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Objective: To assess thermal-sensory thresholds and psychosocial factors in children with Complex Regional Pain Syndrome Type 1 (CRPS-I) compared to healthy children. Methods: We conducted quantitative sensory testing on 34 children with CRPS-I and 56 pain-free children. Warm, cool, heat, and cold stimuli were applied to the forearm. Children with CRPS-I had the protocol administered to the pain site and the contralateral-pain site. Participants completed the self-report Behavior Assessment System for Children. Results: Longer pain durations (>5.1 months) were associated with decreased sensitivity to cold pain on the pain site ( P = .04). Higher pain-intensity ratings were associated with elevated anxiety scores ( P = .03). Anxiety and social stress were associated with warmth sensitivity (both P < .05) on the contralateral-pain site. Conclusions: Pain duration is an important factor in assessing pediatric CRPS-I. Hyposensitivity in the affected limb may emerge due to degeneration of nociceptive nerves. Anxiety may contribute to thermal-sensory perception in childhood CRPS-I.

Average annual temperatures in the Arctic increased by 2–3 °C during the second half of the twentieth century. Because shorebirds initiate northward migration to Arctic nesting sites based on cues at distant wintering grounds, climate-driven changes in the phenology of Arctic invertebrates may lead to a mismatch between the nutritional demands of shorebirds and the invertebrate prey essential for egg formation and subsequent chick survival. To explore the environmental drivers affecting invertebrate availability, we modeled the biomass of invertebrates captured in modified Malaise-pitfall traps over three summers at eight Arctic Shorebird Demographics Network sites as a function of accumulated degree-days and other weather variables. To assess climate-driven changes in invertebrate phenology, we used data from the nearest long-term weather stations to hindcast invertebrate availability over 63 summers, 1950–2012. Our results confirmed the importance of both accumulated and daily temperatures as predictors of invertebrate availability while also showing that wind speed negatively affected invertebrate availability at the majority of sites. Additionally, our results suggest that seasonal prey availability for Arctic shorebirds is occurring earlier and that the potential for trophic mismatch is greatest at the northernmost sites, where hindcast invertebrate phenology advanced by approximately 1–2.5 days per decade. Phenological mismatch could have long-term population-level effects on shorebird species that are unable to adjust their breeding schedules to the increasingly earlier invertebrate phenologies.

The Fontan operation remains the final palliation for thousands of patients with complex congenital heart disease. By creating a Fontan circuit, control of cardiac output and congestion is wrested away from the ventricle and new haemodynamic forces take control. Understanding how to control the flow in the Fontan circuit will enable clinicians to improve patient management and possibly prevent future complications. CONCLUSION: This review proposes a framework of principles to conceptualise the functionality and limitations of a Fontan circulation. ispartof: ACTA PAEDIATRICA vol:109 issue:4 pages:651-658 ispartof: location:Norway status: published

Background Studies have been conducted describing the potential for using virtual care software during disasters and public health emergencies. However, limited data exist on ways in which the Canadian health care system utilizes virtual care during disasters or public health emergencies. Aims Due to the need for social distancing and reduction of nonessential ambulatory services during the COVID-19 pandemic, the SickKids Chronic Pain Clinic sought to transition care delivery from in person to virtual. The virtual clinic aimed to reduce risks associated with physical contact and environmental exposure without reducing access to care itself. Methods Harnessing of various digital tools including Ontario Telemedicine Network Guestlink, Zoom, and Microsoft Teams. The Chronic Pain Clinic Team worked together to communicate with patients and families, schedule virtual visits, establish remote access to clinical data collection tools, digitize the after-visit summary, and add resources on pain self-management to the clinic’s website. Results The Chronic Pain Clinic successfully transitioned all clinic appointments (multidisciplinary and individual; 77 appointments) over a 2-week period to virtual care. Virtual clinics did not surpass the usual time taken pre-COVID-19, suggesting that the clinic workflow was readily adaptable to virtual care. Conclusions Access to quality virtual care is essential to prevent chronic pain from taking a toll on the lives of patients and families. Rapid establishment of a virtual clinic without gaps in service delivery to patients is possible given institutional support and a team culture centered around collaboration and flexibility.

Introduction: Children with congenital heart disease (CHD) are at higher risk for developmental delays than the general population. The American Heart Association (AHA) published a guideline to address these concerns in 2012. This study determined the neurodevelopmental evaluation and referral practices of practitioners in central South Africa. Method: An online survey was administered to practitioners (n=45) including paediatric cardiologists (n=4), cardiothoracic surgeons (n=4) and general paediatricians (n=37). Information on practitioner characteristics, awareness of the 2012 AHA guideline; and neurodevelopmental evaluation and referral practices was collected. Results: Twenty-one practitioners responded, including paediatric cardiologists (n=4), cardiothoracic surgeons (n=2) and paediatricians (n=15). Data for 20 practitioners was included. Despite most practitioners (n=18) indicating guidelines for the management of development were important, the majority (n=16; 80%) were unaware of the guideline. Most practitioners (n=18; 90%) failed to risk stratify children to identify those to be evaluated. Children with developmental delays were referred for formal developmental evaluation (n=11; 55%) and to intervention therapies (n= 15; 75%). Conclusion: Most practitioners are unaware of the 2012 AHA guideline. Awareness of the developmental risks associated with CHD and implementation of the guideline could promote early identification of developmental delays with referral to intervention therapies.

Co-administration of human secretory IgA (sIgA) together with subtherapeutic vancomycin significantly enhanced survival in the Clostridioides difficile infection (CDI) hamster model . Vancomycin (5 or 10 mg/kgx5 days) + healthy donor plasma sIgA/monomeric IgA (TIDx21 days) or hyperimmune sIgA/monomeric IgA (BIDx13 days) enhanced survival of CDI hamsters. Survival curves were significantly improved compared to vancomycin alone (p=0.018 and 0.039 by log-rank (Mantel-Cox) for healthy, and hyperimmune, sIgA, respectively. Passive immunization with sIgA made with recombinant human secretory component and IgA dimer/polymer from pooled human plasma can be administered orally, and prevents lethal infection in a partially treated CDI hamster model.

Coronavirus 2 (SARS-CoV-2) the causative agent of what we now know as “Coronavirus Disease 2019” (COVID-19), is the most serious global health crisis of our generation, with a significant and far-reaching impact upon health, economy, social cohesion and emotional and mental wellbeing. Although children do not bear the brunt of direct mortality, they are significantly affected in terms of morbidity and interruption to access, continuity and complexity of care, as well as the indirect social and financial effects impacting on their health outcomes. In this review we present some of the most recent data relevant to children with congenital and acquired heart disease, and consider some of the cardiac presentations noted. We discuss the necessary protections to staff in the echo and cardiac catherisation laboratories and present some general recommendations to general paediatricians and communities to ensure the continued health of our patients. Finally, we encourage ongoing registries and biorepositories and support clinical trials to ensure that children also receive new technologies and therapeutics as these become available.

The degree to which individuals migrate among particular breeding, migration, and wintering sites can have important implications for prioritizing conservation efforts. Four subspecies of Dunlin (Calidris alpina) migrate along the East Asian-Australasian Flyway. Each subspecies has a distinct and well-defined breeding range, but their migration and winter ranges are poorly defined or unknown. We assessed the migratory connectivity of 3 of these subspecies by evaluating a dataset that encompasses 57 yr (1960-2017), and comprises more than 28,000 Dunlin banding records and 818 observations (71 recaptures and 747 band resightings). We present some of the first evidence that subspecific segregation likely occurs, with arcticola Dunlin wintering in areas of Japan, and other arcticola, actites, and sakhalina Dunlin wintering in areas of the Yellow and China seas. Observations indicate that whether an arcticola Dunlin winters in Japan or the Yellow and China seas is independent of their breeding location, sex, or age. Furthermore, observations indicate that ≥83% of arcticola Dunlin exhibit interannual site fidelity to specific wintering sites. This suggests that the degradation of specific wetland areas may negatively affect particular individuals of a particular subspecies (or combination of subspecies), and, if widespread, could result in population declines. Given the possible biases inherent in analyzing band recovery data, we recommend additional flyway-wide collaboration and the use of lightweight tracking devices and morphological and genetic assignment techniques to better quantify subspecies' migratory movements and nonbreeding distributions. This information, when combined, will enable effective conservation efforts for this species across the East Asian-Australasian Flyway. LAY SUMMARY The East Asian-Australasian Flyway has more threatened and near-Threatened migratory waterbird species than any other flyway in the world; however, developing flyway conservation plans has been challenging, in part due to limited information regarding population-specific migration patterns. Four subspecies of Dunlin migrate and winter along the East Asian-Australasian Flyway. Each has a well-defined breeding range; their migration and winter ranges are poorly defined or unknown. We assessed the migratory connectivity of 3 subspecies using data from 57 yr (1960-2017), which comprises more than 28,000 Dunlin banding records, 71 recaptures, and 747 band resightings. Subspecific segregation likely occurs, with arcticola Dunlin wintering in Japan, and other arcticola, actites, and sakhalina Dunlin wintering in the Yellow and China seas. It is likely that ≥83% of arcticola Dunlin exhibit interannual site fidelity to specific wintering sites. Our findings suggest that degradation of specific wetland areas may negatively affect particular individuals of a particular subspecies (or combination of subspecies) and could result in population declines.

Hereditary haemorrhagic telangiectasia (HHT) is supposedly rare in Africa, with only three pathogenic variants documented to date. We describe the clinical and genetic features of HHT patients in central South Africa, who fulfilled the Curacao criteria. Sixteen patients (median age 38.5 years, range 12–65 years), from six families were included. Fifteen patients were of African descent and one was of Afrikaner descent. The mean epistaxis severity score was 3.18, and the median haemoglobin was 9.5 g/dL (range 3.5–13.5 g/dL). On transthoracic contrast echocardiography 69% had a shunt grade ≥ 1, but only 20% had pulmonary arteriovenous malformations (AVMs) on computed tomography of the chest. Hepatic AVMs were found in 13% of patients, while 13% had brain vascular malformations. Four patients were HIV positive, of whom two had worsening epistaxis while they had opportunistic infections and poor HIV control. We identified six pathogenic variants (four in ENG and two in ACVRL1) in the six probands, three of which had been described previously. Three variants have apparently not been reported previously: ENG c.[1336_1337dup];[ =] p.[(Asp446fs)];[( =)], ENG c.[ 690?_816+?del] p.[(?)], and ACVRL1 c.[268_274delins57];[ =] p.[(Cys90fs)];[( =)]. We confirmed the diagnosis of HHT in sixteen patients and identified pathogenic variants in ENG or ACVRL1 in all six probands in central South Africa, where HHT has been underreported. We describe three pathogenic variants: two of ENG and one of ACVRL1. We will be able to implement pre-symptomatic screening of patients in our area, and improve their management.

Ecological “big data” Human activities are rapidly altering the natural world. Nowhere is this more evident, perhaps, than in the Arctic, yet this region remains one of the most remote and difficult to study. Researchers have increasingly relied on animal tracking data in these regions to understand individual species' responses, but if we want to understand larger-scale change, we need to integrate our understanding across species. Davidson et al. introduce an open-source data archive that currently hosts more than 15 million location data points across 96 species and use it to show distinct climate change responses across species. Such ecological “big data” can lead to a wider understanding of change. Science , this issue p. 712

Conservation status and management priorities are often informed by population trends. Trend estimates can be derived from population surveys or models, but both methods are associated with sources of uncertainty. Many Arctic-breeding shorebirds are thought to be declining based on migration and/or overwintering population surveys, but data are lacking to estimate the trends of some shorebird species. In addition, for most species, little is known about the stage(s) at which population bottlenecks occur, such as breeding vs. nonbreeding periods. We used previously published and unpublished estimates of vital rates to develop the first large-scale population models for 6 species of Arctic-breeding shorebirds in North America, including separate estimates for 3 subspecies of Dunlin. We used the models to estimate population trends and identify life stages at which population growth may be limited. Our model for the arcticola subspecies of Dunlin agreed with previously published information that the subspecies is severely declining. Our results also linked the decline to the subspecies' low annual adult survival rate, thus potentially implicating factors during the nonbreeding period in the East Asian–Australasian Flyway. However, our trend estimates for all species showed high uncertainty, highlighting the need for more accurate and precise estimates of vital rates. Of the vital rates, annual adult survival had the strongest influence on population trend in all taxa. Improving the accuracy, precision, and spatial and temporal coverage of estimates of vital rates, especially annual adult survival, would improve demographic model-based estimates of population trends and help direct management to regions or seasons where birds are subject to higher mortality.LAY SUMMARYDocumenting population trends is essential for evaluating the conservation status of wild species such as Arctic-breeding shorebirds.Trends can be estimated with population surveys or by predicting population growth based on survival rates and fecundity, but both methods are challenging, especially for species with large or remote geographic distributions.We used recent broad-scale estimates of survival and fecundity to develop population models for 6 species of Arctic-breeding shorebirds.The arcticola subspecies of Dunlin is likely in severe decline, but our trend estimates for all species showed high uncertainty.Uncertainty around the values of annual adult survival rates was a key driver of the uncertainty around the trend estimates.Our work highlights the need for better estimates of annual adult survival, seasonal survival, juvenile survival, and breeding propensity for these Arctic-breeding shorebirds.

Background: Over the last decade, the number of health impact assessments (HIAs) conducted has increased. The information contained in these studies provides valuable guidance for stakeholders in many professional fields and industries, also known as sectors. However, a growing body of evidence suggests that practitioners across sectors have unmet information needs and are facing challenges accessing and using information. Methods: The research team conducted a series of focus groups to explore the information needs of practitioners across sectors and to identify challenges they face accessing this information. Participants were stratified by geographic location, sector affiliation, and level of expertise with HIAs. Results: Findings suggest that practitioners from all sectors can benefit from the integration of health-related information, and the information contained in HIAs, into their work. Reported information needs include baseline data, geocoded socio-demographic information, and granular local data. Participants indicated that they obtain information from their professional network, universities sponsoring research, and online resources. Information challenges include lack of data that match the size and the scope of the target area of interest, proprietary or pay-for-access sources, varying terminology for the same concepts across sectors, inadequate resources and HIA expertise for searching, and limited information on the impact of findings of prior completed HIAs. Discussion: Identifying and understanding the information needs of practitioners is essential to maximizing the use of existing and future HIAs. An interactive and comprehensive web-based repository system for HIAs may provide value and assist stakeholders in meeting these needs.

Background To determine the feasibility and clinical result of selective embolization of hepatoduodenal or paratracheal lymphatics in Fontan patients with protein-losing enteropathy (PLE) or plastic bronchitis (PB). Methods Dilated lymph vessels in periportal (PLE) or paratracheal (PB) position were percutaneously punctured with a 22G Chiba needle. Intralymphatic position was confirmed by water soluble contrast injection with drainage to hepatoduodenal or tracheal fistulae. After flushing with 10% glucose solution, occlusion of hepatoduodenal or paratreacheal lymphatics was effected by injection of 1-4 cc mixture 4/1 of Lipiodol/n-butyl cyanoacrylate (n-BCA; Histoacryl). Results Seven patients with proven PLE were treated with periportal lymphatic embolization 10.7 (range: 6.6-13.5) years after the Fontan operation. The Fontan operation was performed at a median age of 3.7 (range: 2.9-5.7) years and PLE started a median of 3.1 (range: 0.9-4.7) years later. Five patients required a second procedure 2-8 months later. Complications were limited (spillage of glue in portal branch, transient cholangitis, and caustic duodenal bleeding). Six of seven patients reported significant improvement in quality of life and normalization of albumin levels after limited follow-up (p

Many Arctic shorebird populations are declining, and quantifying adult survival and the effects of anthropogenic factors is a crucial step toward a better understanding of population dynamics. We used a recently developed, spatially explicit Cormack–Jolly–Seber model in a Bayesian framework to obtain broad-scale estimates of true annual survival rates for 6 species of shorebirds at 9 breeding sites across the North American Arctic in 2010–2014. We tested for effects of environmental and ecological variables, study site, nest fate, and sex on annual survival rates of each species in the spatially explicit framework, which allowed us to distinguish between effects of variables on site fidelity versus true survival. Our spatially explicit analysis produced estimates of true survival rates that were substantially higher than previously published estimates of apparent survival for most species, ranging from S = 0.72 to 0.98 across 5 species. However, survival was lower for the arcticola subspecies of ...

The Yukon–Kuskokwim Delta of Alaska, USA is a globally important region for numerous avian species including millions of migrating and nesting waterbirds. However, data on the current spatial distribution of critical nesting areas and the importance of environmental variables in the selection of nest locations are generally lacking for waterbirds in this region. We modeled nest densities for 6 species of geese and eiders that commonly breed on the Yukon–Kuskokwim Delta, including cackling goose (Branta hutchinsii minima), emperor goose (Chen canagica), black brant (B. bernicla nigricans), greater white-fronted goose (Anser albifrons frontalis), spectacled eider (Somateria fischeri), and common eider (S. mollissima). The data used were from single-visit nest searches on 2,318 plots sampled during 29 years from 1985 to 2013. We modeled nest density for each species by combining data across years and using random forests methods and time-static landscape environmental variables. These models provide the first habitat-specific predictive distributions of nest density for these species breeding on the Yukon–Kuskokwim Delta of Alaska. Predictive performance of the random forests models varied among species, explaining 13–69% of the variance in nest density. For most species, nest density was greatest near the coast and within lowland habitats. Predicted nest densities mapped across the coastal zone of the Yukon–Kuskokwim Delta revealed areas of high and low nest densities that can be used to inform management and conservation decisions. © 2017 The Wildlife Society.

Objective The aim of the study was to assess the feasibility of using commonly available catheterization laboratory equipment for radiofrequency perforation of the pulmonary valve in patients with pulmonary atresia and intact ventricular septum. Methods The system (off-label use for all items) is made up of a co-axial telescopic arrangement consisting of a 0.014" PT 2 ™ coronary guidewire, for insulation inside a 2.7-F microcatheter which has an inner lumen of 0.021". The microcatheter was passed via a standard 4-F right coronary catheter to just below the atretic pulmonary valve. Radiofrequency (RF) energy was delivered using a standard electrosurgical system. In vitro testing had been performed and indicated that 5-10 W for 2-5 s would be sufficient for valve perforation. Results Radiofrequency perforation was successfully performed in all (n = 5, 100%) patients at a median age of 3 days (range: 1-36) and weight 2.7 kg (range 2.3-3.0). In one patient the pericardium was entered during the initial attempt; the generator was put on coagulation mode during retrieval of the guidewire and no haemopericardium occurred. The pulmonary valve was dilated in all; in three patients (n = 3) the ductus arteriosus was stented during the same session. Conclusion Results of the study show that it is feasible to perforate the pulmonary valve safely using this system. Availability, simplicity and cost are noteworthy benefits.

River deltas along Alaska’s Beaufort Sea coast are used by hatch-year semipalmated sandpipers (Calidris pusilla) after leaving their terrestrial natal sites, but the drivers of their use of these stopover sites on the first “hop” of fall migration are unknown. We quantified sandpiper temporal distribution and abundance as related to food resources at three river deltas during the beginning of their fall migration (post-breeding period) to compare the habitat quality among these deltas. We conducted population counts, sampled invertebrates, and captured birds to collect blood samples from individuals for triglyceride and stable isotope analyses to determine fattening rates and diet. Patterns of sandpiper and invertebrate abundance were complex and varied among deltas and within seasons. River deltas were used by sandpipers from late July to late August, and peak sandpiper counts ranged from 1000 to 4000 individuals, of which 98% were hatch-year semipalmated sandpipers. Isotopic signatures from blood plasma samples indicated that birds switched from a diet of upland tundra to delta invertebrate taxa as the migration season progressed, suggesting a dependence on delta invertebrates. Despite differences in diet among deltas, we found no differences in fattening rates of juvenile sandpipers as indicated by triglyceride levels. The number of sandpipers was positively associated with abundance of Amphipoda and Oligochaeta at the Jago and Okpilak-Hulahula deltas; an isotopic mixing model indicated that sandpipers consumed Amphipoda and Oligochaeta at Jago, mostly Chironomidae at Okpilak-Hulahula and Spionidae at Canning. Regardless of the difference in sandpiper diets at the Beaufort Sea deltas, their similar fattening rates throughout the season indicate that all of these stopover sites provide a critical food resource for hatch-year sandpipers beginning their first migration.

Semipalmated Sandpiper (Calidris pusilla) populations have undergone significant declines at core nonbreeding sites in northeastern South America. Breeding populations have also declined in the eastern North American Arctic, but appear to be stable or increasing in the central and western Arctic. To identify vulnerable populations and sites, we documented the migratory connectivity of Semipalmated Sandpipers using light-level geolocators, deploying 250 at 8 Arctic sites across the species' breeding range from 2011 to 2015, plus 87 at a single wintering site in northeastern Brazil in 2013 and 2014. We recovered 59 units and resighted 7 more (26% return rate) on the breeding grounds, but none at the nonbreeding site. We recovered only ∼3% of units deployed in 2013 at eastern Arctic breeding sites, but recovered 33% of those deployed in 2015. Overall, birds with geolocators were 57% as likely to return as those carrying alphanumeric flags. Stopover durations at prairie sites (mean: 8.7 days southbou...

Pulmonary arterial hypertension, although not common in children, has a poor prognosis. The definition, modern classification, causes and pathogenesis are discussed. Although the pathogenesis is complex and not completely understood, we now have a better understanding of it. The mechanisms and structural alterations underlying vasoconstriction of the pulmonary vasculature, remodelling of the pulmonary vessel wall and progressive obstruction and obliteration of the vascular bed with thrombosis are set out with the different mediators involved. Diagnosis can be difficult and a high level of suspicion is necessary to achieve an early diagnosis. The approach to management includes a methodical workup. The medication options discussed are based on an understanding of the pathophysiology.

A patent foramen is commonly found in the general population. Evidence exists that a patent foramen ovale (PFO) and atrial septal aneurysm are strongly associated with cryptogenic stroke. Associations with migraine have also been described, but the status of cause and effect is less clear. Management of PFO is controversial and no form of therapy has been properly evaluated. PFO closure devices are readily available and can be safely and effectively implanted percutaneously. Complication rates are low and symptoms are improved in most patients. At present, there is a lack of guidelines for the treatment of PFO and results of prospective randomised trials are eagerly awaited.

Objective: To evaluate paediatric cardiac services in South Africa with respect to referral base, services provided and human resources. Study design: A descriptive study design was used. An audit of the referral base, personnel and activity of paediatric cardiac units throughout South Africa was conducted by means of a questionnaire. A specialist from each centre was asked to provide the relevant data. Where accurate data was not available, estimates were provided by practitioners within each centre. Results: All identified units participated in the audit. Three were private sector units while the other five were primarily public sector units. Twenty four paediatric cardiologists, equally distributed between public and private sector units, were practicing in the country as at end 2008, with a further eight paediatricians undergoing training in paediatric cardiology. This is significantly less than the 88 paediatric cardiologists required for the population of South Africa. Eight paediatric cardiac surgeons were operating predominantly on children in public hospitals and five in private institutions. An estimated 1370 operations for congenital heart disease were performed over a one year period, with 800 of these in the public sector. Extrapolating from accepted estimates of congenital heart disease incidence, this represents conservatively, less that 40% of operations required for the population. Additionally, only 26% of the estimated 114 simple transposition of great arteries born annually were operated on, indicating serious deficiencies in the ability to adequately detect and intervene in serious congenital heart disease presenting in the neonatal period. Conclusion: The infrastructure and resources to detect and manage heart disease in children in South Africa, particularly within the public sector, are grossly inadequate.

Congenital heart lesions with abnormal right ventricular outfl ow tract anatomy will require early surgical intervention. Re-intervention rates in these patients are high due to homograft degeneration. Until recently, surgery was the only treatment option for right ventricular outfl ow tract dysfunction. Percutaneous pulmonary valve implantation has been introduced as a new therapeutic alternative to prolong conduit life span and to reduce surgical re-intervention rates. Short- and mid-term results have been favourable and showed that it is a safe and effective therapy. These are reviewed with emphasis on the Melody valve.

Objectives: Quality improvement is a critical mechanism to manage public health agency performance and to strengthen accountability for public funds. The objective of this study was to evaluate a relatively new quality improvement resource, the Public Health Quality Improvement Exchange (PHQIX), a free online communication platform dedicated to making public health quality improvement information accessible to practitioners. Methods: We conducted an internet-based survey of registered PHQIX users (n = 536 respondents) in 2013 and key informant interviews with PHQIX frequent users (n = 21) in 2014, in the United States. We assessed use of the PHQIX website, user engagement and satisfaction, communication and knowledge exchange, use of information, and impact on quality improvement capacity and accreditation readiness. Results: Of 462 respondents, 369 (79.9%) browsed quality improvement initiatives, making it the most commonly used site feature, and respondents described PHQIX as a near-unique source for real-world quality improvement examples. Respondents were satisfied with the quality and breadth of topics and relevance to their settings (average satisfaction scores, 3.9-4.1 [where 5 was the most satisfied]). Of 407 respondents, 237 (58.2%) said that they had put into practice information learned on PHQIX, and 209 of 405 (51.6%) said that PHQIX had helped to improve quality improvement capacity. Fewer than half of respondents used the commenting function, the Community Forum, and the Ask an Expert feature. Conclusions: Findings suggest that PHQIX, particularly descriptions of the quality improvement initiatives, is a valued resource for public health practitioners. Users reported sharing information with colleagues and applying what they learned to their own work. These findings may relate to other efforts to disseminate quality improvement knowledge.

Gut microbiota can have important effects on host health, but explanatory factors and pathways that determine gut microbial composition can differ among host lineages. In mammals, host phylogeny is one of the main drivers of gut microbiota, a result of vertical transfer of microbiota during birth. In birds, it is less clear what the drivers might be, but both phylogeny and environmental factors may play a role. We investigated host and environmental factors that underlie variation in gut microbiota composition in eight species of migratory shorebirds. We characterized bacterial communities from 375 fecal samples collected from adults of eight shorebird species captured at a network of nine breeding sites in the Arctic and sub-Arctic ecoregions of North America, by sequencing the V4 region of the bacterial 16S ribosomal RNA gene. Firmicutes (55.4%), Proteobacteria (13.8%), Fusobacteria (10.2%), and Bacteroidetes (8.1%) dominated the gut microbiota of adult shorebirds. Breeding location was the main driver of variation in gut microbiota of breeding shorebirds (R-2 = 11.6%), followed by shorebird host species (R-2 = 1.8%), and sampling year (R-2 = 0.9%), but most variation remained unexplained. Site variation resulted from differences in the core bacterial taxa, whereas rare, lowabundance bacteria drove host species variation. Our study is the first to highlight a greater importance of local environment than phylogeny as a driver of gut microbiota composition in wild, migratory birds under natural conditions. Avian Health Program grants from the U.S. Fish and Wildlife Service [2013-02]; National Science FoundationNational Science Foundation (NSF) [DDIG-1501479]; Arctic Landscape Conservation Cooperative; U.S. Fish and Wildlife ServiceUS Fish & Wildlife Service; Division of Biology at the Kansas State University; Kansas State University Open Access Publishing Fund This work was funded by the Avian Health Program grants from the U.S. Fish and Wildlife Service (to JS and RL, and 2013-02 to KG and RL), a Doctoral Dissertation Improvement Grant from the National Science Foundation (DDIG-1501479 to KG), the Arctic Landscape Conservation Cooperative, the U.S. Fish and Wildlife Service, and the Division of Biology at the Kansas State University. Publication of this article was funded in part by the Kansas State University Open Access Publishing Fund.

Kubelka et al. (Science, 9 November 2018, p. 680-683) claim that climate change has disrupted patterns of nest predation in shorebirds. They report that predation rates have increased since the 1950s, especially in the Arctic. We describe methodological problems with their analyses and argue that there is no solid statistical support for their claims.

Introduction Results and outcomes of ductus arteriosus stenting vary widely. The aim of this study was to determine whether ductus morphology is associated with different procedural outcome. Methods Over an 18-year period, 123 patients presented with ductal dependent pulmonary blood flow. Results were retrospectively assessed based on radiographic anatomic features of the ductus arteriosus: Group 1: "straight" ductus arteriosus, typically seen in patients with Pulmonary atresia with intact septum (PA-IVS), Group 2: "intermediate" ductus arteriosus as seen in severe pulmonary stenosis (PS)-single ventricle, Group 3: "vertical" ductus arteriosus typically seen in patients with pulmonary atresia-ventricular septal defect, Group 4: ductus arteriosus arising from the aorta to a single lung, Group 5: ductus arteriosus arising from the innominate/subclavian artery to a single lung, Group 6: ductus arteriosus from innominate/subclavian artery to both lungs. Results Ductal stenting (DS) was attempted in 98 patients with 99 ducts. Successful stenting was possible in 83 patients. Success of DS was significantly different among the groups (p = .04, F = 5.41). Groups 1, 4, and 5 were "easy" with good success while Groups 2, 3, and 6 were complex and demanding. There were two deaths (after 5 and 7 days, respectively) that could be ascribed to DS. Elective re-interventions were performed in 34 ductuses (40%). Fifty three percent (n = 44/83) of successful ductus stents proceeded to further surgery and 20 ducts closed spontaneously in asymptomatic patients over time. Conclusions Ductus arteriosus morphology influences technique and determines complexity, safety, and final outcome of ductus arteriosus stenting.

Kubelka et al. (Reports, 9 November 2018, p. 680) claim that climate change has disrupted patterns of nest predation in shorebirds. They report that predation rates have increased since the 1950s, especially in the Arctic. We describe methodological problems with their analyses and argue that there is no solid statistical support for their claims. Fil: Bulla, Martin. Nioz Royal Netherlands Institute For Sea Research; Países Bajos. Max Planck Institute For Ornithology; Alemania. Czech University of Life Sciences; República Checa Fil: Reneerkens, Jeroen. Nioz Royal Netherlands Institute For Sea Research; Países Bajos. University of Groningen; Países Bajos Fil: Weiser, Emily L.. Upper Midwest Environmental Sciences Center; Estados Unidos Fil: Sokolov, Aleksandr. Institute Of Plant And Animal Ecology; Rusia Fil: Taylor, Audrey R.. University of Alaska; Estados Unidos Fil: Sittler, Benoît. Albert Ludwigs University of Freiburg; Alemania. Arctic Ecology Research Group; Francia Fil: McCaffery, Brian J.. U.S. Fish and Wildlife Service; Estados Unidos Fil: Ruthrauff, Dan R.. U.S. Geological Survey; Estados Unidos Fil: Catlin, Daniel H.. Virginia Tech University; Estados Unidos Fil: Payer, David C.. National Park Service; Estados Unidos Fil: Ward, David H.. U.S. Geological Survey; Estados Unidos Fil: Solovyeva, Diana V.. Institute of Biological Problems of the North; Rusia Fil: Santos, Eduardo S. A.. Universidade de São Paulo; Brasil Fil: Rakhimberdiev, Eldar. Lomonosov Moscow State University; Rusia. University of Groningen; Países Bajos Fil: Nol, Erica. Trent University; Canadá Fil: Kwon, Eunbi. Virginia Tech; Estados Unidos Fil: Brown, Glen S.. Ministry of Natural Resources and Forestry; Canadá Fil: Hevia, Glenda Denise. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Centro Nacional Patagónico. Centro para el Estudio de Sistemas Marinos; Argentina Fil: Gates, H. River. National Audubon Society; Estados Unidos Fil: Johnson, James A.. Fish and Wildlife Service; Estados Unidos Fil: van Gils, Jan A.. Department of Coastal Systems and Utrecht University; Países Bajos Fil: Hansen, Jannik. Aarhus University. Aarhus Institute Of Advanced Studies.; Dinamarca Fil: Lamarre, Jean-François. Polar Knowledge Canada; Canadá Fil: Rausch, Jennie. Environment and Climate Change Canada; Canadá Fil: Conklin, Jesse R.. University of Groningen; Países Bajos Fil: Liebezeit, Joe. Audubon Society of Portland; Estados Unidos Fil: Bêty, Joël. University of Quebec; Canadá Fil: Lang, Johannes. Arctic Ecology Research Group ; Francia. Giessen University; Alemania Fil: Alves, José A.. University of Aveiro; Portugal. University of Iceland; Islandia Fil: Fernández-Elipe, Juan. No especifíca; Fil: Exo, Klaus-Michael. Institute of Avian Research “Vogelwarte Helgoland"; Alemania Fil: Bollache, Loïc. Universite de Franche-Comte; Francia Fil: Bertellotti, Néstor Marcelo. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Centro Nacional Patagónico. Centro para el Estudio de Sistemas Marinos; Argentina Fil: Giroux, Marie-Andrée. Université de Moncton; Canadá Fil: van de Pol, Martijn. Netherlands Institute of Ecology ; Países Bajos Fil: Johnson, Matthew. USDA Forest Service; Estados Unidos Fil: Boldenow, Megan L.. University of Alaska; Estados Unidos Fil: Valcu, Mihai. Max Planck Institute für Ornithologie; Alemania Fil: Soloviev, Mikhail. Lomonosov Moscow State University; Alemania Fil: Sokolova, Natalya. Arctic Research Station; Rusia Fil: Senner, Nathan R.. University of South Carolina; Estados Unidos Fil: Lecomte, Nicolas. Université de Moncton; Canadá Fil: Meyer, Nicolas. Universite de Franche-Comte; Francia. Arctic Ecology Research Group; Francia Fil: Schmidt, Niels Martin. Aarhus University. Department of Bioscience; Dinamarca Fil: Gilg, Olivier. Arctic Ecology Research Group; Francia. Universite de Franche-Comte; Francia Fil: Smith, Paul A.. Environment and Climate Change Canada; Canadá Fil: Machín, Paula. No especifíca; Fil: McGuire, Rebecca L.. Wildlife Conservation Society; Estados Unidos Fil: Cerboncini, Ricardo A. S.. Universidade Federal do Paraná; Brasil Fil: Ottvall, Richard. No especifíca; Fil: van Bemmelen, Rob S. A.. Wageningen Marine Research; Países Bajos Fil: Swift, Rose J.. Cornell University; Estados Unidos Fil: Saalfeld, Sarah T.. No especifíca; Fil: Jamieson,Sarah E.. Simon Fraser University; Canadá Fil: Brown, Stephen. No especifíca; Fil: Piersma, Theunis. NIOZ Royal Netherlands Institute for Sea Research; Países Bajos. Conservation Ecology Group; Países Bajos Fil: Albrecht, Tomas. Czech Academy of Sciences; República Checa. Charles University; República Checa Fil: D’Amico, Verónica. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Centro Nacional Patagónico. Centro para el Estudio de Sistemas Marinos; Argentina Fil: Lanctot, Richard B.. U.S. Fish and Wildlife Service; Estados Unidos Fil: Kempenaers, Bart. Max Planck Institute für Ornithologie; Alemania

Mercury contamination has become a major concern in the Arctic, where elevated mercury deposition has led to large increases in mercury exposure for some Arctic wildlife over the past century. Chronic mercury exposure in birds is known to reduce reproductive success, which may ultimately result in population declines. Many species of Arctic-breeding shorebirds are declining, and exposure to environmental contaminants, such as mercury, may be an important factor. We quantified mercury exposure in 10 shorebird species breeding and staging in Alaska. We analyzed 229 blood and 73 feather samples collected in 2008–2009 for total mercury concentrations. Mercury in blood represents local exposure, whereas mercury in feathers reflects exposure during feather development. Concentrations of mercury ranged from 0.03 to 2.20 μg g−1 in shorebird blood and from 0.16 to 3.66 μg g−1 in shorebird feathers. Most shorebirds sampled during staging had relatively low blood mercury, but some breeding species had suffi...

The Fontan operation was first performed in 1968. Since then, this operation has been performed on thousands of patients worldwide. Results vary from very good for many decades to very bad with a pleiad of complications and early death. A good understanding of the physiology is necessary to further improve results. The Fontan connection creates a critical bottleneck with obligatory upstream congestion and downstream decreased flow; these two features are the basic cause of the majority of the physiologic impairments of this circulation. The ventricle, while still the engine of the circuit, cannot compensate for the major flow restriction of the Fontan bottleneck: the suction required to compensate for the barrier effect cannot be generated, specifically not in a deprived heart. Except for some extreme situations, the heart therefore no longer controls cardiac output nor can it significantly alter the degree of systemic venous congestion. Adequate growth and development of the pulmonary arteries is extremely important as pulmonary vascular impedance will become the major determinant of Fontan outcome. Key features of the Fontan ventricle are early volume overload and overgrowth, but currently chronic preload deprivation with increasing filling pressures. A functional decline of the Fontan circuit is expected and observed as pulmonary vascular resistance and ventricular filling pressure increase with time. Treatment strategies will only be successful if they open up or bypass the critical bottleneck or act on immediate surroundings (impedance of the Fontan neoportal system, fenestration, enhanced ventricular suction). ispartof: Heart vol:102 issue:14 pages:1081-6 ispartof: location:England status: published

Bioprosthetic valves degenerate over time. Transcatheter valve-in-valve procedures have become an attractive alternative to surgery. However, every valve increasingly diminishes the diameter of the valvar orifice. We report a 12-year-old female who had a previous transcatheter tricuspid valve-in-valve procedure; cracking the ring of a Carpentier Edwards Perimount valve by means of an ultrahigh pressure balloon allowed implantation of a further larger percutaneous valve. The advantage of this novel approach permits enlarging the inner valve diameter and may facilitate future interventions and prolong time to surgery. © 2016 Wiley Periodicals, Inc.

The Arctic is experiencing rapidly warming conditions, increasing predator abundance, and diminishing population cycles of keystone species such as lemmings. However, it is still not known how many Arctic animals will respond to a changing climate with altered trophic interactions. We studied clutch size, incubation duration and nest survival of 17 taxa of Arctic-breeding shorebirds at 16 field sites over 7years. We predicted that physiological benefits of higher temperatures and earlier snowmelt would increase reproductive effort and nest survival, and we expected increasing predator abundance and decreasing abundance of alternative prey (arvicoline rodents) to have a negative effect on reproduction. Although we observed wide ranges of conditions during our study, we found no effects of covariates on reproductive traits in 12 of 17 taxa. In the remaining taxa, most relationships agreed with our predictions. Earlier snowmelt increased the probability of laying a full clutch from 0.61 to 0.91 for Western Sandpipers, and shortened incubation by 1.42days for arcticola Dunlin and 0.77days for Red Phalaropes. Higher temperatures increased the probability of a full clutch from 0.60 to 0.93 for Western Sandpipers and from 0.76 to 0.97 for Red-necked Phalaropes, and increased daily nest survival rates from 0.9634 to 0.9890 for Semipalmated Sandpipers and 0.9546 to 0.9880 for Western Sandpipers. Higher abundance of predators (foxes) reduced daily nest survival rates only in Western Sandpipers (0.9821-0.9031). In contrast to our predictions, the probability of a full clutch was lowest (0.83) for Semipalmated Sandpipers at moderate abundance of alternative prey, rather than low abundance (0.90). Our findings suggest that in the short-term, climate warming may have neutral or positive effects on the nesting cycle of most Arctic-breeding shorebirds. National Fish and Wildlife Foundation [2010-0061-015, 2011-0032-014, 0801.12.032731, 0801.13.041129]; Neotropical Migratory Bird Conservation Act [F11AP01040, F12AP00734, F13APO535, 4073]; Arctic Goose Joint Venture; Arctic National Wildlife Refuge; BP Exploration (Alaska) Inc.; Bureau of Land Management; Canada Fund for InnovationCanada Foundation for Innovation; Canada Research ChairsCanada Research Chairs; Cape Krusenstern National Monument grant; Centre for Wildlife Ecology at Simon Fraser University; Churchill Northern Studies Centre; Cornell University Graduate School Mellon Grant; Ducks Unlimited Canada; Environment and Climate Change Canada; FQRNT (Quebec)FQRNT; Government of Nunavut; Indigenous and Northern Affairs Canada; Kansas State University; Kresge Foundation; Liz Claiborne and Art Ortenberg Foundation; Manomet Center for Conservation Sciences; Mississippi Flyway Council; Murie Science and Learning Center grants; National Fish and Wildlife Foundation; National Park Service; National Science Foundation (Office of Polar Programs Grant) [ARC-1023396]; National Science Foundation (Doctoral Dissertation Improvement Grant)National Science Foundation (NSF) [1110444]; Natural Resources Canada (Polar Continental Shelf Program); Natural Sciences and Engineering Research Council of CanadaNatural Sciences and Engineering Research Council of Canada; Northern Studies Training Program; Selawik National Wildlife Refuge; Trust for Mutual Understanding; Universite du Quebec a Rimouski; University of Alaska Fairbanks; University of Colorado Denver; University of Missouri Columbia; University of Moncton; US Fish and Wildlife Service (Migratory Bird Management Division, Survey, Monitoring and Assessment Program); US Fish and Wildlife Service (Alaska National Wildlife Refuge System's Challenge Cost Share Program); US Fish and Wildlife Service (Avian Influenza Health and Influenza programmes); US Geological Survey (USGS) (Changing Arctic Ecosystem Initiative, Wildlife Program of the USGS Ecosystem Mission Area); W. Garfield Weston Foundation; Alaska Department of Fish and Game E.L.W compiled the field data, designed and performed the statistical analyses and wrote the manuscript. B.K.S. assisted with design of analyses and preparation of the manuscript. R.B.L., S.C.B. and H.R.G. led development of standardized field protocols and coordinated field work. B.K.S., R.B.L., S.C.B., H.R.G. and all other authors, who are listed in alphabetical order, designed and conducted the field studies, contributed to interpreting the results and assisted with editing the manuscript. Major support for the ASDN was provided by the National Fish and Wildlife Foundation (grants 2010-0061-015, 2011-0032-014, 0801.12.032731 and 0801.13.041129), the Neotropical Migratory Bird Conservation Act (grants F11AP01040, F12AP00734 and F13APO535) and the Arctic Landscape Conservation Cooperative. Additional funding for participating field sites was provided by: Alaska Department of Fish and Game, Arctic Goose Joint Venture, Arctic National Wildlife Refuge, BP Exploration (Alaska) Inc., Bureau of Land Management, Canada Fund for Innovation, Canada Research Chairs, Cape Krusenstern National Monument grant, Centre for Wildlife Ecology at Simon Fraser University, Churchill Northern Studies Centre, Cornell University Graduate School Mellon Grant, Ducks Unlimited Canada, Environment and Climate Change Canada, FQRNT (Quebec), Government of Nunavut, Indigenous and Northern Affairs Canada, Kansas State University, Kresge Foundation, Liz Claiborne and Art Ortenberg Foundation, Manomet Center for Conservation Sciences, Mississippi Flyway Council, Murie Science and Learning Center grants, National Fish and Wildlife Foundation, National Park Service, National Science Foundation (Office of Polar Programs Grant ARC-1023396 and Doctoral Dissertation Improvement Grant 1110444), Natural Resources Canada (Polar Continental Shelf Program), Natural Sciences and Engineering Research Council of Canada (Discovery Grant and Northern Supplement), Neotropical Migratory Bird Conservation Act (grant 4073), Northern Studies Training Program, Selawik National Wildlife Refuge, Trust for Mutual Understanding, Universite du Quebec a Rimouski, University of Alaska Fairbanks, University of Colorado Denver, University of Missouri Columbia, University of Moncton, US Fish and Wildlife Service (Migratory Bird Management Division, Survey, Monitoring and Assessment Program, Alaska National Wildlife Refuge System's Challenge Cost Share Program and Avian Influenza Health and Influenza programmes), US Geological Survey (USGS) (Changing Arctic Ecosystem Initiative, Wildlife Program of the USGS Ecosystem Mission Area), and the W. Garfield Weston Foundation. Logistical support was provided by Arctic National Wildlife Refuge, Barrow Arctic Science Consortium, BP Exploration (Alaska) Inc., Kinross Gold Corporation, Umiaq LLC, Selawik National Wildlife Refuge (USFWS), ConocoPhillips Alaska Inc., Cape Krusenstern National Monument (National Park Service) and Sirmilik National Park (Parks Canada). We thank local communities and landowners, including the Ukpeagvik Inupiat Corporation, the people of the Inuvialuit Settlement Region, Sitnasuak Native Corporation, the Kuukpik Corporation and the North Slope Borough for permitting us to conduct research on their lands.; Animal handling, marking and monitoring procedures were approved by Environment and Climate Change Canada, Government of Nunavut, Kansas State University, National Park Service, Ontario Ministry of Natural Resources and Forestry, University of Alaska Fairbanks, University of Moncton, US Fish & Wildlife Service and US Geological Survey. All applicable international, national and institutional guidelines for the care and use of animals were followed. We thank A. Tygart for assistance in compiling JAGS for use on the Beocat supercomputer at Kansas State University, D. Payer and S. Freeman for their work at Canning River, and H. Meltofte, P. Battley, B. Ross, J. Sutton, L. Martin and the Sandercock lab for comments on earlier drafts of the manuscript. We thank the many field assistants who were involved in data collection, especially field crew leaders K. Bennet, M. Burrell, J. Cunningham, E. D'Astous, S. Carvey, A. Doll, L. Pirie Dominix, K. Gold, A. Gottesman, K. Grond, P. Herzog, B. Hill, D. Hodgkinson, A. J. Johnson, D. Pavlik, M. Peck, L. Pollock, S. Sapora, B. Schwarz, F. Smith, H. M. Specht, M. VanderHeyden, B. M. Walker and B. Wilkinson. The findings and conclusions in this article are those of the author(s) and do not necessarily represent the views of the US Fish and Wildlife Service. Any use of trade names is for descriptive purposes only and does not imply endorsement by the US Government. Public domain – authored by a U.S. government employee

Marking wild birds is an integral part of many field studies. However, if marks affect the vital rates or behavior of marked individuals, any conclusions reached by a study might be biased relative to the general population. Leg bands have rarely been found to have negative effects on birds and are frequently used to mark individuals. Leg flags, which are larger, heavier, and might produce more drag than bands, are commonly used on shorebirds and can help improve resighting rates. However, no one to date has assessed the possible effects of leg flags on the demographic performance of shorebirds. At seven sites in Arctic Alaska and western Canada, we marked individuals and monitored nest survival of four species of Arctic-breeding shorebirds, including Semipalmated Sandpipers (Calidris pusilla), Western Sandpipers (C. mauri), Red-necked Phalaropes (Phalarope lobatus), and Red Phalaropes (P. fielicarius). We used a daily nest survival model in a Bayesian framework to test for effects of leg flags, relative to birds with only bands, on daily survival rates of 1952 nests. We found no evidence of a difference in nest survival between birds with flags and those with only bands. Our results suggest, therefore, that leg flags have little effect on the nest success of Arctic-breeding sandpipers and phalaropes. Additional studies are needed, however, to evaluate the possible effects of flags on shorebirds that use other habitats and on survival rates of adults and chicks. National Fish and Wildlife Foundation [2010-0061-015, 2011-0032-014, 0801.12.032731, 0801.13.041129]; Neotropical Migratory Bird Conservation Act of the U.S. Fish and Wildlife Service [F11AP01040, F12AP00734, F13APO535, 4073, 4102]; Alaska Department of Fish and Game; State Wildlife Grant [T-16]; Arctic National Wildlife Refuge; Bureau of Land Management; Centre for Wildlife Ecology at Simon Fraser University; Environment and Climate Change Canada; Indigenous and Northern Affairs Canada; Kansas State University; Kresge Foundation; Liz Claiborne/Art Ortenberg Foundation; Manomet Center for Conservation Sciences; National Park Service; Murie Science and Learning Center Research Fellowship Program; National Science Foundation (Office of Polar Programs)National Science Foundation (NSF) [ARC-1023396]; National Science Foundation (Doctoral Dissertation Improvement Grant)National Science Foundation (NSF) [1501479]; Natural Resources Canada (Polar Continental Shelf Program); Natural Sciences and Engineering Research Council of Canada (Strategic Grant - Discovery Grants) [357054]; Northern Scientific Training Program (Canadian Polar Commission); U.S. Fish and Wildlife Service (Migratory Bird Management Division, Survey, Monitoring and Assessment Program); U.S. Fish and Wildlife Service (Alaska National Wildlife Refuge System's Challenge Cost Share Program); U.S. Fish and Wildlife Service (Avian Influenza Health and Influenza programs); U.S. Geological Survey (Changing Arctic Ecosystem Initiative, Wildlife Program of the USGS Ecosystem Mission Area); University of Colorado Denver; University of Alaska Fairbanks; University of Missouri Columbia Major support for the infrastructure of the Arctic Shorebird Demographics Network was provided by the Arctic Landscape Conservation Cooperative, National Fish and Wildlife Foundation (grants 2010-0061-015, 2011-0032-014, 0801.12.032731, and 0801.13.041129), and Neotropical Migratory Bird Conservation Act of the U.S. Fish and Wildlife Service (grants F11AP01040, F12AP00734, F13APO535, 4073, and 4102). Additional funding for individual sites was provided by Alaska Department of Fish and Game (including State Wildlife Grant T-16), Arctic National Wildlife Refuge, Bureau of Land Management, Centre for Wildlife Ecology at Simon Fraser University, Environment and Climate Change Canada, Indigenous and Northern Affairs Canada, Kansas State University, Kresge Foundation, Liz Claiborne/Art Ortenberg Foundation, Manomet Center for Conservation Sciences, National Park Service (including Murie Science and Learning Center Research Fellowship Program), National Science Foundation (Office of Polar Programs grant ARC-1023396 and Doctoral Dissertation Improvement Grant 1501479), Natural Resources Canada (Polar Continental Shelf Program), Natural Sciences and Engineering Research Council of Canada (Strategic Grant - 357054, Discovery Grants), Northern Scientific Training Program (Canadian Polar Commission), U.S. Fish and Wildlife Service (Migratory Bird Management Division, Survey, Monitoring and Assessment Program, Alaska National Wildlife Refuge System's Challenge Cost Share Program, and Avian Influenza Health and Influenza programs), U.S. Geological Survey (Changing Arctic Ecosystem Initiative, Wildlife Program of the USGS Ecosystem Mission Area), University of Colorado Denver, University of Alaska Fairbanks, and University of Missouri Columbia. We thank local communities and landowners, including the people of the Inuvialuit Settlement Region, North Slope Borough, Ukpeagvik Inupiat Corporation, and Sitnasuak Native Corporation for permitting us to conduct research on their lands. Logistical support was provided by Arctic National Wildlife Refuge (U.S. Fish and Wildlife Service), Barrow Arctic Science Consortium, Cape Krusenstern National Monument (National Park Service), ConocoPhillips Alaska, Inc., Sisualik National Wildlife Refuge (U.S. Fish and Wildlife Service), and Umiaq, LLC. We thank the many field assistants who helped on this project throughout the years, including S. Carvey, T. Donnelly, A. Gottesman, D. Pavlik, and B. Wilkinson for their key roles in field work at the Colville River Delta, and D. Payer for his key role in implementing and overseeing field work at Canning River Delta. J. Lamb, L. Rosen, and B. Ross provided comments on an early draft of the manuscript. Animal handling, marking, and monitoring procedures were approved by animal care and use committees and permitting agencies at Environment and Climate Change Canada, Kansas State University, National Park Service, University of Alaska Fairbanks, U.S. Fish and Wildlife Service, and U.S. Geological Survey - Alaska Science Center. The findings and conclusions in this article are those of the author(s) and do not necessarily represent the views of the U.S. Fish and Wildlife Service. Any use of trade names is for descriptive purposes only and does not imply endorsement by the U.S. Government. Public domain – authored by a U.S. government employee

Children living with a congenital heart defect (CHD) carry the burden of a condition affecting their biological, psychological, and social functioning. Even though the physical heartbeats of these children might be inaudible and defective, their intra- and inter-personal ‘stories in sound’ need to be heard and understood. The aim of this research study was to explore these ‘stories in sound’ in children diagnosed with CHD. A qualitative, exploratory, descriptive study using thematic analysis was conducted. Semi-structured interviews were conducted with six boys and three girls between the ages of eight and fourteen years, who were diagnosed with CHD. The developmental psychopathology model (DPM) served as a conceptual framework. Five main themes emerged and were related to (i) the participants’ understanding of their cardiac diagnoses; (ii) the participants’ perceptions regarding their post-operative cardiac statuses; (iii) the participants’ psychological experiences related to their cardiac statuses; (iv) the effects of living with CHD on their social functioning; and (v) a unique relationship to their chronic cardiac condition. Within each of these themes, thirteen subthemes were identified. The article concludes that an age-appropriate understanding of CHD and post-operative cardiac status is important, as children’s perceptions have implications for their psychosocial experiences and acceptance of living with CHD. These children need comprehensive support from health care professionals.