Reproductive inequality in humans and other mammals.

To address claims of human exceptionalism, we determine where humans fit within the greater mammalian distribution of reproductive inequality. We show that humans exhibit lower reproductive skew (i.e., inequality in the number of surviving offspring) among males and smaller sex differences in reproductive skew than most other mammals, while nevertheless falling within the mammalian range. Additionally, female reproductive skew is higher in polygynous human populations than in polygynous nonhumans mammals on average. This patterning of skew can be attributed in part to the prevalence of monogamy in humans compared to the predominance of polygyny in nonhuman mammals, to the limited degree of polygyny in the human societies that practice it, and to the importance of unequally held rival resources to women's fitness. The muted reproductive inequality observed in humans appears to be linked to several unusual characteristics of our species-including high levels of cooperation among males, high dependence on unequally held rival resources, complementarities between maternal and paternal investment, as well as social and legal institutions that enforce monogamous norms.

Metabolic acceleration and the evolution of human brain size and life history.

Humans are distinguished from the other living apes in having larger brains and an unusual life history that combines high reproductive output with slow childhood growth and exceptional longevity. This suite of derived traits suggests major changes in energy expenditure and allocation in the human lineage, but direct measures of human and ape metabolism are needed to compare evolved energy strategies among hominoids. Here we used doubly labelled water measurements of total energy expenditure (TEE; kcal day(-1)) in humans, chimpanzees, bonobos, gorillas and orangutans to test the hypothesis that the human lineage has experienced an acceleration in metabolic rate, providing energy for larger brains and faster reproduction without sacrificing maintenance and longevity. In multivariate regressions including body size and physical activity, human TEE exceeded that of chimpanzees and bonobos, gorillas and orangutans by approximately 400, 635 and 820 kcal day(-1), respectively, readily accommodating the cost of humans' greater brain size and reproductive output. Much of the increase in TEE is attributable to humans' greater basal metabolic rate (kcal day(-1)), indicating increased organ metabolic activity. Humans also had the greatest body fat percentage. An increased metabolic rate, along with changes in energy allocation, was crucial in the evolution of human brain size and life history.

What is "safety"?: Lethal means counseling as a cross-cultural communication.

U.S. suicide rates have risen every year over the past two decades with self-directed firearm use as the method accounting for the highest proportion of deaths. This pattern is particularly pronounced among veterans and members of the U.S. Armed Forces. The numerical burden of firearm-related suicide accompanied by characteristics of self-directed firearm injury have motivated the development of lethal means safety initiatives focused on firearms. Simultaneously, research has sought to characterize patterns of firearm ownership and use among veterans as well as optimal strategies for clinicians to deliver suicide prevention messages to firearm owners. Increasingly, findings from research have been understood as cultural factors that warrant greater attention to improve the quality of lethal means counseling. Here, we review and interpret selected research on cultural aspects of firearm ownership and suggest that cultural differences between health care practitioners and firearm owners may result in health care practitioners delivering clinical interventions that are broadly divergent from perspectives within the cultural frameworks of firearm owners. We follow by organizing these cultural factors into existing frameworks of cultural competency training as a basis for developing curriculum for health care practitioners to improve clinical care.

Characterizing Veterans Crisis Line callers and regional follow-up efforts.

The Veterans Crisis Line (VCL) is a national resource offering Veterans 24/7 access to crisis responders and follow-up by a licensed mental health clinician at a Veterans Affairs medical center. This quality improvement project aimed to improve local suicide prevention efforts at the VA Puget Sound Health Care System by characterizing 344 VCL calls and outcomes. Data was extracted from documentation by national VCL responders and local Suicide Prevention Team members. Overall, most callers were assessed at low-to-moderate risk. VCL responders were more likely to assess callers reporting suicidal ideation (SI) as high-risk, but less likely to assess those reporting financial issues as high-risk. VCL calls about SI, about physical health, or that occurred on weekends were more likely to end with immediate evaluation (i.e., emergency room, evaluated by first-responders) compared to their respective comparison groups. VCL calls assessed as high-risk were more likely to report SI during local follow-up contact, whereas VCL calls ending in immediate evaluation (i.e., emergency room, evaluated by first-responders) were less likely to report SI during follow-up with the local VA clinician; 17% of VCL calls without SI reported SI at follow-up. Training of local Suicide Prevention Team members should include that SI can change rapidly and requires assessment regardless of SI during the VCL call.

Assessing conservation attitudes and behaviors of Congolese children neighboring the world's first bonobo (Pan paniscus) release site.

Poaching and habitat destruction in the Congo Basin threaten African great apes including the bonobo (Pan paniscus), chimpanzees (Pan troglodytes), and gorillas (Gorilla spp.) with extinction. One way to combat extinction is to reintroduce rescued and rehabilitated apes and repopulate native habitats. Reintroduction programs are only successful if they are supported by local populations. Ekolo ya Bonobo, located in Equateur province of the Democratic Republic of Congo (DRC), is the world's only reintroduction site for rehabilitated bonobos. Here we assess whether children, of the Ilonga-Pôo, living adjacent to Ekolo ya Bonobo demonstrate more pro-ape conservation attitudes than children living in, Kinshasa, the capital city. We examined children's attitudes toward great apes because children are typically the focus of conservation education programs. We used the Great Ape Attitude Questionnaire to test the Contact Hypothesis, which posits that proximity to great ape habitat influences pro-conservation attitudes toward great apes. Ilonga-Pôo children who live in closer contact with wild bonobos felt greater responsibility to protect great apes compared to those in Kinshasa who live outside the natural habitat of great apes. These results suggest that among participants in the DRC, spatial proximity to a species fosters a greater sense of responsibility to protect and conserve. These results have implications for the successful implementation of great ape reintroduction programs in the Congo Basin. The data analyzed in this study were collected in 2010 and therefore provide a baseline for longitudinal study of this reintroduction site.

Sexual dimorphism in chimpanzee (Pan troglodytes schweinfurthii) and human age-specific fertility.

Across vertebrates, species with intense male mating competition and high levels of sexual dimorphism in body size generally exhibit dimorphism in age-specific fertility. Compared with females, males show later ages at first reproduction and earlier reproductive senescence because they take longer to attain adult body size and musculature, and maintain peak condition for a limited time. This normally yields a shorter male duration of effective breeding, but this reduction might be attenuated in species that frequently use coalitionary aggression. Here, we present comparative genetic and demographic data on chimpanzees from three long-term study communities (Kanyawara: Kibale National Park, Uganda; Mitumba and Kasekela: Gombe National Park, Tanzania), comprising 581 male risk years and 112 infants, to characterize male age-specific fertility. For comparison, we update estimates from female chimpanzees in the same sites and append a sample of human foragers (the Tanzanian Hadza). Consistent with the idea that aggressive mating competition favors youth, chimpanzee males attained a higher maximum fertility than females, followed by a steeper decline with age. Males did not show a delay in reproduction compared with females, however, as adolescents in both sites successfully reproduced by targeting young, subfecund females, who were less attractive to adults. Gombe males showed earlier reproductive senescence and a shorter duration of effective breeding than Gombe females. By contrast, older males in Kanyawara generally continued to reproduce, apparently by forming coalitions with the alpha. Hadza foragers showed a distinct pattern of sexual dimorphism in age-specific fertility as, compared with women, men gained conceptions later but continued reproducing longer. In sum, both humans and chimpanzees showed sexual dimorphism in age-specific fertility that deviated from predictions drawn from primates with more extreme body size dimorphism, suggesting altered dynamics of male-male competition in the two lineages. In both species, coalitions appear important for extending male reproductive careers.

Maturation is prolonged and variable in female chimpanzees.

Chimpanzees are important referential models for the study of life history in hominin evolution. Age at sexual maturity and first reproduction are key life history milestones that mark the diversion of energy from growth to reproduction and are essential in comparing life history trajectories between chimpanzees and humans. Yet, accurate information on ages at these milestones in wild chimpanzees is difficult to obtain because most females transfer before breeding. Precise age at first birth is only known from a relatively small number of non-dispersing individuals. Moreover, due to small sample sizes, the degree to which age at maturation milestones varies is unknown. Here we report maturation milestones and explore sources of variance for 36 wild female chimpanzees of known age, including eight dispersing females born in Gombe National Park, Tanzania. Using Kaplan-Meier survival analysis, including censored intervals, we find an average age of 11.5 years (range 8.5-13.9) at sexual maturity and 14.9 years (range 11.1-22.1) at first birth. These values exceed previously published averages for wild chimpanzees by one or more years. Even in this larger sample, age at first birth is likely underestimated due to the disproportionate number of non-dispersing females, which, on average, give birth two years earlier than dispersing females. Model selection using Cox Proportional Hazards models shows that age at sexual maturity is delayed in females orphaned before age eight years and those born to low-ranking mothers. Age at first birth is most delayed in dispersing females and those orphaned before age eight years. These data provide improved estimates of maturation milestones in a population of wild female chimpanzees and indicate the importance of maternal factors in development.

What influences a pet dog's first impression of a stranger?

Dogs live in the dynamic human social networks full of strangers, yet they form strong and selective bonds with familiar caretakers. Little is known about how a bond is initially formed between a dog and a complete stranger. The first-impression hypothesis suggests that interacting with strangers can present an opportunity to form a mutualistic partnership. It predicts that dogs should respond positively toward a complete stranger to facilitate bonding (Prediction 1) and adjust their preferences in response to the perceived risk and benefit of interacting with strangers (Prediction 2). We examine the social preferences of pet dogs toward a complete stranger whom they have never met before and several other potential partners - the owner with whom subjects have had a positive, long-term bond (Experiment 1), and an exposed stranger with whom they have had a positive short-term interaction (Experiment 2) or a negative one (Experiment 3). In support of Prediction 1, subjects were exceptionally trusting across contexts. Mixed results were found with regard to Prediction 2. Subjects preferred their owner over a stranger when following social cues and (to a lesser degree) when approaching and feeding in close proximity. However, relative to a complete stranger, subjects did not consistently prefer the positively exposed stranger or avoid the negatively exposed one. The lack of clear selectivity might be due to pet dogs' high baseline level of trust of complete strangers or reflect the strength of their existing bonds that negated the need for another positive bond with a new human partner.

Morphological Identification of Hair Recovered from Feces for Detection of Cannibalism in Eastern Chimpanzees.

Chimpanzees (Pan troglodytes) are primarily frugivorous but consume a variable amount of meat from a variety of organisms, including other chimpanzees. Cannibalism is rare, usually follows lethal aggression, and does not occur following natural deaths. While chimpanzee cannibalism has been documented at multiple sites, many instances of this behavior go unrecorded. Identification of chimpanzee remains in feces, however, can provide indirect evidence of cannibalism. Hair, in particular, typically passes through the gastrointestinal tract undamaged and is commonly used for purposes of identification in wildlife forensics. Here we test the hypothesis that eastern chimpanzee (Pan troglodytes schweinfurthii) guard hair morphology can be reliably distinguished from the hairs of their most common prey species. Methods and results are presented in the context of a case study involving a suspected chimpanzee infanticide from Gombe, Tanzania. We find that chimpanzee guard hair morphology is unique among tested mammals and that the presence of abundant chimpanzee hair in feces is likely the result of cannibalism and not incidental ingestion from grooming or other means. Accordingly, morphological analysis of guard hairs from feces is a promising, cost-effective tool for the determination of cannibalistic acts in chimpanzees.

Predation by female chimpanzees: Toward an understanding of sex differences in meat acquisition in the last common ancestor of Pan and Homo.

Among modern foraging societies, men hunt more than women, who mostly target relatively low-quality, reliable resources (i.e., plants). This difference has long been assumed to reflect human female reproductive constraints, particularly caring for and provisioning mates and offspring. Long-term studies of chimpanzees (Pan troglodytes) enable tests of hypotheses about the possible origins of human sex differences in hunting, prior to pair-bonding and regular provisioning. We studied two eastern chimpanzee communities (Kasekela, Mitumba) in Gombe, Tanzania and one (Kanyawara) in Kibale, Uganda. Relative to males, females had low hunting rates in all three communities, even where they encountered red colobus monkeys (the primary prey of chimpanzees) as often as males did. There was no evidence that clinging offspring hampered female hunting. Instead, consistent with the hypothesis that females should be more risk-averse than males, females at all three sites specialized in low-cost prey (terrestrial/sedentary prey at Gombe; black and white colobus monkeys at Kanyawara). Female dominance rank was positively correlated with red colobus hunting probability only at Kasekela, suggesting that those in good physical condition were less sensitive to the costs of possible failure. Finally, the potential for carcass appropriation by males deterred females at Kasekela (but not Kanyawara or Mitumba) from hunting in parties containing many adult males. Although chimpanzees are not direct analogs of the last common ancestor (LCA) of Pan and Homo, these results suggest that before the emergence of social obligations regarding sharing and provisioning, constraints on hunting by LCA females did not necessarily stem from maternal care. Instead, they suggest that a risk-averse foraging strategy and the potential for losing prey to males limited female predation on vertebrates. Sex differences in hunting behavior would likely have preceded the evolution of the sexual division of labor among modern humans.

Primate energy expenditure and life history.

Humans and other primates are distinct among placental mammals in having exceptionally slow rates of growth, reproduction, and aging. Primates' slow life history schedules are generally thought to reflect an evolved strategy of allocating energy away from growth and reproduction and toward somatic investment, particularly to the development and maintenance of large brains. Here we examine an alternative explanation: that primates' slow life histories reflect low total energy expenditure (TEE) (kilocalories per day) relative to other placental mammals. We compared doubly labeled water measurements of TEE among 17 primate species with similar measures for other placental mammals. We found that primates use remarkably little energy each day, expending on average only 50% of the energy expected for a placental mammal of similar mass. Such large differences in TEE are not easily explained by differences in physical activity, and instead appear to reflect systemic metabolic adaptation for low energy expenditures in primates. Indeed, comparisons of wild and captive primate populations indicate similar levels of energy expenditure. Broad interspecific comparisons of growth, reproduction, and maximum life span indicate that primates' slow metabolic rates contribute to their characteristically slow life histories.

A Comprehensive Review of Hirudiniasis: From Historic Uses of Leeches to Modern Treatments of Their Bites.

Exposure to leeches in the wilderness setting is common. Leeches may attach themselves to exposed skin or pass through one of the body's orifices and attach internally. The condition of leech attachment is known as hirudiniasis, which can result in serious morbidity and, rarely, mortality. A comprehensive review of the literature was performed to detail the prevention of leech attachment, as well as both anecdotal and studied methods of removal. Complications from leech attachments include ongoing bleeding, wound infection, and poor wound healing. Although medicinal leeches are the most well-studied variety, this review examines all aspects of leech attachment, prevention, and management.

Preventive Services Use Among African American and Latino Adult Caregivers in South Los Angeles.

BACKGROUND: The burden of informal caregiving is significant and well-documented, yet the evidence is mixed as to whether being a caregiver presents an additional barrier to receiving recommended preventive care. OBJECTIVES: To determine whether (1) caregivers compared with noncaregivers were less likely to receive preventive health services; and (2) higher intensity caregivers were less likely to receive preventive health services than lower intensity caregivers. RESEARCH DESIGN, SUBJECTS, AND MEASURES: Data were from a telephone survey of Latino and African American adults 50 years or older in South Los Angeles (n=702). Outcomes were flu vaccination, pneumococcal vaccination, and colorectal cancer screening. Logistic regression models adjusted for predisposing, enabling, and need factors according to the Andersen Model of Access to Health Care for Low-income Populations. RESULTS: Caregiver type (eg, adult child, nonrelated) was associated with varying odds of receiving a preventive service. Caregivers had lower odds than noncaregivers of receiving preventive services although odds of receiving a flu vaccination improved slightly for caregivers of persons with memory loss compared with other caregivers. More weekly caregiving hours was associated with higher odds of receiving flu vaccination (adjusted odds ratios, 1.1; 95% confidence interval=1.0, 1.1) or colorectal cancer screening (adjusted odds ratios, 1.1; 95% confidence interval=1.0, 1.1). Caregivers and noncaregivers age 65 and older or with chronic conditions were more likely to receive vaccinations. CONCLUSIONS: Preventive service use was influenced by characteristics of the caregiving situation. An opportunity may exist to leverage care recipients' ongoing contact with health care providers to increase caregivers' own access to preventive services.

Development of a survey instrument to measure patient experience of integrated care.

BACKGROUND: Healthcare systems are working to move towards more integrated, patient-centered care. This study describes the development and testing of a multidimensional self-report measure of patients' experiences of integrated care. METHODS: Random-digit-dial telephone survey in 2012 of 317 adults aged 40 years or older in the San Francisco region who had used healthcare at least twice in the past 12 months. One-time cross-sectional survey; psychometric evaluation to confirm dimensions and create multi-item scales. Survey data were analyzed using VARCLUS and confirmatory factor analysis and internal consistency reliability testing. RESULTS: Scales measuring five domains were confirmed: coordination within and between care teams, navigation (arranging appointments and visits), communication between specialist and primary care doctor, and communication between primary care doctor and specialist. Four of these demonstrated excellent internal consistency reliability. Mean scale scores indicated low levels of integration. CONCLUSION: These scales measuring integrated care capture meaningful domains of patients' experiences of health care. The low levels of care integration reported by patients in the study sample suggest that these types of measures should be considered in ongoing evaluations of health system performance and improvement. Further research should examine whether differences in patient experience of integrated care are associated with differences in the processes and outcomes of care received.

Alternative Payment Models and Working with Payers-Key Considerations for Advancing Population Health Goals and Achieving Child Health Equity.

This article summarizes approaches to achieving value-based care in Pediatrics, providing a framework for understanding the continuum of models from fee-for-service to advanced alternative payment models. We present key examples of how alternative payment models have been developed and applied at the federal level within Medicare through the work of the Centers for Medicare and Medicaid Services (CMS) and the Center for Medicaid and Medicaid Innovation (CMMI). We further describe key lessons learned and opportunities to adapt value-based payment models to promote whole child health and equity. Finally, we summarize policy considerations and challenges in achieving accountability and aligning financial incentives for children's health within a complex payer landscape.

The association among specialty, race, ethnicity, and practice location among California physicians in diverse specialties.

BACKGROUND: Minority physicians are more likely than their counterparts to work in underserved communities and care for minority, poor, and uninsured patients, but much of this research has examined primary care physicians alone. Few have investigated whether non-primary care specialists of minority backgrounds are more likely to serve the underserved than nonminority specialists. OBJECTIVE: We examined whether underrepresented minority (URM) physicians from a wide variety of specialties are more likely than non-URM physicians to practice in underserved communities. METHODS: Using California Medical Board Physician Licensure Survey (2007) data for 48388 physicians, we geo-coded practice zip codes to medically underserved areas (MUAs) and primary care health professional shortage areas (HPSAs). Logistic regression models adjusting for age, gender, specialty, and other characteristics were used to explore associations with race, ethnicity, specialty, and designated underserved areas. RESULTS: We found that African American, Latino, and Pacific Islanders were more likely to work in MUAs and HPSAs than were white physicians (adjusted odds ratio, 1.22-2.25; p < .05). Similar patterns of practice in MUAs and HPSAs by physician race and ethnicity were found when performing the analyses separately among primary care physicians and physicians in non-primary care specialties. CONCLUSION: In summary, our study underscores the importance of underrepresented minority physicians in all specialties for the physician workforce needs of disadvantaged communities. To improve health care for underserved communities, continued efforts to increase physician diversity are essential.

Do physicians with self-reported non-English fluency practice in linguistically disadvantaged communities?

BACKGROUND: Language concordance between physicians and patients may reduce barriers to care faced by patients with limited English proficiency (LEP). It is unclear whether physicians with fluency in non-English languages practice in areas with high concentrations of people with LEP. OBJECTIVE: To investigate whether physician non-English language fluency is associated with practicing in areas with high concentrations of people with LEP. DESIGN: Cross-sectional cohort study. PARTICIPANTS: A total of 61,138 practicing physicians no longer in training who participated in the California Medical Board Physician Licensure Survey from 2001-2007. MEASURES: Self-reported language fluency in Spanish and Asian languages. Physician practice ZIP code corresponding to: (1) high concentration of people with LEP and (2) high concentration of linguistically isolated households. METHODS: Practice location ZIP code was geocoded with geographic medical service study designations. We examined the unadjusted relationships between physician self-reported fluency in Spanish and selected Asian languages and practice location, stratified by race-ethnicity. We used staged logistic multiple variable regression models to isolate the effect of self-reported language fluency on practice location controlling for age, gender, race-ethnicity, medical specialty, and international medical graduate status. RESULTS: Physicians with self-reported fluency in Spanish or an Asian language were more likely to practice in linguistically designated areas in these respective languages compared to those without fluency. Physician fluency in an Asian language [adjusted odds ratio (AOR) = 1.77; 95% confidence intervals (CI): 1.63-1.92] was independently associated with practicing in areas with a high number of LEP Asian speakers. A similar pattern was found for Spanish language fluency (AOR = 1.77; 95% CI: 1.43-1.82) and areas with high numbers of LEP Spanish-speakers. Latino and Asian race-ethnicity had the strongest effect on corresponding practice location, and this association was attenuated by language fluency. CONCLUSIONS: Physicians who are fluent in Spanish or an Asian language are more likely to practice in geographic areas where their potential patients speak the corresponding language.