Bat activity is related to habitat structure and time since prescribed fire in managed pine barrens in New England.

Background: Several insectivorous bat species are found in New England, yet research on them is still scarce. Current research shows the ecological importance of bats due to their control of insect populations, but they are endangered by habitat loss and White Nose Syndrome, among other threats. Pine barrens are an uncommon ecosystem found in New England that supports other rare taxa and could be important for these bat species. Methods: With hand-held audio recorders, we surveyed for bats in Montague Plains Wildlife Management Area in Massachusetts and Concord Pine Barrens in New Hampshire in June 2022. Our study objectives were to (1) describe the most common bat species and (2) compare bat activity across different habitat types at two managed pine barrens in New England. In particular, we examined bat activity related to habitat type (scrub oak, mature pitch pine, treated pitch pine, hardwood forest), habitat structure (i.e., canopy closure), time since prescribed fire, and path width. We analyzed our data through generalized linear modeling and logistic regression. Results: Overall, we were able to measure the presence of five out of the nine total species found in the area, including the endangered Myotis lucifugus (little brown bat). We recorded 293 bat calls, with the majority of calls from big brown bats (71%). We found significant differences (p < 0.05) in bat activity in relation to time since prescribed fire and habitat structure. The index of bat activity was greatest in pitch pine and hardwood forests and lowest in scrub oak and treated pitch pine habitats. With preliminary data, we also found that silver-haired bat presence was influenced by habitat type, with more detections at survey points in hardwood forests. Discussion: These findings demonstrate the importance of pine barrens as an ecosystem that supports bats in New England. According to the activity of bats in our study, closed canopy and mature pitch pine habitats may be prioritized in conservation efforts at managed barrens for bat species. Further research is recommended to better understand the relationship between prescribed fires, which are common in managed barrens, and bat activity.

Plastic Surgery Roles in Wound Centers in the Northeastern United States.

INTRODUCTION: Wound care is a substantial industry costing nearly $19 billion USD, and dedicated wound care centers play a critical role via a multidisciplinary team-based approach. At the same time, plastic surgeons are often considered experts in evaluation and management of wounds, particularly chronic and complex wounds. However, the extent of direct involvement of plastic surgeons in wound care centers is unclear. In this study, we sought to evaluate the presence of plastic surgeons and other specialties in wound care centers across all Northeastern states Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Jersey, New York, New Hampshire, Pennsylvania, Rhode Island, Virginia, West Virginia, and Vermont. METHODS: A comprehensive list of wound care clinics in northeastern United States was obtained from the Healogics website. For each site, information was gathered via website listings, including number of providers and the professional certification/specialization for each provider. Providers were those with qualifications including Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Doctor of Physical Therapy (DPT), Doctor of Podiatric Medicine (DPM), Certified Registered Nurse Anesthetist (CRNA), Certified Registered Nurse Practitioner (CRNP), Physician Associate (PA), and Physical Therapist (PT). RESULTS: A total of 118 Healogics wound care clinics and 492 providers were located across 14 northeastern states including District of Columbia. After researching each location, updated in November 2022, plastic surgeons were only 3.7% (18 of 492) providers employed. Specialties such as internal medicine (90 of 492 [18%]), general surgery (76 of 492 [15%]), podiatry (68 of 292 [13.8% ]), and other midlevel providers such as nurse practitioners (35 of 492 [7.1%]) were more frequently employed over plastic surgery. All plastic surgeons were board certified the American Board of Plastic Surgery. CONCLUSIONS: Wound care requires collaboration between specialties, with significant repercussions on health care costs and patient outcomes. Plastic surgery provides unique surgical services for the healing of wounds, and the natural expectation would be that plastic surgery should be heavily involved at wound care centers. However, the data do not reflect significant involvement at an official level. Further studies will investigate causes and the societal, financial, and patient impacts of this lack of direct engagement. Although many plastic surgeons may not desire the majority of their practice to be wound care management, it stands to reason that some affiliation, at least for patient awareness and referral, may be warranted.

Dietary Supplement Intake and Factors Associated with Increased Use in Preadolescent Endurance Runners.

BACKGROUND: The prevalence of dietary supplement intake among preadolescent endurance runners is currently unknown. OBJECTIVE: Our aim was to describe use of dietary supplements, higher-risk supplements, and sport foods among preadolescent endurance athletes and identify associated characteristics of dietary supplement users in this population. DESIGN: This was a retrospective, cross-sectional study. PARTICIPANTS/SETTING: Participants were 2,113 preadolescent endurance runners (male: n = 1,255, female: n = 858; mean age ± standard deviation = 13.2 ± 0.9 years). MAIN OUTCOME MEASURES: Use of dietary supplements, higher-risk dietary supplements, and sport foods on 2 or more days per week during the past year. STATISTICAL ANALYSES PERFORMED: Mann-Whitney U tests, χ2 tests, univariate and multivariate analyses. RESULTS: Twenty-six percent (n = 551) of preadolescent runners used dietary supplements on 2 or more days per week during the past year; 1.3% (n = 27) reported taking higher-risk supplements. Compared with male runners, female runners reported higher use of 1 or more supplements (32.5% vs 21.7%; P < .001) and 4 or more supplements (4.0% vs 1.9%; P = 0.005), multivitamin/minerals (24.2% vs 14.4%; P < .001), vitamin D (12.4% vs 5.6%; P < .001), calcium (8.9% vs 4.8%; P < .001), iron (3.1 vs 1.1%; P < .001), probiotic supplements (8.2% vs 1.3%; P < .001), and diet pills (0.5% vs 0.0%; P = .02). Male runners reported higher use of creatine (1.3% vs 0.0%; P < .001) and sport foods, including protein bars and drinks (19.5% vs 8.4%; P < .001), energy bars (23.5% vs 9.7%; P < .001), and carbohydrate-electrolyte drinks (27.9% vs 13.3%; P < .001) than female runners. Factors independently associated with a higher likelihood for dietary supplement use included weight loss in the past year, female (vs male) gender, following a vegetarian diet, skipping meals, attempting to gain weight, and history of a running-related bone stress injury. CONCLUSIONS: More than one-quarter of preadolescent runners regularly consumed dietary supplements. Behaviors consistent with dietary restriction and history of bone stress injury were associated with higher likelihood for supplement use. Further work to understand supplement use patterns and potential value for nutrition education is advised to optimize health of preadolescent runners.

Findings From a Provider-Led, Mindfulness-Based, Internet-Streamed Yoga Video Addressing the Psychological Outcomes of Breast Cancer Survivors.

The aim of this study was to explore the psychological outcomes of a mindfulness-based Internet-streamed yoga video in breast cancer survivors. A one-group, repeated-measures, purposive sample using a directed qualitative descriptive and convergent mixed-methods approach was used. Participants were recruited from breast oncology practices across 2 settings in the northeastern United States in April 2019. Education about the video was provided, and the link to the video was sent to participants. Demographic information, Knowing Participation in Change Short Form (KPCSF), Short Warwick-Edinburgh Mental Well-being Scale (WEMWBS), and the Generalized Anxiety Distress Scale (GAD-7) were obtained at baseline and at 2 and 4 weeks. A semistructured interview was conducted at 4 weeks. Thirty-five women (mean age = 56 years) participated. A one-group, repeated-measures analysis of variance indicated statistically significant changes occurred in all measures between week 0 and week 4: decreased GAD (t = -2.97, P = .004), improved WEMWBS (t = 2.52, P = .008), and increased KPC (t = 2.99, P = .004). Qualitative findings suggest the overall experience of the video was positive and the women would recommend its use to others. Improvements in all psychological measures were achieved with video use. Findings indicate an improvement in psychological measures and support the theory of Knowing Participation in Change. This work further contributes to accessible, flexible interventions available through the Internet and/or mobile applications aimed at improving breast cancer survivorship.

Assessing the immediate impact of COVID-19 on surgical oncology practice: Experience from an NCI-designated Comprehensive Cancer Center in the Northeastern United States.

BACKGROUND: The effects of the coronavirus disease 2019 (COVID-19) pandemic on surgical oncology practice are not yet quantified. The aim of this study was to measure the immediate impact of COVID-19 on surgical oncology practice volume. METHODS: A retrospective study of patients treated at an NCI-Comprehensive Cancer Center was performed. "Pre-COVID" era was defined as January-February 2020 and "COVID" as March-April 2020. Primary outcomes were clinic visits and operative volume by surgical oncology subspecialty. RESULTS: Abouyt 907 new patient visits, 3897 follow-up visits, and 644 operations occurred during the study period. All subspecialties experienced significant decreases in new patient visits during COVID, though soft tissue oncology (Mel/Sarc), gynecologic oncology (Gyn/Onc), and endocrine were disproportionately affected. Telehealth visits increased to 11.4% of all visits by April. Mel/Sarc, Gyn/Onc, and Breast experienced significant operative volume decreases during COVID (25.8%, p = 0.012, 43.6% p < 0.001, and 41.9%, p < 0.001, respectively), while endocrine had no change and gastrointestinal oncology had a slight increase (p = 0.823) in the number of cases performed. CONCLUSIONS: The effects of the COVID-19 pandemic are wide-ranging within surgical oncology subspecialties. The addition of telehealth is a viable avenue for cancer patient care and should be considered in surgical oncology practice.

Gender Differences in Patterns and Correlates of Continued Substance Use among Patients in Methadone Maintenance Treatment.

BACKGROUND: Continued substance use is common during opioid use disorder (OUD) treatment. There are still inconsistencies in how continued substance use and concurrent patterns of substance use among patients with OUD varies by gender. There is still more to learn regarding how factors associated with continued and concurrent use might differ for men and women in methadone maintenance treatment (MMT). Methods: This cross-sectional study examined predictors of concurrent substance use subgroups among patients receiving MMT. The sample included 341 (n = 161 women) MMT patients aged 18 and older from opioid treatment programs in Southern New England and the Pacific Northwest. Patients completed a survey assessing sociodemographic and clinical characteristics including past-month substance use. Latent class analyses were conducted by gender to identify groups based on substance use and determine predictors of those classes. Results: Three-class solutions were the optimal fit for both men and women. For both genders, the first subgroup was characterized as Unlikely Users (59.8% women, 52.8% men). Classes 2 and 3 among women were Cannabis/Opioid Users (23.7%) and Stimulant/Opioid Users (13.0%). Among men, Classes 2 and 3 consisted of Alcohol/Cannabis Users (21.9%) and Cannabis/Stimulant/Opioid Users (25.3%). Ever using Suboxone (buprenorphine/naloxone) and depression/anxiety symptoms were significantly linked to substance use group among women, whereas homelessness and employment status were significantly associated with substance use group among men. Conclusions: This study furthers understanding of gender differences in factors associated with continued substance use and distinctive patterns of concurrent substance use that may guide tailored treatments among patients MMT.

Integrated substance use and prenatal care delivery in the era of COVID-19.

The COVID-19 pandemic has directly impacted integrated substance use and prenatal care delivery in the United States and has driven a rapid transformation from in-person prenatal care to a hybrid telemedicine care model. Additionally, changes in regulations for take home dosing for methadone treatment for opioid use disorder due to COVID-19 have impacted pregnant and postpartum women. We review the literature on prenatal care models and discuss our experience with integrated substance use and prenatal care delivery during COVID-19 at New England's largest safety net hospital and national leader in substance use care. In our patient-centered medical home for pregnant and postpartum patients with substance use disorder, patients' early responses to these changes have been overwhelmingly positive. Should clinicians continue to use these models, thoughtful planning and further research will be necessary to ensure equitable access to the benefits of telemedicine and take home dosing for all pregnant and postpartum patients with substance use disorder.

Cannabis Use and Nonfatal Opioid Overdose among Patients Enrolled in Methadone Maintenance Treatment.

BACKGROUND: Some ecological studies found lower rates of opioid overdose in states with liberalized cannabis legislation, but results are mixed, and the association has not been analyzed in individuals. We quantified the association between cannabis use and nonfatal opioid overdose among individuals enrolled in methadone maintenance treatment (MMT) for opioid use disorder (OUD). METHODS: We recruited a convenience sample of individuals enrolled in four MMT clinics in Washington State and southern New England who completed a one-time survey.Descriptive statistics and multivariate logistic regression compared the prevalence and risk of nonfatal opioid overdose in the past 12 months between participants reporting frequent (at least weekly) or infrequent (once or none) cannabis use in the past month. RESULTS: Of 446 participants, 35% (n = 156) reported frequent cannabis use and 7% (n = 32) reported nonfatal opioid overdose in the past year. The prevalence of nonfatal opioid overdose was 3% among reporters of frequent cannabis use, and 9% among reporters of infrequent/no use (p = 0.02). After imputing missing data and controlling for demographic and clinical factors, the likelihood of self-reported nonfatal opioid overdose in the past year was 71% lower among reporters of frequent cannabis use in the past month (adjusted RR = 0.29, 95% CI 0.10-0.80, p = 0.02). CONCLUSIONS: Among individuals enrolled in MMT, frequent cannabis use in the past month was associated with fewer self-reported nonfatal opioid overdoses in the past year. Methodological limitations caution against causal interpretation of this relationship. Additional studies are needed to understand the prospective impact of co-occurring cannabis on opioid-related outcomes.

Regional Changes in Patterns of Stroke Presentation During the COVID-19 Pandemic.

[Figure: see text].

The HIV Care Continuum in Small Cities of Southern New England: Perspectives of People Living with HIV/AIDS, Public Health Experts, and HIV Service Providers.

The HIV care continuum (HCC), comprised of five steps (screening, linkage to care, treatment initiation, retention, and viral suppression), is used to monitor treatment delivery to people living with HIV (PLWH). The HCC has primarily focused on large urban or metropolitan areas where the situation may differ from that in smaller cities. Three themes (i.e., knowledge, stigma, stability) that shaped HCC outcomes were identified from analysis of two qualitative studies involving HIV service providers, public health experts, and PLWH in smaller cities of southern New England. The findings suggest that enhancing HCC outcomes require a multiprong approach that targets both the individual and organizational levels and includes interventions to increase health literacy, staff communication skills, universal screening to assess patients' religiosity/spirituality and supplemental service needs. Interventions that further ensure patient confidentiality and the co-location and coordination of HIV and other healthcare services are particularly important in smaller cities.

RESUMEN: El cuidado continuo de VIH (HCC), constado de cinco etapas (pruebas, vinculación al cuidado, inico del tratamiento, retención, y supresión viral), se emplea para monitorizar la entrega de tratamientos a las personas que vivien con VIH (PLWH). El HCC ha enfocado principalmente en áreas grandes y urbanas o áreas metropolitanas, donde la situación podría ser diferente que la de las ciudades más pequeñas. Tres temas (i.e., conocimiento, estigma, estabilidad) que formaron los resultados de HCC fueron identificados con análisis de dos estudios cualitativos que involucraron los proveedores de servicios de VIH, expertos de la salud pública, y PLWH en ciudades más pequeñas en las partes sureñas de Nueva Inglaterra. Los hallazgos sugieren que la mejora de los resultados de HCC requiere un enfoque multidimensional que se dirigen a ambos niveles del individuo y organización, y que incluyen intervenciones para aumentar la alfabetización sanitaria, la habilidad de comunicación del personal, la prueba universal para evaluar la religiosidad/espiritualidad de los pacientes y la necesidad de servicios suplementarios. Intervenciones que aseguran aún más la confidencialidad de los pacientes y el co-ubicación y coordinación de los servicios de VIH y otras asistencias medicas son particularmente importantes en ciudades pequeñas.

Seeing the whole elephant - How lobstermen's local ecological knowledge can inform fisheries management.

Lobstermen in Southern New England come from a longstanding intergenerational fishing tradition. Their local ecological knowledge (LEK) on the American lobster, Homarus americanus can be an important source of information for management. This paper examines lobstermen's LEK as it relates to stock assessment and the overlap to science based ecological knowledge (SEK). Although in recent years, using vent-less trap assessments and conducting young of the year surveys, has set the stage for more cooperative research, in our opinion, lobstermen's LEK remains underutilized in fisheries management. There has been a steady decline in the lobster stocks over the years, raising concerns regarding fisheries management. For this reason, we turn to lobstermen's knowledge as an important source that could inform fisheries management. Using a semi-structured approach, the stakeholders' LEK and open discussions were recorded during three meetings where lobstermen participated with managers and scientists. LEK was transcribed and categorized and matched to the corresponding SEK described in the literature. Results generally found that the lobstermen's LEK corresponded with the best available SEK. LEK is compatible with an ecosystem view of the fishery that integrates the complexities of interacting systems. The lobstermen explained that they viewed their fishing grounds as "managed landscapes", areas used productively, maintained and protected by them. These results are a starting point to broaden the base of the knowledge used in fisheries management enabling us to see the whole picture. Topics of LEK and SEK convergence are promising common ground, while topics where lobstermen and managers' views differ, can serve as points of entry to enable research and cooperative management. Both can be the basis for cooperative hypothesis testing.

Forty Years of University of New England's Research and Scholarship and its Impact in Maine, New England, and Beyond.

The University of New England College of Osteopathic Medicine (UNE COM) was founded by a group of osteopathic physicians who wanted to ensure that the practice of Osteopathic Medicine would endure in northern New England and that patients in the region would continue to receive the best health care possible. UNECOM merged with St. Francis College in 1978 to form the University of New England (UNE). 1 UNE has grown and developed over the years, building on the shared Franciscan and osteopathic traditions of integrating philosophy and intellect. Following the 1996 merger with Westbrook College in Portland, Maine, UNE now comprises 3 campuses, 13 additional health profession programs, 6 Centers of Excellence in Research, and strong undergraduate programs that link the environment, people, and community in a "One Health" concept.

Fatty Acid Content of Retail Cow's Milk in the Northeastern United States-What's in It for the Consumer?

The fatty acid (FA) composition and content of whole milk (3.25% fat) from organic, omega-3 (n-3) FA fortified, and conventional retail brands available in the northeastern U.S. were assessed monthly via gas chromatography. Among the retail labels, organic milk stood out as it contained a distinct and more healthful FA profile, consistently comprising a higher content of unique bioactive FAs (short-chain FAs, odd- and branched-chain FAs, vaccenic acid, and conjugated linoleic acids) per serving, particularly during the warm season. The total content of saturated FAs did not differ by retail label. While organic and n-3 fortified milk contained a similar content of total n-3 FAs, the proportion of individual n-3 FAs differed significantly (organic milk: 18:3 n-3; n-3 fortified milk: 20:6 n-3) as a result of the production system and process, respectively. Overall, per serving, the FA profile of organic milk may provide added nutritional and health benefits.

Trends in Telestroke Care Delivery: A 15-Year Experience of an Academic Hub and Its Network of Spokes.

BACKGROUND: Telestroke provides access to vascular neurology expertise for hospitals lacking stroke coverage, and its use has risen rapidly in the past decade. We aim to characterize consultations, spoke behavior, and the relationship between spoke telestroke utilization (number of telestroke consults per year) and spoke alteplase treatment metrics in an academic telestroke network. METHODS AND RESULTS: We analyzed prospectively collected data on all telestroke consults from 2003 to 2018. Trends in network performance and spoke characteristics were analyzed using generalized estimating equations and Kendall τß nonparametric tests as appropriate. Unadjusted and adjusted linear regression models determined associations between telestroke utilization and treatment metrics. The network included 2 hubs and 43 spokes with 12 803 consults performed during the study period. Network growth overall was +1.8 spokes per year, and median duration of spoke participation was 7.9 years. The numbers of consults and alteplase-treated patients increased annually, even after adjusting for the number of spokes in the network (P<0.01 for both). Although times from last seen well to spoke emergency department arrival and to consult request increased, door-to-needle time, time from teleconsult request to callback, and time from teleconsult to alteplase administration all decreased (all P<0.01). With time, the network included more spokes without a Primary Stroke Center designation. In adjusted analyses, for every 10 telestroke consults requested by a spoke, the spoke door-to-needle decreased by 1.8 minutes (P=0.02), number of patients treated with alteplase was an additional 1.7 (P<0.01), and the percent of eligible patients treated with alteplase increased by 8% (P=0.03). CONCLUSIONS: Telestroke network size and utilization increased over time. Increased use of teleconsults was associated with increased and timely use of alteplase. Over time, the delivery of timely emergency care has improved significantly among emergency departments participating in this telestroke network. Replication of these findings in other networks is warranted.

Categorizing Cannabis and Alcohol Use Patterns of Emerging Adults in Psychiatric Partial Hospitalization Treatment.

BACKGROUND: Emerging adulthood is a common and problematic time for alcohol and cannabis use. Emerging adulthood also represents a vulnerable time period for anxiety and depression. Substance use and mental health issues are highly comorbid, yet substance use is commonly neglected in psychiatric care. OBJECTIVE: The goal of this study was to categorize the cannabis and alcohol use patterns of emerging adults in psychiatric care and to evaluate relationships with use-related problems, psychiatric symptomatology, and motives for use. METHODS: Participants were emerging adults who were consecutive admissions to a young adult psychiatric partial hospital program from 2017 to 2018. Of 318 participants who completed questionnaires, 244 (76.7%) reported cannabis and/or alcohol use in the previous month. Cluster analyses and analysis of variance tests were conducted to categorize and differentiate between participants who reported use. RESULTS: Results from cluster analyses identified 4 categories of use: low cannabis/high alcohol (35.7%), low cannabis/low alcohol (17.6%), high cannabis/low alcohol (29.1%), and high cannabis/high alcohol (17.6%). Individuals in categories with the highest rates of use and co-use reported more alcohol problems (F=24.31, P<0.001), cannabis problems (F=36.75, P<0.001), depression (F=3.60, P=0.01), and motives: social (F=6.12, P<0.001), coping with anxiety (F=20.43, P<0.001), coping with depression (F=17.80, P<0.001), enhancement (F=7.85, P<0.001), and conformity (F=4.92, P<0.01). CONCLUSIONS/IMPORTANCE: Clear categories of substance use emerged. Participants who were heavier users were more likely to use to alleviate psychiatric symptomatology, yet they also reported greater psychiatric symptomatology and use-related problems. Among a psychiatric sample of emerging adults, cannabis and alcohol use was common and problematic. Thus, substance use should be evaluated for and, if present, targeted with interventions during psychiatric care.

The cresting wave: larval settlement and ocean temperatures predict change in the American lobster harvest.

Adding to the challenge of predicting fishery recruitment in a changing environment is downscaling predictions to capture locally divergent trends over a species' range. In recent decades, the American lobster (Homarus americanus) fishery has shifted poleward along the northwest Atlantic coast, one of the most rapidly warming regions of the world's oceans. Building on evidence that early post-settlement life stages predict future fishery recruitment, we describe enhancements to a forecasting model that predict landings using an annual larval settlement index from 62 fixed sites among 10 study areas from Rhode Island, USA to New Brunswick, Canada. The model is novel because it incorporates local bottom temperature and disease prevalence to scale spatial and temporal changes in growth and mortality. For nine of these areas, adding environmental predictors significantly improved model performance, capturing a landings surge in the eastern Gulf of Maine, and collapse in southern New England. On the strength of these analyses, we project landings within the next decade to decline to near historical levels in the Gulf of Maine and no recovery in the south. This approach is timely as downscaled ocean temperature projections enable decision makers to assess their options under future climate scenarios at finer spatial scales.

[The beginning of modern nursing education: the first hospital nursing school in the United States at New England Hospital for Women and Children].

In 1872, New England Hospital for Women and Children was established as the first hospital nursing school in the United States, which became the beginning of modern nursing education in the United States. Its establishment and development were influenced by Nightingale's nursing educational thought, and were also closely related to the work of two American female doctors. The establishment of New England Hospital for Women and Children nursing school made it possible to train professional nurses through formal nursing education, and laid the foundation for the development of nursing education in the United States.

Dietary quality, as measured by the Alternative Healthy Eating Index for Pregnancy (AHEI-P), in couples planning their first pregnancy.

OBJECTIVE: Dietary quality (DQ), as assessed by the Alternative Healthy Eating Index for Pregnancy (AHEI-P), and conception and pregnancy outcomes were evaluated. DESIGN: In this prospective cohort study on couples planning their first pregnancy. Cox proportional hazards regression assessed the relationship between AHEI-P score and clinical pregnancy, live birth and pregnancy loss. SETTING: Participants were recruited from the Northeast region of the USA.Participants: Healthy, nulliparous couples (females, n 132; males, n 131; one male did not enrol). RESULTS: There were eighty clinical pregnancies, of which sixty-nine resulted in live births and eleven were pregnancy losses. Mean (sd) female AHEI-P was 71·0 (13·7). Of those who achieved pregnancy, those in the highest tertile of AHEI-P had the greatest proportion of clinical pregnancies; however, this association was not statistically significant (P = 0·41). When the time it took to conceive was considered, females with the highest AHEI-P scores were 20 % and 14 % more likely to achieve clinical pregnancy (model 1: hazard ratio (HR) = 1·20; 95 % CI 0·66, 2·17) and live birth (model 1: HR = 1·14; 95 % CI 0·59, 2·20), respectively. Likelihood of achieving clinical pregnancy and live birth increased when the fully adjusted model, including male AHEI-P score, was examined (clinical pregnancy model 4: HR = 1·55; 95 % CI 0·71, 3·39; live birth model 4: HR = 1·36; 95 % CI 0·59, 3·13). CONCLUSIONS: The present study is the first to examine AHEI-P score and achievement of clinical pregnancy. DQ was not significantly related to pregnancy outcomes, even after adjustments for covariates.

Medicaid Accountable Care Organizations in Four States: Implementation and Early Impacts.

Policy Points Maine, Massachusetts, Minnesota, and Vermont leveraged State Innovation Model awards to implement Medicaid accountable care organizations (ACOs). Flexibility in model design, ability to build on existing reforms, provision of technical assistance to providers, and access to feedback data all facilitated ACO development. Challenges included sustainability of transformation efforts and the integration of health care and social service providers. Early estimates showed promising improvements in hospital-related utilization and Vermont was able to reduce or slow the growth of Medicaid costs. These states are sustaining Medicaid ACOs owing in part to provider support and early successes in generating shared savings. The states are modifying their ACOs to include greater accountability and financial risk. CONTEXT: As state Medicaid programs consider alternative payment models (APMs), many are choosing accountable care organizations (ACOs) as a way to improve health outcomes, coordinate care, and reduce expenditures. Four states (Maine, Massachusetts, Minnesota, and Vermont) leveraged State Innovation Model awards to create or expand Medicaid ACOs. METHODS: We used a mixed-methods design to assess achievements and challenges with ACO implementation and the impact of Medicaid ACOs on health care utilization, quality, and expenditures in three states. We integrated findings from key informant interviews, focus groups, document review, and difference-in-difference analyses using data from Medicaid claims and an all-payer claims database. FINDINGS: States built their Medicaid ACOs on existing health care reforms and infrastructure. Facilitators of implementation included allowing flexibility in design and implementation, targeting technical assistance, and making clinical, cost, and use data readily available to providers. Barriers included provider concerns about their ability to influence patient behavior, sustainability of provider practice transformation efforts when shared savings are reinvested into the health system and not shared with participating clinicians, and limited integration between health care and social service providers. Medicaid ACOs were associated with some improvements in use, quality, and expenditures, including statistically significant reductions in emergency department visits. Only Vermont's ACO demonstrated slower growth in total Medicaid expenditures. CONCLUSIONS: Four states demonstrated that adoption of ACOs for Medicaid beneficiaries was both possible and, for three states, associated with some improvements in care. States revised these models over time to address stakeholder concerns, increase provider participation, and enable some providers to accept financial risk for Medicaid patients. Lessons learned from these early efforts can inform the design and implementation of APMs in other Medicaid programs.

Citizen science observations reveal rapid, multi-decadal ecosystem changes in eastern Long Island Sound.

Long-term environmental records are among the most valuable assets for understanding the trajectory and consequences of climate change. Here we report on a newly recovered time-series from Project Oceanology, a non-profit ocean science organization serving New England schools (USA) since 1972. As part of its educational mission, Project Oceanology has routinely and consistently recorded water temperature, pH, and oxygen as well as invertebrate and fish abundance in nearshore waters of the Thames River estuary in eastern Long Island Sound (LIS). We digitized these long-term records to test for decadal trends in abiotic and biotic variables including shifts in species abundance, richness, and diversity. Consistent with previous studies, the data revealed an above-average warming rate of eastern LIS waters over the past four decades (+0.45 °C decade-1), a non-linear acidification trend twice the global average (-0.04 pH units decade-1), and a notable decline in whole water-column dissolved oxygen concentrations (-0.29 mg L-1 decade-1). Trawl catches between 1997 and 2016 suggested a significant decrease in overall species diversity and richness, declines in cold-water adapted species such as American lobster (Homarus americanus), rock crab (Cancer irroratus), and winter flounder (Pseudopleuronectes americanus), but concurrent increases in the warm-water decapod Libinia emarginata (spider crab). Our study confirmed that Long Island Sound is a rapidly changing urban estuary, while demonstrating the value of long-term observations made by citizen-scientists, educators, and other stakeholders.