Race and outcomes after percutaneous coronary intervention: Insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium.

BACKGROUND: Current studies show similar in-hospital outcomes following percutaneous coronary intervention (PCI) between Black and White patients. Long-term outcomes and the role of individual and community-level socioeconomic factors in differential risk are less understood. METHODS: We linked clinical registry data from PCIs performed between January, 2013 and March, 2018 at 48 Michigan hospitals to Medicare Fee-for-service claims. We analyzed patients of Black and White race. We used propensity score matching and logistic regression models to estimate the odds of 90-day readmission and Cox regression to evaluate the risk of postdischarge mortality. We used mediation analysis to evaluate the proportion of association mediated by socioeconomic factors. RESULTS: Of the 29,317 patients included in this study, 10.28% were Black and 89.72% were White. There were minimal differences between groups regarding post-PCI in-hospital outcomes. Compared with White patients, Black patients were more likely to be readmitted within 90-days of discharge (adjusted OR 1.62, 95% CI [1.32-2.00]) and had significantly higher risk of all-cause mortality (adjusted HR 1.45, 95% CI 1.30-1.61) when adjusting for age and gender. These associations were significantly mediated by dual eligibility (proportion mediated [PM] for readmission: 11.0%; mortality: 21.1%); dual eligibility and economic well-being of the patient's community (PM for readmission: 22.3%; mortality: 43.0%); and dual eligibility, economic well-being of the community, and baseline clinical characteristics (PM for readmission: 45.0%; mortality: 87.8%). CONCLUSIONS: Black patients had a higher risk of 90-day readmission and cumulative mortality following PCI compared with White patients. Associations were mediated by dual eligibility, community economic well-being, and traditional cardiovascular risk factors. Our study highlights the need for improved upstream care and streamlined postdischarge care pathways as potential strategies to improve health care disparities in cardiovascular disease.

Cardiac medications in obstetric patients.

PURPOSE OF REVIEW: This review summarizes recent literature, updated safety data, and major clinical considerations for commonly used medications for arrhythmias, heart failure, hypertension, ischemic heart disease, and anticoagulation during pregnancy and lactation. RECENT FINDINGS: Recent studies have shown a benefit to more aggressive treatment of mild chronic hypertension to a blood pressure goal of <140/90 with oral labetalol and nifedipine remaining first-line agents. Aspirin is now routinely used for preeclampsia prevention, while experience with other antiplatelet agents, such as purinergic receptor P2Y G protein-coupled 12 (P2Y12) inhibitors, continues to grow. Data on statin therapy are rapidly changing and recent studies suggest this class may not be associated with fetal harm and can be continued in select cases. SUMMARY: As data regarding medication safety continues to evolve, a multidisciplinary team is needed for full consideration of maternal and fetal risks and benefits. Ongoing studies are needed to improve and expand our understanding of medication safety during pregnancy and lactation.

Frequency of peripheral vestibular pathology following traumatic brain injury: a systematic review of literature.

OBJECTIVE: To establish the frequency of occurrence of peripheral vestibular dysfunction in adults who have sustained non-blast-related traumatic brain injury (TBI) as measured through the standard audiological vestibular test battery. DESIGN: A systematic search of English language literature using MEDLINE, EMBASE, PsycINFO, CINAHL, hand-searching of reference lists and SCOPUS author search was conducted from January 1, 1990 to May 14, 2019. STUDY SAMPLES: Twenty-three out of 417 originally identified articles were retained. TBI and peripheral vestibular findings were extracted and synthesised. RESULTS: Quality appraisal using the Oxford Centre for Evidence-Based Medicine (OCEBM) revealed Level 2b as the highest level of evidence. None of the primary studies explored vestibular deficits in acute settings, with data collected from tertiary institutions and in 20 of 23 studies retrospectively. Although retrospective studies provided important data, they fail to control for numerous threats to internal validity. BPPV was the most frequently identified peripheral vestibular deficit following TBI, diagnosed in 39.7% of 239 participants across six of 23 studies. CONCLUSIONS: Further prospective longitudinal research into comparative recovery trajectories in patients across TBI severity levels would provide additional information to guide clinical diagnosis, prognosis and management of this patient population.

The Behavioural Contexts of Red Langur (Presbytis rubicunda) Loud Calls in the Wehea Forest, East Kalimantan, Indonesia.

Researchers hypothesize that male loud calls play several roles in primate societies including in the context of intergroup spacing and spatial coordination. Field studies examining the behavioural correlates of vocalizations are essential to evaluate the function of these calls. This preliminary study, from July 2011 to January 2012, explores the behavioural contexts and correlates of male loud calls in a habituated group of red langurs (Presbytis rubicunda) in the Wehea Forest, East Kalimantan, Indonesia. In analysing 418 h of data collection, we find a total of 87 vocal behaviours, including bouts of multiple calls in rapid succession (i.e. calling events) and individual loud calls. In this sample, most vocal behaviour takes place in the morning with 59% of calling events occurring before 8.00 h. The mean rate of calling events is 0.12 events/h, and the mean rate of individual loud calls is 0.20 calls/h. The mean number of calling events per day is 1.31 (range: 0-4), and the mean number of individual loud calls per day is 2.81 (range: 0-13). The rate of calling events is highest in the context of intragroup conflict, followed by intergroup encounters, predator threat, group travel, and the highest number of individual loud calls occurred during intergroup encounters. Although these results are preliminary, they suggest that adult male loud calls among red langurs at Wehea may play a role in both intergroup spacing and social coordination, supporting the hypothesis that these calls can serve different functions.

Body mass of wild Bornean orangutans living in human-dominated landscapes: Implications for understanding their ecology and conservation.

Body mass is a key determinant of a species' ecology, including locomotion, foraging strategies, and energetics. Accurate information on the body mass of wild primates allows us to develop explanatory models for relationships among body size, ecology, and behavior and is crucial for reconstructing the ecology and behavior of fossil primates and hominins. Information on body mass can also provide indirect information on health and can be an important tool for conservation in the context of increasingly widespread habitat disturbance. This study reports body mass data recorded for wild Northeast Bornean orangutans (Pongo pygmaeus morio) during relocation efforts in forestry and oil palm plantations in East Kalimantan, Indonesia. The average mass of flanged adult males (n = 12, 74 ± 9.78 kg) and adult females (n = 7, 35.29 ± 7.32 kg) from this study were 13.6% and 9% lower, respectively, than the only other published wild Bornean orangutan body mass measurements, but the range of weights for both males and females was larger for this study. This pattern could be due to sampling error, data collection differences, or the influence of habitat disturbance, specifically a lack of access to resources, on individual health. When necessary relocations present the opportunity, we encourage researchers to prioritize the collection of body size data for the purposes of understanding ecology but also as an indirect means of monitoring population viability. As primate habitat becomes increasingly fragmented and altered by humans such data will become critical to our ability to make informed conservation decisions.

Terrestriality in the Bornean orangutan (Pongo pygmaeus morio) and implications for their ecology and conservation.

Aside from anecdotal evidence, terrestriality in orangutans (Pongo spp.) has not been quantified or subject to careful study and important questions remain about the extent and contexts of terrestrial behavior. Understanding the factors that influence orangutan terrestriality also has significant implications for their conservation. Here we report on a camera trapping study of terrestrial behavior in the northeastern Bornean orangutan, Pongo pygmaeus morio, in Wehea Forest, East Kalimantan, Indonesia. We used 78 non-baited camera traps set in 43 stations along roads, trails, and at mineral licks (sepans) to document the frequency of orangutan terrestriality. Habitat assessments were used to determine how terrestrial behavior was influenced by canopy connectivity. We compared camera trapping results for P. p. morio to those for a known terrestrial primate (Macaca nemestrina), and another largely arboreal species (Presbytis rubicunda) to assess the relative frequency of terrestrial behavior by P. p. morio. A combined sampling effort of 14,446 trap days resulted in photographs of at least 15 individual orangutans, with females being the most frequently recorded age sex class (N=32) followed by flanged males (N=26 records). P. p. morio represented the second most recorded primate (N=110 total records) of seven primate species recorded. Capture scores for M. nemestrina (0.270) and P. p. morio (0.237) were similar and almost seven times higher than for the next most recorded primate, P. rubicunda (0.035). In addition, our results indicate that for orangutans, there was no clear relationship between canopy connectivity and terrestriality. Overall, our data suggest that terrestriality is relatively common for the orangutans in Wehea Forest and represents a regular strategy employed by individuals of all age-sex classes. As Borneo and Sumatra increasingly become characterized by mixed-use habitats, understanding the ecological requirements and resilience in orangutans is necessary for designing optimal conservation strategies.

Implications of large-scale infrastructure development for biodiversity in Indonesian Borneo.

Indonesia is embarking on an ambitious relocation of its capital city to Kalimantan, Borneo, bringing with it major urban and road infrastructure. Yet, despite being one of the world's most biologically diverse regions, the potential implications of this development for wildlife have yet to be fully assessed. We explored the potential impacts of the capital relocation, and road expansion and upgrades to critical habitat for medium-large mammals (>1 kg) using camera trap data from 11 forested landscapes. We applied Bayesian multi-species occupancy models to predict community and species-level responses to anthropogenic and environmental factors. We extrapolated spatial patterns of occupancy and species diversity across the forests of Kalimantan and identified "critical habitats" as the top 20th percentile of occupancy and species richness values. We subsequently overlapped these critical habitat layers with infrastructure impact zones to estimate the area that could potentially be affected by direct or secondary impacts. At both the community and species-level, distance to primary roads had the strongest negative influence on habitat-use. Occupancy was also influenced by forest quality and multidimensional poverty conditions in adjacent villages, demonstrating the sensitivity of biodiversity to socio-ecological pressures. Less than 1 % of the critical habitat for the threatened mammal community lay within the direct impact zone (30 km radius) of the capital relocation. However, approximately 16 % was located within 200 km and could potentially be affected by uncontrolled secondary impacts such as urban sprawl and associated regional development. The often-overlooked secondary implications of upgrading existing roads could also intersect a large amount of critical habitat for lowland species. Mitigating far-reaching secondary impacts of infrastructure development should be fully incorporated into environmental impact assessments. This will provide Indonesia with an opportunity to set an example of sustainable infrastructure development in the tropics.

Discovery of Miller's Grizzled Langur (Presbytis hosei canicrus) in Wehea Forest confirms the continued existence and extends known geographical range of an endangered primate.

Miller's Grizzled Langur (Presbytis hosei canicrus) is one of the least known and rarest primates in Borneo. With a limited geographic range along the central coast of East Kalimantan and the highly degraded Kutai National Park, its former stronghold, this subspecies is now extremely rare and has been listed as one of the world's 25 most endangered primates. From June 6 to August 2, 2011, we carried out both direct observation and camera trap surveys at two mineral springs (sepans) in the Wehea Forest, East Kutai district, East Kalimantan. Presbytis hosei canicrus was observed at the large sepan on 3 of 6 observation days and at the small sepan on 2 of 3 observation days with up to 11 individuals observed in a single day at a single site. Camera traps recorded a per day capture rate of 0.72 at the small sepan and 0.25 at the large sepan and a per photo capture rate of 0.50 and 0.005, respectively. These data suggest relatively frequent occurrence of P. h. canicrus at the sepans, but the langurs are rarely encountered elsewhere in the Wehea Forest. The discovery of P. h. canicrus in the Wehea Forest confirms the continued existence of this endangered primate and is the first solid evidence demonstrating that its geographic range extends further inland than previously thought. It is not known whether the population of P. h. canicrus within Wehea Forest is large and stable enough to be considered viable, but it is likely part of a larger population that may possibly occur across surrounding protected forests and logging concessions. Surveying this potentially large population, and securing its protection, should be a priority measure for ensuring the continued existence of P. h. canicrus.

Effectiveness of 20 years of conservation investments in protecting orangutans.

Conservation strategies are rarely systematically evaluated, which reduces transparency, hinders the cost-effective deployment of resources, and hides what works best in different contexts. Using data on the iconic and critically endangered orangutan (Pongo spp.), we developed a novel spatiotemporal framework for evaluating conservation investments. We show that around USD 1 billion was invested between 2000 and 2019 into orangutan conservation by governments, nongovernmental organizations, companies, and communities. Broken down by allocation to different conservation strategies, we find that habitat protection, patrolling, and public outreach had the greatest return on investment for maintaining orangutan populations. Given the variability in threats, land-use opportunity costs, and baseline remunerations in different regions, there were differential benefits per dollar invested across conservation activities and regions. We show that although challenging from a data and analysis perspective, it is possible to fully understand the relationships between conservation investments and outcomes and the external factors that influence these outcomes. Such analyses can provide improved guidance toward a more effective biodiversity conservation. Insights into the spatiotemporal interplays between the costs and benefits driving effectiveness can inform decisions about the most suitable orangutan conservation strategies for halting population declines. Although our study focuses on the three extant orangutan species of Sumatra and Borneo, our findings have broad application for evidence-based conservation science and practice worldwide.

Male and female range use in a group of white-bellied spider monkeys (Ateles belzebuth) in Yasuní National Park, Ecuador.

Spider monkeys (Ateles sp.) live in a flexible fission-fusion social system in which members of a social group are not in constant association, but instead form smaller subgroups of varying size and composition. Patterns of range use in spider monkeys have been described as sex-segregated, with males and females often ranging separately, females utilizing core areas that encompass only a fraction of the entire community range, and males using much larger portions of the community range that overlap considerably with the core areas of females and other males. Males are also reported to use the boundary areas of community home ranges more often than females. Spider monkeys thus seem to parallel the "male-bonded" patterns of ranging and association found among some groups of chimpanzees. Over several years of research on one group of spider monkeys (Ateles belzebuth) in Yasuní National Park, Ecuador, we characterized the ranging patterns of adult males and females and evaluated the extent to which they conform to previously reported patterns. In contrast to ranging patterns seen at several other spider monkey sites, the ranges of our study females overlapped considerably, with little evidence of exclusive use of particular areas by individual monkeys. Average male and female home range size was comparable, and males and females were similar in their use of boundary areas. These ranging patterns are similar to those of "bisexually bonded" groups of chimpanzees in West Africa. We suggest that the less sex-segregated ranging patterns seen in this particular group of spider monkeys may be owing to a history of human disturbance in the area and to lower genetic relatedness between males, highlighting the potential for flexibility some aspects of the spider monkeys' fission-fusion social system.

Association of sedentary time with blood pressure in women of reproductive age.

While the beneficial impact of moderate-vigorous physical activity (MVPA) on blood pressure is well-understood, the relationship between sedentary time (ST) and blood pressure is less clear. We aimed to evaluate the associations between ST and BP in reproductive-age women. This cross-sectional analysis consisted of 431 women enrolled in the Placenta as a Window to Maternal Microvascular Disease Risk study at Magee-Womens Hospital. Blood pressure and self-reported physical activity and ST were collected 8-10 years after delivery at study enrollment. Logistic and linear regression models examined associations between ST and blood pressure and adjusted for MVPA. Women with the highest amount of ST were less likely to be normotensive and more likely to have elevated blood pressure and Stage II hypertension (p = 0.02). Each additional hour of ST was associated with an increased risk of Stage II hypertension (OR 1.12 [1.01-1.24]) and higher systolic blood pressure (0.45 mmHg [0.08-0.82]), diastolic blood pressure (0.29 mmHg [0.02-0.56]), and mean arterial pressure (0.34 mmHg [0.05-0.63]), after adjustment for covariates. This relationship was more apparent in women who participated in less MVPA (bottom 50th percentile) versus more MVPA (top 50th percentile). ST is associated with higher blood pressure, particularly in women who engage in less aerobic activity, and could serve as an important intervention target for reducing blood pressure and hypertension during the reproductive years.

Prolonged antepartum hospitalization: no time for rest.

OBJECTIVE: To characterize sleep patterns among pregnant women undergoing prolonged antepartum hospitalization. STUDY DESIGN: We conducted a prospective cohort study of women undergoing prolonged antepartum hospitalization after 20 weeks' gestation. Women were recruited to wear an Actigraph, complete a sleep log for 7 consecutive days, and complete a sleep survey at the end of the study period. Actigraphy was used to determine rest and sleep intervals, sleep onset latency, and wake time after sleep onset. RESULTS: A total of 40 participants were recruited, and 28 had ≥ 5 nights of data for a total of 177 nights of antepartum sleep data. Mean gestational age was 30 weeks. Median sleep duration was 7.05 h ± 1.71 h. In all, 43.5% of women had an average sleep duration of <7 h per night. In all, 28.2% of the study nights had a bedtime between midnight and 5 am. Going to bed between midnight and 5 am was significantly associated with sleep durations of <7 h (70.7 vs. 32.5%, p < .001). Participants reported an average of 2.4 awakenings per night due to hospital-related events. CONCLUSIONS: Prolonged antepartum hospitalization has a negative impact on sleep duration and quality.

Orangutans venture out of the rainforest and into the Anthropocene.

Conservation benefits from understanding how adaptability and threat interact to determine a taxon's vulnerability. Recognizing how interactions with humans have shaped taxa such as the critically endangered orangutan (Pongo spp.) offers insights into this relationship. Orangutans are viewed as icons of wild nature, and most efforts to prevent their extinction have focused on protecting minimally disturbed habitat, with limited success. We synthesize fossil, archeological, genetic, and behavioral evidence to demonstrate that at least 70,000 years of human influence have shaped orangutan distribution, abundance, and ecology and will likely continue to do so in the future. Our findings indicate that orangutans are vulnerable to hunting but appear flexible in response to some other human activities. This highlights the need for a multifaceted, landscape-level approach to orangutan conservation that leverages sound policy and cooperation among government, private sector, and community stakeholders to prevent hunting, mitigate human-orangutan conflict, and preserve and reconnect remaining natural forests. Broad cooperation can be encouraged through incentives and strategies that focus on the common interests and concerns of different stakeholders. Orangutans provide an illustrative example of how acknowledging the long and pervasive influence of humans can improve strategies to preserve biodiversity in the Anthropocene.

Global Demand for Natural Resources Eliminated More Than 100,000 Bornean Orangutans.

Unsustainable exploitation of natural resources is increasingly affecting the highly biodiverse tropics [1, 2]. Although rapid developments in remote sensing technology have permitted more precise estimates of land-cover change over large spatial scales [3-5], our knowledge about the effects of these changes on wildlife is much more sparse [6, 7]. Here we use field survey data, predictive density distribution modeling, and remote sensing to investigate the impact of resource use and land-use changes on the density distribution of Bornean orangutans (Pongo pygmaeus). Our models indicate that between 1999 and 2015, half of the orangutan population was affected by logging, deforestation, or industrialized plantations. Although land clearance caused the most dramatic rates of decline, it accounted for only a small proportion of the total loss. A much larger number of orangutans were lost in selectively logged and primary forests, where rates of decline were less precipitous, but where far more orangutans are found. This suggests that further drivers, independent of land-use change, contribute to orangutan loss. This finding is consistent with studies reporting hunting as a major cause in orangutan decline [8-10]. Our predictions of orangutan abundance loss across Borneo suggest that the population decreased by more than 100,000 individuals, corroborating recent estimates of decline [11]. Practical solutions to prevent future orangutan decline can only be realized by addressing its complex causes in a holistic manner across political and societal sectors, such as in land-use planning, resource exploitation, infrastructure development, and education, and by increasing long-term sustainability [12]. VIDEO ABSTRACT.

First integrative trend analysis for a great ape species in Borneo.

For many threatened species the rate and drivers of population decline are difficult to assess accurately: species' surveys are typically restricted to small geographic areas, are conducted over short time periods, and employ a wide range of survey protocols. We addressed methodological challenges for assessing change in the abundance of an endangered species. We applied novel methods for integrating field and interview survey data for the critically endangered Bornean orangutan (Pongo pygmaeus), allowing a deeper understanding of the species' persistence through time. Our analysis revealed that Bornean orangutan populations have declined at a rate of 25% over the last 10 years. Survival rates of the species are lowest in areas with intermediate rainfall, where complex interrelations between soil fertility, agricultural productivity, and human settlement patterns influence persistence. These areas also have highest threats from human-wildlife conflict. Survival rates are further positively associated with forest extent, but are lower in areas where surrounding forest has been recently converted to industrial agriculture. Our study highlights the urgency of determining specific management interventions needed in different locations to counter the trend of decline and its associated drivers.

Coming down from the trees: is terrestrial activity in Bornean orangutans natural or disturbance driven?

The orangutan is the world's largest arboreal mammal, and images of the red ape moving through the tropical forest canopy symbolise its typical arboreal behaviour. Records of terrestrial behaviour are scarce and often associated with habitat disturbance. We conducted a large-scale species-level analysis of ground-based camera-trapping data to evaluate the extent to which Bornean orangutans Pongo pygmaeus come down from the trees to travel terrestrially, and whether they are indeed forced to the ground primarily by anthropogenic forest disturbances. Although the degree of forest disturbance and canopy gap size influenced terrestriality, orangutans were recorded on the ground as frequently in heavily degraded habitats as in primary forests. Furthermore, all age-sex classes were recorded on the ground (flanged males more often). This suggests that terrestrial locomotion is part of the Bornean orangutan's natural behavioural repertoire to a much greater extent than previously thought, and is only modified by habitat disturbance. The capacity of orangutans to come down from the trees may increase their ability to cope with at least smaller-scale forest fragmentation, and to cross moderately open spaces in mosaic landscapes, although the extent of this versatility remains to be investigated.

Understanding the impacts of land-use policies on a threatened species: is there a future for the Bornean orang-utan?

The geographic distribution of Bornean orang-utans and its overlap with existing land-use categories (protected areas, logging and plantation concessions) is a necessary foundation to prioritize conservation planning. Based on an extensive orang-utan survey dataset and a number of environmental variables, we modelled an orang-utan distribution map. The modelled orang-utan distribution map covers 155,106 km(2) (21% of Borneo's landmass) and reveals four distinct distribution areas. The most important environmental predictors are annual rainfall and land cover. The overlap of the orang-utan distribution with land-use categories reveals that only 22% of the distribution lies in protected areas, but that 29% lies in natural forest concessions. A further 19% and 6% occurs in largely undeveloped oil palm and tree plantation concessions, respectively. The remaining 24% of the orang-utan distribution range occurs outside of protected areas and outside of concessions. An estimated 49% of the orang-utan distribution will be lost if all forest outside of protected areas and logging concessions is lost. To avoid this potential decline plantation development in orang-utan habitats must be halted because it infringes on national laws of species protection. Further growth of the plantation sector should be achieved through increasing yields in existing plantations and expansion of new plantations into areas that have already been deforested. To reach this goal a large scale island-wide land-use masterplan is needed that clarifies which possible land uses and managements are allowed in the landscape and provides new standardized strategic conservation policies. Such a process should make much better use of non-market values of ecosystem services of forests such as water provision, flood control, carbon sequestration, and sources of livelihood for rural communities. Presently land use planning is more driven by vested interests and direct and immediate economic gains, rather than by approaches that take into consideration social equity and environmental sustainability.

Unexpected ecological resilience in Bornean orangutans and implications for pulp and paper plantation management.

Ecological studies of orangutans have almost exclusively focused on populations living in primary or selectively logged rainforest. The response of orangutans to severe habitat degradation remains therefore poorly understood. Most experts assume that viable populations cannot survive outside undisturbed or slightly disturbed forests. This is a concern because nearly 75% of all orangutans live outside protected areas, where degradation of natural forests is likely to occur, or where these are replaced by planted forests. To improve our understanding of orangutan survival in highly altered forest habitats, we conducted population density surveys in two pulp and paper plantation concessions in East Kalimantan, Indonesia. These plantations consist of areas planted with fast-growing exotics intermixed with stands of highly degraded forests and scrublands. Our rapid surveys indicate unexpectedly high orangutan densities in plantation landscapes dominated by Acacia spp., although it remains unclear whether such landscapes can maintain long-term viable populations. These findings indicate the need to better understand how plantation-dominated landscapes can potentially be incorporated into orangutan conservation planning. Although we emphasize that plantations have less value for overall biodiversity conservation than natural forests, they could potentially boost the chances of orangutan survival. Our findings are based on a relatively short study and various methodological issues need to be addressed, but they suggest that orangutans may be more ecologically flexible than previously thought.