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Adults with autism spectrum disorder (ASD) demonstrate low levels of community participation, though no studies have examined the perceived value and satisfaction when assessing community participation among young adults with ASD. Using the Temple University Community Participation measure, young adults with and without ASD were compared on the frequency, perceived importance, and satisfaction of community participation. Adults with ASD participated less frequently in participation areas and identified fewer important participation areas. Importantly, no differences were reported in satisfaction with participation between the two groups despite adults with ASD participating less frequently in the community. Results suggest a need for further exploration of predictors of poor community participation in adults with ASD, as well as effective interventions targeting community participation in this population.

Background and study aims Transoral incisionless fundoplication (TIF) is a safe and effective minimally invasive endoscopic technique for treating gastroesophageal reflux disease (GERD). The learning curve for this technique has not been reported. We studied the learning curve for TIF when performed by a gastroenterologist by identifying the threshold number of procedures needed to achieve consistent technical success or proficiency (consistent creation of TIF valve ≥ 270 degrees in circumference, ≥ 2 cm long) and efficiency after didactic, hands-on and case observation experience. Patients and methods We analyzed prospectively collected data from patients who had TIF performed by a single therapeutic endoscopist within 17 months after basic training. We determined thresholds for procedural learning using cumulative sum of means (CUSUM) analysis to detect changes in achievement rates over time. We used breakpoint analysis to calculate procedure metrics related to proficiency and efficiency. Results A total of 69 patients had 72 TIFs. The most common indications were refractory GERD (44.7 %) and proton pump inhbitor intolerance (23.6 %). Proficiency was achieved at the 18th to 20th procedure. The maximum efficiency for performing a plication was achieved after the 26th procedure, when mean time per plication decreased to 2.7 from 5.1 minutes (P Conclusions TIF can be safely, successfully, and efficiently performed in the endoscopy suite by a therapeutic endoscopist. The TIF learning curve is steep but proficiency can be achieved after a basic training experience and 18 to 20 independently performed procedures.

Parasitism of cephalopods is common, including infection with Aggregata spp., Ichthyobodo spp., dicyemids, cestodes of the orders Tetraphyllidea and Trypanorhynchidea, and various crustaceans. Cestodiasis in octopuses is reported, although a full histologic description of lesions has not been previously described. Cestodiasis was identified in 10 octopuses of 4 different species, which included 4 common octopuses ( Octopus vulgaris), 3 Caribbean reef octopuses ( Octopus briareus), 2 two-spot octopuses ( Octopus bimaculoides), and 1 giant Pacific octopus ( Enteroctopus dofleini). Larval cestodes were present in the cecum ( n = 5), intestines ( n = 4), digestive gland ( n = 3), chitinous alimentary tract ( n = 2), renal appendage ( n = 1), and salivary duct ( n = 1). In 5 cases, larval cestodes invaded tissue and were associated with hemocytic inflammation and tracts of necrotic tissue in the intestines ( n = 3), digestive gland ( n = 3), and/or renal appendage ( n = 1). When present in the chitinous alimentary tract (esophagus, stomach) or cecum, larval cestodes were in the central lumen and not associated with lesions. One adult cestode was identified in the mantle cavity and was not associated with lesions. Other common concurrent parasitic infections included enteric Aggregata spp. infection, branchial Rickettsia-like organism infection, enteric nematodiasis, and an arthropod-associated branchitis.

Sea otters (Enhydra lutris) demonstrate rapid, accurate tactile abilities using their paws and facial vibrissae. Anatomical investigations of neural organization in the vibrissal bed and somatosensory cortex coincide with measured sensitivity, but no studies describe sensory receptors in the paws or other regions of glabrous (i.e., hairless) skin. In this study, we use histology to assess the presence, density, and distribution of mechanoreceptors in the glabrous skin of sea otters: paws, rhinarium, lips, and flipper digits, and we use scanning electron microscopy to describe skin-surface texture and its potential effect on the transduction of mechanical stimuli. Our results confirm the presence of Merkel cells and Pacinian corpuscles, but not Meissner corpuscles, in all sea otter glabrous skin. The paws showed the highest density of Merkel cells and Pacinian corpuscles. Within the paw, relative densities of mechanoreceptor types were highest in the distal metacarpal pad and digits, which suggests that the distal paw is a tactile fovea for sea otters. In addition to the highest receptor density, the paw displayed the thickest epidermis. Rete ridges (epidermal projections into the dermis) and dermal papillae (dermal projections into the epidermis) were developed across all glabrous skin. These quantitative and qualitative descriptions of neural organization and physical features, combined with previous behavioral results, contribute to our understanding of how structure relates to function in the tactile modality. Our findings coincide with behavioral observations of sea otters, which use touch to maintain thermoregulatory integrity of their fur, explore objects, and capture visually cryptic prey.

OBJECTIVE To compare serum cardiac troponin I (cTnI) concentrations between sea otters with and without cardiomyopathy and describe 2 cases of cardiomyopathy with different etiologies. ANIMALS 25 free-ranging southern sea otters (Enhydra lutris nereis) with (n = 14; cases) and without (11; controls) cardiomyopathy and 17 healthy managed southern sea otters from aquariums or rehabilitation centers (controls). PROCEDURES Serum cTnI concentration was measured in live sea otters. Histopathologic and gross necropsy findings were used to classify cardiomyopathy status in free-ranging otters; physical examination and echocardiography were used to assess health status of managed otters. Two otters received extensive medical evaluations under managed care, including diagnostic imaging, serial cTnI concentration measurement, and necropsy. RESULTS A significant difference in cTnI concentrations was observed between cases and both control groups, with median values of 0.279 ng/mL for cases and < 0.006 ng/mL for free-ranging and managed controls. A cutoff value of ≥ 0.037 ng/mL yielded respective sensitivity and specificity estimates for detection of cardiomyopathy of 64.3% and 90.9% for free-ranging cases versus free-ranging controls and 64.3% and 94.1% for free-ranging cases versus managed controls. CONCLUSIONS AND CLINICAL RELEVANCE Cardiomyopathy is a common cause of sea otter death that has been associated with domoic acid exposure and protozoal infection. Antemortem diagnostic tests are needed to identify cardiac damage. Results suggested that serum cTnI concentration has promise as a biomarker for detection of cardiomyopathy in sea otters. Serial cTnI concentration measurements and diagnostic imaging are recommended to improve heart disease diagnosis in managed care settings.

The 2016 National Academies of Science, Engineering and Medicine report included a proposal to establish a National Trauma Research Action Plan. In response, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care from prehospital care to rehabilitation as part of an overall strategy to achieve zero preventable deaths and disability after injury. The Postadmission Critical Care Research panel was 1 of 11 panels constituted to develop this research agenda.We recruited interdisciplinary experts in surgical critical care and recruited them to identify current gaps in clinical critical care research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. The first of four survey rounds asked participants to generate key research questions. On subsequent rounds, we asked survey participants to rank the priority of each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category.Twenty-five subject matter experts generated 595 questions. By Round 3, 249 questions reached ≥60% consensus. Of these, 22 questions were high, 185 were medium, and 42 were low priority. The clinical states of hypovolemic shock and delirium were most represented in the high-priority questions. Traumatic brain injury was the only specific injury pattern with a high-priority question.The National Trauma Research Action Plan critical care research panel identified 22 high-priority research questions, which, if answered, would reduce preventable death and disability after injury.Diagnostic Tests or Criteria; Level IV.

Using the 2008-2013 Medicaid Analytic eXtract files, this retrospective cohort study was to evaluate the effect of Medicaid home and community-based services (HCBS) waiver programs on emergency department (ED) utilizations among youth with autism spectrum disorder (ASD). Our study showed that the annual ED utilization rates were 13.5% and 18.8% for individuals on autism specific and intellectual and developmental disabilities (IDD) waivers respectively, vs. 28.5% for those without a waiver. Multivariable logistic regression showed that, compared to no waiver, autism specific waivers (adjusted odds ratio: 0.62; 95% Confidence Interval: [0.58-0.66]) and IDD waivers (0.65; [0.64-0.66]) were strongly associated with reduced ED. These findings suggest that HCBS waivers are effective in reducing the incidence of ED visits among youth with ASD.

Reliable age estimation is an essential tool to assess the status of wildlife populations and inform successful management. Aging methods, however, are often limited by too few data, skewed demographic representation, and by single or uncertain morphometric relationships. In this study, we synthesize age estimates in southern sea otters Enhydra lutris nereis from 761 individuals across 34 years of study, using multiple noninvasive techniques and capturing all life stages from 0 to 17 years of age. From wild, stranded, and captive individuals, we describe tooth eruptions, tooth wear, body length, nose scarring, and pelage coloration across ontogeny and fit sex‐based growth functions to the data. Dental eruption schedules provided reliable and identifiable metrics spanning 0.3–9 months. Tooth wear was the most reliable predictor of age of individuals aged 1–15 years, which when combined with total length, explained >93% of observed age. Beyond age estimation, dental attrition also indicated the maximum lifespan of adult teeth is 13‒17 years, corresponding with previous estimates of life expectancy. Von Bertalanffy growth function model simulations of length at age gave consistent estimates of asymptotic lengths (male Loo = 126.0‒126.8 cm, female Loo = 115.3‒115.7 cm), biologically realistic gestation periods (t 0 = 115 days, SD = 10.2), and somatic growth (male k = 1.8, SD = 0.1; female k = 2.1, SD = 0.1). Though exploratory, we describe how field radiographic imaging of epiphyseal plate development or fusions may improve aging of immature sea otters. Together, our results highlight the value of integrating information from multiple and diverse datasets to help resolve conservation problems., By synthesizing more than two decades of southern sea otter physical examination data from strandings, captive‐rearing for release, and field studies, we provide strong support for adopting minimally invasive aging techniques based on metrics obtainable during brief field capture. These techniques provide the means to gather age‐specific information from a living, wild population to inform management decisions focused on restoring sea otters and their ecosystems throughout California. Our results also highlight the value of integrating information from multiple and diverse datasets to help resolve conservation problems.

In this essay we respond to the comments of Tom McCall, William Lane Craig, and Stephen C. Meyer on mere theistic evolution.

A key takeaway from the recent volume Theistic Evolution: A Scientific, Philosophical, and Theological Critique is that no version of theistic evolution that adheres largely to consensus views in biology is a plausible option for orthodox Christians. In this paper we argue that this is false: contrary to the arguments in the volume, evolutionary theory, properly understood, is perfectly compatible with traditional Christian commitments. In addition, we argue that the lines between Intelligent Design and theistic evolution are not as sharp as most scholars have assumed, such that many who self-identify as Intelligent Design adherents would also qualify as theistic evolutionists.

Southern sea otter (Enhydra lutris nereis) population recovery is influenced by a variety of factors, including predation, biotoxin exposure, infectious disease, oil spills, habitat degradation, and resource limitation. This population has also experienced a significant genetic bottleneck, resulting in low genetic diversity. We investigated how two metrics, familial relatedness and genetic diversity, are correlated with common causes of mortality in southern sea otters, including cardiomyopathy, acanthocephalan (Profilicollis spp.) peritonitis, systemic protozoal infection (Toxoplasma gondii and Sarcocystis neurona), domoic acid intoxication, end-lactation syndrome, and shark bite. Microsatellite genetic markers were used to examine this association in 356 southern sea otters necropsied from 1998 to 2012. Significant associations with genetic diversity or familial relatedness (P

Objective: Patients with laryngopharyngeal reflux (LPR) symptoms may not respond to proton pump inhibitors (PPI) if they have an alternative laryngeal diagnosis or high-volume reflux. Transoral incisionless fundoplication (TIF) or TIF with concomitant hiatal hernia repair (cTIF) are effective in decreasing symptoms of gastroesophageal reflux disease (GERD) but are not well studied in patients with LPR symptoms. This prospective multicenter study assessed the patient-reported and clinical outcomes after TIF/cTIF in patients with LPR symptoms and proven GERD. Methods: Patients with refractory LPR symptoms (reflux symptom index [RSI] > 13) and with erosive esophagitis, Barrett’s esophagus, and/or pathologic acid reflux by distal esophageal pH testing were evaluated before and after a minimum of 6 months after TIF/cTIF. The primary outcome was normalization of RSI. Secondary outcomes were >50% improvement in GERD-Health-Related Quality of Life (GERD-HRQL), normalization of esophageal acid exposure time, discontinuation of PPI, and patient satisfaction. Results: Forty-nine patients had TIF (n = 26) or cTIF (n = 23) with at least 6 months follow-up. Mean pre- and post TIF/cTIF RSI were 23.6 and 5.9 (mean difference: 17.7, P Conclusion: In patients with objective evidence of GERD, TIF, or cTIF are safe and effective in controlling LPR symptoms as measured by normalization of RSI and improvement in patient satisfaction after TIF/cTIF. Level of Evidence Level 4

Translocation and rehabilitation programmes are critical tools for wildlife conservation. These methods achieve greater impact when integrated in a combined strategy for enhancing population or ecosystem restoration. During 2002–2016 we reared 37 orphaned southern sea otter Enhydra lutris nereis pups, using captive sea otters as surrogate mothers, then released them into a degraded coastal estuary. As a keystone species, observed increases in the local sea otter population unsurprisingly brought many ecosystem benefits. The role that surrogate-reared otters played in this success story, however, remained uncertain. To resolve this, we developed an individual-based model of the local population using surveyed individual fates (survival and reproduction) of surrogate-reared and wild-captured otters, and modelled estimates of immigration. Estimates derived from a decade of population monitoring indicated that surrogate-reared and wild sea otters had similar reproductive and survival rates. This was true for males and females, across all ages (1–13 years) and locations evaluated. The model simulations indicated that reconstructed counts of the wild population are best explained by surrogate-reared otters combined with low levels of unassisted immigration. In addition, the model shows that 55% of observed population growth over this period is attributable to surrogate-reared otters and their wild progeny. Together, our results indicate that the integration of surrogacy methods and reintroduction of juvenile sea otters helped establish a biologically successful population and restore a once-impaired ecosystem.

Sleep disturbances (SD) are prevalent in individuals diagnosed with Autism Spectrum Disorder (ASD). Less is known about the effects of SD on cognition and learning in adolescents with high-functioning ASD (HF-ASD). Adolescents with HF-ASD (N = 96) were evaluated for the relationships of SD to working memory and learning problems. Results found SD to modify the relationship between working memory and learning problems. Working memory deficits were associated with learning problems among those with SD, while not among those without SD. SD and working memory deficits should be targeted in interventions for these adolescents with HF-ASD (e.g., cognitive behavior therapy for insomnia, pharmacological treatments). Future studies should examine if improvement in SD reduces the impact of working memory deficits on learning problems.

Background In recent years, most U.S. states have passed autism mandates requiring private insurers to cover autism spectrum disorders (ASD). Little is known about the post-mandate changes in healthcare expenditures. Method This study utilized 2006–2012 de-identified insurance claims data from the largest private insurer in Pennsylvania (PA), where the mandate went into effect in mid 2009. Healthcare expenditures were defined as the amount the insurer paid for healthcare services and were adjusted to 2012 price level. A mixed effects model was used to analyze the expenditures. Results A total of 9471 children with ASD were included. Although the pre-mandate total expenditures per child with ASD were similar, the post-mandate expenditures significantly increased for groups subject to the autism mandate (87% increase from $7754 in 2008 to $14,486 in 2010) compared to the exempt groups (27% increase from $7238 to $9171). By insurance type, the change from 2008 to 2010 in ASD-related expenditures per child with ASD was $8439 for fully insured large employer sponsored plans and $43 for the Children’s Health Insurance Program (CHIP), both subject to the PA mandate; and $2631 for the self-insured, $980 for small-employers, and $-92 for individual plans, all of which are exempt from the mandate. These increases were due to outpatient services but not inpatient or drug costs. Conclusions Healthcare expenditures increased significantly following the PA autism mandate. Nonexempt, large employer groups had the largest increase in spending. Some exempt, self-insured companies may have voluntarily covered ASD services, leading to a moderate increase.

Information about antemortem cardiac evaluation in sea otters (Enhydra lutris) is limited, despite well-established clinical care and rehabilitation procedures and a reported elevated risk of cardiac disease for this species. Serum cardiac troponin I (cTnI) concentration and echocardiographic assessment are two ways of screening for and diagnosing cardiac disease. However, no baseline data or reference intervals for either evaluation are published for sea otters. The objectives of this prospective study were to establish serum cTnI concentrations and echocardiographic technique and quantitative measurements in anesthetized healthy female southern sea otters (Enhydra lutris nereis) (n=15). Serum cTnI values were assessed by a high-sensitivity assay. Serum cTnI concentration ranged from

Southern sea otters (SSO: Enhydra lutris nereis) are a federally-listed threatened subspecies found almost exclusively in California, USA. Despite their zoonotic potential and lack of host specificity, K. pneumoniae and Klebsiella spp. have largely unknown epizootiology in SSOs. Klebsiella pneumoniae is occasionally isolated at necropsy, but not from live SSOs. Hypermucoviscous (HMV) K. pneumoniae strains are confirmed pathogens of Pacific Basin pinnipeds, but have not been previously isolated from SSOs. We characterized the virulence profiles of K. pneumoniae isolates from necropsied SSOs, evaluated killing of marine mammal K. pneumoniae following in vitro exposure to California sea lion (CSL: Zalophanus californianus) whole blood and serum, and characterized lesion patterns associated with Klebsiella spp. infection in SSOs. Four of 15 SSO K. pneumoniae isolates were HMV and all were recovered from SSOs that stranded during 2005. Many K. pneumoniae infections were associated with moderate to severe pathology as a cause of death or sequela. All HMV infections were assessed as a primary cause of death or as a direct result of the primary cause of death. Klebsiella-infected SSOs exhibited bronchopneumonia, tracheobronchitis and/or pleuritis, enteritis, Profilicollis sp. acanthocephalan peritonitis, septic peritonitis, and septicemia. All SSO HMV isolates were capsular type K2, the serotype most associated with HMV infections in CSLs. Multiplex PCR revealed two distinct virulence gene profiles within HMV isolates and two within non-HMV isolates. In vitro experiments investigating CSL whole blood and serum killing of K. pneumoniae suggest that HMV isolates are more resistant to serum killing than non-HMV isolates.

The marine biotoxin domoic acid (DA) is an analog of the neurotransmitter glutamate that exerts potent excitatory activity in the brain, heart, and other tissues. Produced by the diatomPseudo-nitzschiaspp., DA accumulates in marine invertebrates, fish, and sediment. Southern sea otters (Enhydra lutris nereis) feed primarily on invertebrates, including crabs and bivalves, that concentrate and slowly depurate DA. Due to their high prey consumption (25% of body weight/day), sea otters are commonly exposed to DA. A total of 823 necropsied southern sea otters were examined to complete this study; first we assessed 560 subadult, adult, and aged adult southern sea otters sampled from 1998 through 2012 for DA-associated pathology, focusing mainly on the central nervous system (CNS) and cardiovascular system. We applied what was learned to an additional cohort of necropsied sea otters of all demographics (including fetuses, pups, juveniles, and otters examined after 2012:n= 263 additional animals). Key findings derived from our initial efforts were consistently observed in this more demographically diverse cohort. Finally, we assessed the chronicity of DA-associated pathology in the CNS and heart independently for 54 adult and aged adult sea otters. Our goals were to compare the temporal consistency of DA-associated CNS and cardiovascular lesions and determine whether multiple episodes of DA toxicosis could be detected on histopathology. Sea otters with acute, fatal DA toxicosis typically presented with neurological signs and severe, diffuse congestion and multifocal microscopic hemorrhages (microhemorrhages) in the brain, spinal cord, cardiovascular system, and eyes. The congestion and microhemorrhages were associated with detection of high concentrations of DA in postmortem urine or gastrointestinal content and preceded histological detection of cellular necrosis or apoptosis. Cases of chronic DA toxicosis often presented with cardiovascular pathology that was more severe than the CNS pathology; however, the lesions at both sites were relatively quiescent, reflecting previous damage. Sea otters with fatal subacute DA toxicosis exhibited concurrent CNS and cardiovascular pathology that was characterized by progressive lesion expansion and host response to DA-associated tissue damage. Acute, subacute, and chronic cases had the same lesion distribution in the CNS and heart. CNS pathology was common in the hippocampus, olfactory, entorhinal and parahippocampal cortex, periventricular neuropil, and ventricles. The circumventricular organs were identified as important DA targets; microscopic examination of the pituitary gland, area postrema, other circumventricular organs, and both eyes facilitated confirmation of acute DA toxicosis in sea otters. DA-associated histopathology was also common in cardiomyocytes and coronary arterioles, especially in the left ventricular free wall, papillary muscles, cardiac apex, and atrial free walls. Progressive cardiomyocyte loss and arteriosclerosis occurred in the same areas, suggesting a common underlying mechanism. The temporal stage of DA-associated CNS pathology matched the DA-associated cardiac pathology in 87% (n= 47/54) of cases assessed for chronicity, suggesting that the same underlying process (e.g., DA toxicosis) was the cause of these lesions. This temporally matched pattern is also indicative of a single episode of DA toxicosis. The other 13% of examined otters (n= 7/54) exhibited overlapping acute, subacute, or chronic DA pathology in the CNS and heart, suggestive of recurrent DA toxicosis. This is the first rigorous case definition to facilitate diagnosis of DA toxicosis in sea otters. Diagnosing this common but often occult condition is important for improving clinical care and assessing population-level impacts of DA exposure in this federally listed threatened subspecies. Because the most likely source of toxin is through prey consumption, and because humans, sea otters, and other animals consume the same marine foods, our efforts to characterize health effects of DA exposure in southern sea otters can provide strong collateral benefits.

Using the 2008-2013 Medicaid Analytic eXtract files, this retrospective cohort study was to evaluate the effect of Medicaid home and community-based services (HCBS) waiver programs on emergency department (ED) utilizations among youth with autism spectrum disorder (ASD). Our study showed that the annual ED utilization rates were 13.5% and 18.8% for individuals on autism specific and intellectual and developmental disabilities (IDD) waivers respectively, vs. 28.5% for those without a waiver. Multivariable logistic regression showed that, compared to no waiver, autism specific waivers (adjusted odds ratio: 0.62; 95% Confidence Interval: [0.58-0.66]) and IDD waivers (0.65; [0.64-0.66]) were strongly associated with reduced ED. These findings suggest that HCBS waivers are effective in reducing the incidence of ED visits among youth with ASD.

The COVID-19 infectious disease pandemic has caused significant fear and uncertainty around the world and had significant adverse psychological impact. Children, adolescents and adults with autism spectrum disorder (ASD) are a particularly vulnerable population, impacted by stay-at-home orders, closures at nonessential services, and social distancing standards. This commentary describes various challenges faced by individuals with ASD in the United States including disruptions caused by educational and vocational changes, challenges to home and leisure routines, limited access to behavioral health services and changes in health services delivery due to the pandemic. We highlight the need for ongoing skills development for individuals and development within systems to better respond to needs of the ASD population in future emergencies.