherence to EI services, as well as to focus on non-opioid based maternal MOUD. Longitudinal studies assessing the safety of MOUD on short and long-term child health outcomes are needed.

Background Despite being highly motivated to recover, pregnant and postpartum women with opioid use disorders (OUD) are at high risk of relapse and death. While many services mitigate this risk, engagement in voluntary, outpatient services remains low. Our aim was to understand the experiences of and factors influencing outpatient service engagement during the perinatal period among women in recovery from OUD. Methods We conducted semi-structured interviews about perinatal experiences engaging with outpatient services, with 20 women in recovery aged 22–46 years who had children between 6 months and 10 years old. Interviews were audio-recorded, transcribed, coded, and analyzed using conventional content analysis. Results Women described a continuum of ‘collaborative engagement’ experiences, defined by the extent to which they perceived their providers or service organizations were invested in their journeys as a partners and advocates. The ability to achieve collaborative engagement depended upon two factors: (1) the woman's transformational development as a mother and woman in recovery, and (2) her perception of the providers’ ability to meet her multifaceted needs. Conclusions Women in recovery from OUD may experience deeper engagement in voluntary outpatient perinatal services when they perceive that their providers are invested and collaboratively engaging in their recovery and personal growth. Future research should test whether collaborative engagement improves service retention. Abbreviations: IPV: Intimate Partner Violence; OUD: opioid use disorder

In this commentary, we describe the triple threat that parents in recovery face during the COVID-19 pandemic due to the loss of social support. We explore how the absence of human connection during the pandemic can be detrimental to parents in recovery as well as the parent-child relationship. We conclude by proposing strategies to offer critical support for families as this period of social isolation extends and the effects become increasingly apparent.

The COVID-19 pandemic has required healthcare systems to be creative and adaptable in response to an unprecedented crisis. Below we describe how we prepared for and adapted to this pandemic at our decentralized, quaternary-care department of emergency medicine, with specific recommendations from our experience. We discuss our longstanding history of institutional preparedness, as well as adaptations in triage, staffing, workflow, and communications. We also discuss innovation through working with industry on solutions in personal protective equipment, as well as telemedicine and methods for improving morale. These preparedness and response solutions and recommendations may be useful moving forward as we transition between response and recovery in this pandemic as well as future pandemics.

A demanding lifestyle Polar bears appear to be well adapted to the extreme conditions of their Arctic habitat. Pagano et al. , however, show that the energy balance in this harsh environment is narrower than we might expect (see the Perspective by Whiteman). They monitored the behavior and metabolic rates of nine free-ranging polar bears over 2 years. They found that high energy demands required consumption of high-fat prey, such as seals, which are easy to come by on sea ice but nearly unavailable in ice-free conditions. Thus, as sea ice becomes increasingly short-lived annually, polar bears are likely to experience increasingly stressful conditions and higher mortality rates. Science , this issue p. 568 ; see also p. 514

Climate change is altering habitat for many species, leading to shifts in distributions that can increase levels of human-wildlife conflict. To develop effective strategies for minimizing human-wildlife conflict, we must understand the relative influences that climate change and other factors have on wildlife distributions. Polar bears (Ursus maritimus) are increasingly using land during summer and autumn due to sea ice loss, leading to higher incidents of conflict and concerns for human safety. We sought to understand the relative influence of sea ice conditions, onshore habitat characteristics, and human-provisioned food attractants on the distribution and abundance of polar bears while on shore. We also wanted to determine how mitigation measures might reduce human-polar bear conflict associated with an anthropogenic food source. We built a Bayesian hierarchical model based on 14 years of aerial survey data to estimate the weekly number and distribution of polar bears on the coast of northern Alaska in autumn. We then used the model to predict how effective two management options for handling subsistence-harvested whale remains in the community of Kaktovik, Alaska might be. The distribution of bears on shore was most strongly influenced by the presence of whale carcasses and to a lesser extent sea ice and onshore habitat conditions. The numbers of bears on shore were related to sea ice conditions. The two management strategies for handling the whale carcasses reduced the estimated number of bears near Kaktovik by > 75%. By considering multiple factors associated with the onshore distribution and abundance of polar bears we discerned what role human activities played in where bears occur and how successful efforts to manage the whale carcasses might be for reducing human-polar bear conflict.

BACKGROUND AND OBJECTIVES: Opioid-exposed infants frequently qualify for early intervention (EI). However, many eligible families choose not to enroll in this voluntary service. This study aims to understand the perceptions and experiences that may impact engagement with, and the potential benefits of, EI services among mothers in recovery from opioid use disorders (OUDs). METHODS: We conducted semistructured qualitative interviews (n = 22) and 1 focus group (n = 6) with mothers in recovery from OUDs in western Massachusetts. Transcripts were coded and analyzed by using a descriptive approach. RESULTS: The mean participant age was 32 years, and 13 had a high school degree or less. Five major themes emerged revealing mothers’ development through stages of engagement in EI services: (1) fear, guilt, and shame related to drug use (emotions acting as barriers to enrollment); (2) the question of whether it is “needed” (deciding whether there is value in EI for opioid-exposed infants); (3) starting with “judgment” (baseline level of perceived stigma that parents in recovery associate with EI); (4) breaking down the “wall” (how parents overcome the fear and perceived judgment to build partnerships with providers); and (5) “above and beyond” (need for a personal connection with mothers and concrete supports through EI in addition to the child-focused services provided). CONCLUSIONS: Barriers to engagement in EI among mothers in recovery from OUDs include a range of emotions, perceived stigma, and ambivalence. An effort to purposefully listen to and care for mothers through a strengths-based, bigenerational approach may help establish greater connections and foster stronger EI engagement among families affected by OUDs.

Background: Emergency departments (EDs) have seen dramatic surges in patients infected with COVID-19 and are high-risk transmission environments. Knowledge, attitudes and practice regarding personal protective equipment (PPE) among ED health care workers (HCWs) during the COVID-19 pandemic have not been studied, thus this study examines this knowledge gap. Methods: This was a cross-sectional survey of 308 HCWs in two urban EDs in Atlanta, Georgia in April and May of 2020. Results: We surveyed 308 HCWs; 137 responded (44% response rate). All HCWs reported adequate knowledge and 96% reported compliance with PPE guidelines. Reported sources of PPE information: 56.7% charge nurse, 67.3% the institutional COVID-19 website. Frequency of training was positively associated with understanding how to protect themselves and patients (OR = 1.7, 95% CI: 1.0–2.9). Conclusions: Few HCWs are willing to care for patients without PPE, and therefore we should aim for resiliency in the PPE supply chain. EDs should consider multiple communication strategies, including a website with concise information and enhanced training for key personnel, particularly the charge nurse. Attention to frequency in HCW training may be key to improve confidence in protecting themselves and patients. Findings can be leveraged by EDs to implement effective PPE training.

Since the last Arctic Monitoring and Assessment Programme (AMAP) effort to review biological effects of the exposure to organohalogen compounds (OHCs) in Arctic biota, there has been a considerable number of new Arctic effect studies. Here, we provide an update on the state of the knowledge of OHC, and also include mercury, exposure and/or associated effects in key Arctic marine and terrestrial mammal and bird species as well as in fish by reviewing the literature published since the last AMAP assessment in 2010. We aimed at updating the knowledge of how single but also combined health effects are or can be associated to the exposure to single compounds or mixtures of OHCs. We also focussed on assessing both potential individual as well as population health impacts using population-specific exposure data post 2000. We have identified quantifiable effects on vitamin metabolism, immune functioning, thyroid and steroid hormone balances, oxidative stress, tissue pathology, and reproduction. As with the previous assessment, a wealth of documentation is available for biological effects in marine mammals and seabirds, and sentinel species such as the sledge dog and Arctic fox, but information for terrestrial vertebrates and fish remain scarce. While hormones and vitamins are thoroughly studied, oxidative stress, immunotoxic and reproductive effects need further investigation. Depending on the species and population, some OHCs and mercury tissue contaminant burdens post 2000 were observed to be high enough to exceed putative risk threshold levels that have been previously estimated for non-target species or populations outside the Arctic. In this assessment, we made use of risk quotient calculations to summarize the cumulative effects of different OHC classes and mercury for which critical body burdens can be estimated for wildlife across the Arctic. As our ultimate goal is to better predict or estimate the effects of OHCs and mercury in Arctic wildlife at the individual, population and ecosystem level, there remain numerous knowledge gaps on the biological effects of exposure in Arctic biota. These knowledge gaps include the establishment of concentration thresholds for individual compounds as well as for realistic cocktail mixtures that in fact indicate biologically relevant, and not statistically determined, health effects for specific species and subpopulations. Finally, we provide future perspectives on understanding Arctic wildlife health using new in vivo, in vitro, and in silico techniques, and provide case studies on multiple stressors to show that future assessments would benefit from significant efforts to integrate human health, wildlife ecology and retrospective and forecasting aspects into assessing the biological effects of OHC and mercury exposure in Arctic wildlife and fish. © 2019 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Recent improvements in child health have led to substantial decreases in child mortality globally.1 While progress is still needed, especially in regions afflicted by conflict and political instability,2 the next step is to promote young children’s development and early learning so they can remain healthy, take advantage of growing educational opportunities, and contribute to their communities’ economic growth. Every year, approximately 249 million children, mainly from low- and middle- income countries, fail to reach their developmental potential in the context of poverty and related health, nutrition, and social factors.3 Recessions and climate change additionally contribute to loss of developmental potential globally.4–7 While principles of early childhood development are universal, a global perspective must consider exposure to extreme poverty and high prevalence of infectious diseases, cultural context, and availability and type of resources. This chapter will describe biological and social factors that influence brain development and early learning and resilience, their cultural context, and examples of successful child development interventions globally. We also provide recommendations to rapidly accelerate the promotion of early childhood development globally with key strategies, including an emphasis on universal prevention programs rather than universal screening, multigenerational models that emphasize universal support for parents and targeted support for high-risk populations, integration of child development programs into child health and nutrition efforts, and use of technology.

OBJECTIVE As antiretroviral therapy (ART) expands for HIV-infected children, it is important to determine its impact on growth. We quantified growth and its determinants following ART in resource-limited (RLS) and developed settings. DESIGN Systematic review and meta-analysis. METHODS We searched publications reporting growth [weight-for-age (WAZ), height-for-age (HAZ), and weight-for-height (WHZ) z scores] in HIV-infected children following ART through August 2014. Inclusion criteria were as follows: younger than 18 years; ART; at least 20 patients; growth at ART; and post-ART growth. Standardized and overall weighted mean differences were calculated using random-effects models. RESULTS A total of 67 articles were eligible (RLS = 54; developed settings = 13). Mean age was 5.8 years, and comparable between settings (P = 0.90). Baseline growth was substantially lower in RLS vs. developed settings (WAZ -2.1 vs. -0.5; HAZ -2.2 vs. -0.9; both P

Significant information gaps exist regarding the status of polar bears, especially with respect to the impacts of climate change, across large portions of the Arctic. To obtain an updated abundance estimate for the Foxe Basin population, we conducted comprehensive aerial surveys during the 2009 and 2010 ice-free seasons, when bears are confined to land. We sampled with mark-recapture distance sampling protocols on inland and coastal transects and surveyed small islands and remnant ice floes. We observed 816 and 1,003 bears in 2009 and 2010, respectively. Although detection functions differed substantially between years, estimates were consistent between analytical methods and years. Averaging four estimates (two from each year) yielded 2,585 (2,096–3,189) bears, which is similar to an estimate from the 1990s. This result, along with robust cub production, suggests a stable and healthy population despite deteriorating sea ice conditions. Collectively, this and other recent on-land surveys provide a framework for implementing aerial surveys elsewhere. Although aerial surveys do not yield estimates of vital rates or population growth, they enable more rapid and frequent monitoring than mark-recapture. Integrating them in long-term monitoring programs will require consideration of ancillary data to infer status and facilitate setting harvest levels.

* Abbreviation: EI — : early intervention In the current issue of Pediatrics, Magnusson et al1 describe findings from 22 semistructured interviews with low-income African American and Hispanic mothers. The mothers discuss health beliefs that facilitate or impede engagement with early intervention (EI) services for their children after a positive screen for developmental delay in the primary care setting. From these interviews, the authors identify 5 themes: (1) comparisons with other children influence perceptions of their own children’s development, (2) perceptions that children develop at their own pace can lead mothers to believe their children are developing normally, (3) social networks inform decisions to seek services, (4) competing stressors are often prioritized over services, and (5) conflicting information about EI referral processes can discourage engagement with services. These health beliefs clearly have important consequences for individual patients. What may be less clear is the role such health beliefs can (and should) play in informing research and clinical approaches to developmental screening within US pediatric primary care delivery systems. The principal implication of Magnusson et al’s1 study is that it offers a series of evidence-informed hypotheses for why families sort into those who engage with developmental services and those who … Address correspondence to Michael Silverstein, MD, MPH, Department of Pediatrics, Boston Medical Center, 1 Boston Medical Center Pl, Vose Hall 3rd Floor, Boston, MA 02118. E-mail: michael.silverstein{at}bmc.org

We evaluated total mercury (THg) concentrations and trends in polar bears from the southern Beaufort Sea subpopulation from 2004 to 2011. Hair THg concentrations ranged widely among individuals from 0.6 to 13.3 μg g–1 dry weight (mean: 3.5 ± 0.2 μg g–1). Concentrations differed among sex and age classes: solitary adult females ≈ adult females with cubs ≈ subadults > adult males ≈ yearlings > cubs-of-the-year ≈ 2 year old dependent cubs. No variation was observed between spring and fall samples. For spring-sampled adults, THg concentrations declined by 13% per year, contrasting recent trends observed for other Western Hemispheric Arctic biota. Concentrations also declined by 15% per year considering adult males only, while a slower, nonsignificant decrease of 4.4% per year was found for adult females. Lower THg concentrations were associated with higher body mass index (BMI) and higher proportions of lower trophic position food resources consumed. Because BMI and diet were related, and the relationship to ...

Objective: Disparities persist in breastfeeding exclusivity and duration despite increases in breastfeeding initiation. The objective of this study was to examine factors that influence maternal decision making surrounding infant feeding practices over time in a diverse inner-city population. Methods: We conducted a prospective qualitative study with 20 mothers recruited from 2 urban primary care clinics. Participants completed open-ended interviews and demographic questionnaires in English or Spanish administered at approximately 2 weeks and 6 months postpartum. Transcripts were analyzed using a combined technique of inductive (data-driven) and deductive (theory-driven, based on the Theory of Planned Behavior) thematic analysis using 3 independent coders and iterative discussion to reach consensus. Results: All women initiated breastfeeding, and 65% reported perceived insufficient milk (PIM). An association between PIM and behavioral control emerged as the overarching theme impacting early breastfeeding cessation and evolved over time. Early postpartum, PIM evoked maternal distress—strong emotional responses to infant crying and need to control infant behaviors. Later, mothers accepted a perceived lack of control over milk supply with minimal distress or as a natural process. Decisions to stop breastfeeding occurred through an iterative process, informed by trials of various strategies and observations of subsequent changes in infant behavior, strongly influenced by competing psychosocial demands. Conclusion: Infant feeding decisions evolve over time and are influenced by perceptions of control over infant behavior and milk supply. Tailored anticipatory guidance is needed to provide time-sensitive strategies to cope with challenging infant behaviors and promote maternal agency over breastfeeding in low-income populations.

The February 2010 earthquake and tsunamis destroyed 80% of the coastal town of Dichato, Chile, displacing over 400 families for nearly 4 years. The coalition Recupera Chile (RC) participated in the town’s integrated recovery process from January 2011 to the present with a focus on children’s mental health. The multidisciplinary RC coalition emphasized community-led post-disaster recovery, economic capacity rebuilding, and community health promotion (www.recuperachile.org). RC’s child health team fostered partnerships between the local elementary school, health clinic, Universidad de Concepcion, and Boston Children’s Hospital. The team responded to priorities identified by the town with a three-pronged approach of (1) case management, (2) resource development, and (3) monitoring and evaluation. This work resulted in the development of a model school-based program: La Escuela Basada en Realidad, which encompassed (1) health and mental health, (2) language and literacy, and (3) love of the sea. Post-disaster programs targeting mental health require a multi-year approach that extends beyond the completion of the physical reconstruction. Recovery is an organic process that cannot be prescripted and depends on solutions that emerge from the community. Finally, partnerships between schools and universities can foster resiliency and sustainability of programs for children and families. (Disaster Med Public Health Preparedness. 2017;11:633–636)

Remains of bowhead whales (Balaena mysticetus) harvested by Inupiat whalers are deposited in bone piles along the coast of Alaska and have become persistent and reliable food sources for polar bears (Ursus maritimus). The importance of bone piles to individuals and the population, the patterns of use, and the number, sex, and age of bears using these resources are poorly understood. We implemented barbed-wire hair snaring to obtain genetic identities from bears using the Point Barrow bone pile in winter 2010–11. Eighty-three percent of genotyped samples produced individual and sex identification. We identified 97 bears from 200 samples. Using genetic mark–recapture techniques, we estimated that 228 bears used the bone pile during November to February, which would represent approximately 15% of the Southern Beaufort Sea polar bear subpopulation, if all bears were from this subpopulation. We found that polar bears of all age and sex classes simultaneously used the bone pile. More males than females...

Remote biopsy darting of polar bears (Ursus maritimus) is less invasive and time intensive than physical capture and is therefore useful when capture is challenging or unsafe. We worked with two manufacturers to develop a combination biopsy and marking dart for use on polar bears. We had an 80% success rate of collecting a tissue sample with a single biopsy dart and collected tissue samples from 143 polar bears on land, in water, and on sea ice. Dye marks ensured that 96% of the bears were not resampled during the same sampling period, and we recovered 96% of the darts fired. Biopsy heads with 5 mm diameters collected an average of 0.12 g of fur, tissue, and subcutaneous adipose tissue, while biopsy heads with 7 mm diameters collected an average of 0.32 g. Tissue samples were 99.3% successful (142 of 143 samples) in providing a genetic and sex identification of individuals. We had a 64% success rate collecting adipose tissue and we successfully examined fatty acid signatures in all adipose samples. Adipose lipid content values were lower compared to values from immobilized or harvested polar bears, indicating that our method was not suitable for quantifying adipose lipid content.

Bulimia nervosa is an eating disorder associated with a drive for thinness or frequent episodes of binge eating and harmful compensatory behaviors to avoid an increase in weight (American Psychiatric Association, 2000). A binge eating episode involves a lack of control over the intake of substantial amounts of food. Compensatory behaviors can include vomiting, laxatives, diuretics, fasting, and extreme exercise (Keel & Haedt, 2008; Shapiro et al., 2007). Characteristics of bulimia nervosa also include a severe concern with one's body shape and weight (Stefano, Bacaltchuk, Blay, & Hay, 2006) and perceptual distortion and extreme body dissatisfaction (Cash & Deagle, 1997). Cash and Deagle (1997) found that 73% of patients with bulimia nervosa perceived their body size to be larger than it actually was, and their body dissatisfaction attitudes exceeded 87% of the control participants. Hudson, Hiripi, Pope, and Kessler (2007) estimated that bulimia nervosa affected 0.5% of males and 1.5% of females over their lifetime, with prevalence rates increasing in recent generations. The estimated mean age of onset was 19.7 years, and the average duration of the disorder was 8.3 years (Hudson et al., 2007). Hudson and colleagues reported that 94.5% of participants with bulimia nervosa had at least one other diagnosed mental disorder, and most participants had received mental health assistance for other emotional issues. Seventy-eight percent of participants reported significant role impairments in their home, work, personal, or social life, and 43.9% reported a severe impairment. However, only 48.3% of individuals with bulimia nervosa sought treatment for their eating disorder. Although the full syndromal incidence of bulimia nervosa has been stable over time, the report of bulimia nervosa is on the rise. With less than half of those diagnosed seeking treatment, it is important to determine the most effective and accessible treatment modalities available to restore individuals to a healthy level of functioning. Common treatment approaches for bulimia nervosa include counseling/psychotherapy, pharmacotherapy, and guided self-help. There is debate over which approach is most effective. For example, many studies have reported the efficacy of counseling and psychotherapy in the treatment of bulimia nervosa (Fettes & Peters, 1992; Ghaderi & Anderson, 1999; Lewandowski, Gebing, Anthony, & O'Brien, 1997; Shapiro et al., 2007; Thompson-Brenner, Glass, & Westen, 2003; Whitbread & Mcgown, 1994; Whittal, Agras, & Gould, 1999). Although medication alone produced an initial positive result, Nakash-Eisikovits, Dierberger, and Westen (2002) concluded that the effects did not last, and better results were obtained when medication was combined with psychotherapy. Counseling/psychotherapy alone, as well as in combination with pharmacotherapy, requires highly trained mental health and/or medical professionals working in outpatient or inpatient facilities, and these treatments can be quite expensive. At the same time, there have been studies on client-directed (pure) self-help and therapist-directed guided self-help approaches, and clinical trials have yielded mixed results. Shapiro et al. (2007) reported that the guided self-help approach yielded smaller effects than psychotherapy, whereas Stefano et al. (2006) recommended the self-help approach as an effective and less expensive alternative to psychotherapy and medication for the treatment of bulimia nervosa. Significant advantages of the guided self-help approach are lower cost, convenience, and accessibility of services in rural locales. Counseling/psychotherapy was the most common treatment approach for clients with eating disorders, and effect sizes of clinical trials were generally positive (i.e., d > 0). Simultaneously, recent research also inconsistently supported the use of guided self-help, although far fewer clinical trials on this approach were reported. …

Until recently, the sea ice habitat of polar bears was understood to be variable, but environ- mental variability was considered to be cyclic or random, rather than progressive. Harvested populations were believed to be at levels where density effects were considered not significant. However, because we now understand that polar bear demography can also be influenced by progressive change in the environment, and some populations have increased to greater densities than historically lower numbers, a broader suite of factors should be considered in demographic studies and management. We analyzed 35 years of capture and harvest data from the polar bear (Ursus maritimus) subpopulation in Davis Strait, including data from a new study (2005-2007), to quantify its current demography. We estimated the population size in 2007 to be 2,158 � 180 (SE), a likely increase from the 1970s. We detected variation in survival, reproductive rates, and age-structure of polar bears from geographic sub-regions. Survival and reproduction of bears in southern Davis Strait was greater than in the north and tied to a concurrent dramatic increase in breeding harp seals (Pagophilus groenlandicus) in Labrador. The most supported survival models contained geographic and temporal variables. Harp seal abundance was significantly related to polar bear survival. Our estimates of declining harvest recovery rate, and increasing total survival, suggest that the rate of harvest declined over time. Low recruitment rates, average adult survival rates, and high population density, in an environment of high prey density, but deteriorating and variable ice conditions, currently characterize the Davis Strait polar bears. Low reproductive rates may reflect negative effects of greater densities or worsening ice conditions. Published 2012. This article is a U.S. Government work and is in the public domain in the USA.

Harvest of polar bears by aboriginal peoples has occurred for millennia across the circumpolar Arctic. While harvest for sport and the commercial fur trade increased dramatically as southerners expanded into the Arctic, the 1973 international Agreement for the Conservation of Polar Bears curtailed harvest largely to aboriginal peoples. This Agreement, catalyzed by global concern for declining polar bear populations, is a hallmark for international cooperation in conservation. In Russia, polar bear harvest has been illegal since 1957, although there are concerns of poaching by local people for food security and also for the black market fur trade. Norway banned all harvest with their ratification of the Agreement. The USA allows for polar bear harvest by the Inupiat of Alaska. Quotas for the two populations shared with the USA are determined by an international user-to-user agreement between aboriginal people of Alaska and Canada and an international agreement between the USA and Russia, respectively. In Greenland, polar bears are harvested by professional Inuit hunters under a quota system, currently based on historic numbers. In most of Canada, where two-thirds of the world’s polar bears are harvested, anyone can harvest a polar bear but only within a quota system assigned to and managed by Inuit communities. This harvest is based not only on scientific information, but also on historic levels by treaty and local traditional ecological knowledge. Globally, polar bear harvest averages 798 (44 SD) per year. The vast majority is for subsistence, with 6% for sport (Canada), and a lesser proportion for defense of life and property. The legal international market for polar bear hides is supplied only by exports from Canada. Climate change poses a greater threat to polar bears than do the current levels of harvest. However, habitat change and harvest interact because of the increasing use of land by polar bears. Further, there are scientific and conservation questions about the appropriateness of harvesting polar bears, even for subsistence, from populations that are declining due to climate change.

Randomized controlled trials, the gold standard, have been the backbone for 50 years of advancing medical knowledge to benefit patients.1 More recently, it has become the gold standard to test selected health policy, health systems, and even economic ideas. The article by Goff et al in this month’s Pediatrics is an example of an elegantly developed and implemented randomized controlled trial to evaluate the efficacy of patient navigators providing low-income prenatal patients with traditional quality measures of pediatric practices to see if it would inform their choice of pediatric care.2 The authors found that women in the intervention group were more likely to use this information presented by the navigator compared with a control group to make their decision to select a practice with higher clinical quality and patient experience scores. However, few women (5%) rated quality measures as among the most important factors in their selection. The authors conducted multiple additional analyses, including assessing potential effect modifiers with no important changes in findings. Given the labor-intensive approach of using patient navigators to get this marginal effect, it is unlikely to be implemented … Address correspondence to Barry Zuckerman, MD, East Concord St, Vose Building, Room 324L, Boston, MA 02118. E-mail: barry.zuckerman{at}bmc.org.

To: 1) examine sociodemographic factors associated with high parental self-efficacy and perceived control, and 2) determine how self-efficacy and control relate to the home learning environment (HLE), including whether they mediate the relationship between sociodemographic characteristics and HLE, among low-income parents of young children.Cross-sectional survey of English- and Spanish-speaking parents, 18 years of age and older, with children 15 to 36 months old, to assess parental self-efficacy, perceived control, HLE, and sociodemographic characteristics. Bivariate analysis identified sociodemographic predictors of high self-efficacy and control. Separate multivariate linear regression models were used to examine associations between self-efficacy, control, and the HLE. Formal path analysis was used to assess whether self-efficacy and control mediate the relationship between sociodemographic characteristics and HLE.Of 144 participants, 25% were white, 65% were immigrants, and 35% completed the survey in Spanish. US-born subjects, those who completed English surveys, or who had higher educational levels had significantly higher mean self-efficacy and perceived control scores (P .05). Higher self-efficacy and perceived control were associated with a positive change in HLE score in separate multivariate models (self-efficacy β = .7 [95% confidence interval (CI), 0.5-0.9]; control β = .5 [95% CI, 0.2-0.8]). Self-efficacy acted as a mediator such that low self-efficacy explained part of the association between parental depressive symptoms, immigrant status, and less optimal HLE (P = .04 and .001, respectively).High parental self-efficacy and perceived control positively influence HLEs of young children. Self-efficacy alone mediates the relationship between parental depressive symptoms, immigrant status, and less optimal early home learning.

Difficult infant temperament is associated with higher weight status in infancy. However, the association of infant temperament, including regulatory capacities, has not been well studied as a possible predictor of future weight status in early childhood. We examined prospective associations of infant regulatory difficulties with obesity in early childhood in a large, diverse cohort.We used data from 5750 children in the Early Childhood Longitudinal Study-Birth Cohort, excluding preterm infants and infants small or large for gestational age. Infant regulatory ability was measured at age 9 months by the Infant Toddler Symptom Checklist (ITSC). We created a multivariable logistic regression model comparing risk of obesity at preschool age in infants with ITSC scores ≥6 to infants with scores6. We further examined the association when stratified by a measure of maternal sensitivity.The cohort of children was 48% non-Hispanic white, and 51% were boys. Twenty-one percent of children with ITSC scores ≥6 were obese at preschool age. Infants with ITSC scores ≥6 had 32% increased odds of being obese at preschool age (adjusted odds ratio 1.32 [95% confidence interval 1.03, 1.70]). The strongest association existed among children described as demanding attention constantly. There was no difference in the association when comparing mothers with high or low maternal sensitivity.Infant regulatory difficulties are associated with a higher risk of obesity at preschool age. Helping parents manage and respond to difficult infant behaviors before preschool may serve as a focal point for future interventions.

Polar bears (Ursus maritimus) occupy remote regions that are characterized by harsh weather and limited access. Polar bear populations can only persist where temporal and spatial availability of sea ice provides adequate access to their marine mammal prey. Observed declines in sea ice availability will continue as long as greenhouse gas concentrations rise. At the same time, human intrusion and pollution levels in the Arctic are expected to increase. A circumpolar understanding of the cumulative impacts of current and future stressors is lacking, long-term trends are known from only a few subpopulations, and there is no globally coordinated effort to monitor effects of stressors. Here, we describe a framework for an integrated circumpolar monitoring plan to detect ongoing patterns, predict future trends, and identify the most vulnerable polar bear subpopulations. We recommend strategies for monitoring subpopulation abundance and trends, reproduction, survival, ecosystem change, human-caused morta...

One of the primary mechanisms by which sea ice loss is expected to affect polar bears is via reduced body condition and growth resulting from reduced access to prey. To date, negative effects of sea ice loss have been documented for two of 19 recognized populations. Effects of sea ice loss on other polar bear populations that differ in harvest rate, population density, and/or feeding ecology have been assumed, but empirical support, especially quantitative data on population size, demography, and/or body condition spanning two or more decades, have been lacking. We examined trends in body condition metrics of captured bears and relationships with summertime ice concentration between 1977 and 2010 for the Baffin Bay (BB) and Davis Strait (DS) polar bear populations. Polar bears in these regions occupy areas with annual sea ice that has decreased markedly starting in the 1990s. Despite differences in harvest rate, population density, sea ice concentration, and prey base, polar bears in both populations exhibited positive relationships between body condition and summertime sea ice cover during the recent period of sea ice decline. Furthermore, females and cubs exhibited relationships with sea ice that were not apparent during the earlier period (1977–1990s) when sea ice loss did not occur. We suggest that declining body condition in BB may be a result of recent declines in sea ice habitat. In DS, high population density and/or sea ice loss, may be responsible for the declines in body condition.

CONTEXT: No formal comparison has been made between the pediatric post–highly active antiretroviral therapy (HAART) outcomes of resource-limited and developed countries. OBJECTIVE: To systematically quantify and compare major baseline characteristics and clinical end points after HAART between resource-limited and developed settings. METHODS: Published articles and abstracts (International AIDS Society 2009, Conference on Retroviruses and Opportunistic Infections 2010) were examined from inception (first available publication for each search engine) to March 2010. Publications that contained data on post-HAART mortality, weight-for-age z score (WAZ), CD4 count, or viral load (VL) changes in pediatric populations were reviewed. Selected studies met the following criteria: (1) patients were younger than 21 years; (2) HAART was given (≥3 antiretroviral medications); and (3) there were >20 patients. Data were extracted for baseline age, CD4 count, VL, WAZ, and mortality, CD4 and virologic suppression over time. Studies were categorized as having been performed in a resource-limited country (RLC) or developed country (DC) on the basis of the United Nations designation. Mean percentage of deaths per cohort and deaths per 100 child-years, baseline CD4 count, VL, WAZ, and age were calculated for RLCs and DCs and compared by using independent samples t tests. RESULTS: Forty RLC and 28 DC publications were selected (N = 17 875 RLCs; N = 1835 DC). Mean percentage of deaths per cohort and mean deaths per 100 child-years after HAART were significantly higher in RLCs than DCs (7.6 vs 1.6, P < .001, and 8.0 vs 0.9, P < .001, respectively). Mean baseline CD4% was 12% in RLCs and 23% in DCs (P = .01). Mean baseline VLs were 5.5 vs 4.7 log10 copies per mL in RLCs versus DCs (P < .001). CONCLUSIONS: Baseline CD4% and VL differ markedly between DCs and RLCs, as does mortality after pediatric HAART. Earlier diagnosis and treatment of pediatric HIV in RLCs would be expected to result in better HAART outcomes.

The relative contribution of regional contamination versus dietary differences to geographic variation in polar bear (Ursus maritimus) contaminant levels is unknown. Dietary variation between Alaska, Canada, East Greenland, and Svalbard subpopulations was assessed by muscle nitrogen and carbon stable isotope (δ(15)N, δ(13)C) and adipose fatty acid (FA) signatures relative to their main prey (ringed seals). Western and southern Hudson Bay signatures were characterized by depleted δ(15)N and δ(13)C, lower proportions of C(20) and C(22) monounsaturated FAs and higher proportions of C(18) and longer chain polyunsaturated FAs. East Greenland and Svalbard signatures were reversed relative to Hudson Bay. Alaskan and Canadian Arctic signatures were intermediate. Between-subpopulation dietary differences predominated over interannual, seasonal, sex, or age variation. Among various brominated and chlorinated contaminants, diet signatures significantly explained variation in adipose levels of polybrominated diphenyl ether (PBDE) flame retardants (14-15%) and legacy PCBs (18-21%). However, dietary influence was contaminant class-specific, since only low or nonsignificant proportions of variation in organochlorine pesticide (e.g., chlordane) levels were explained by diet. Hudson Bay diet signatures were associated with lower PCB and PBDE levels, whereas East Greenland and Svalbard signatures were associated with higher levels. Understanding diet/food web factors is important to accurately interpret contaminant trends, particularly in a changing Arctic.

Two global environmental issues, climate change and contamination by persistent organic pollutants, represent major concerns for arctic ecosystems. Yet, it is unclear how these two stressors interact in the Arctic. For instance, the influence of climate-associated changes in food web structure on exposure to pollutants within arctic ecosystems is presently unknown. Here, we report on recent changes in feeding ecology (1991-2007) in polar bears (Ursus maritimus) from the western Hudson Bay subpopulation that have resulted in increases in the tissue concentrations of several chlorinated and brominated contaminants. Differences in timing of the annual sea ice breakup explained a significant proportion of the diet variation among years. As expected from climate change predictions, this diet change was consistent with an increase in the consumed proportions of open water-associated seal species compared to ice-associated seal species in years of earlier sea ice breakup. Our results demonstrate that climate change is a modulating influence on contaminants in this polar bear subpopulation and may pose an additional and previously unidentified threat to northern ecosystems through altered exposures to contaminants.