The effect of a startle-eliciting device on the foraging success of individual harbor seals (Phoca vitulina).

Pinniped predation on commercially and ecologically important prey has been a source of conflict for centuries. In the Salish Sea, harbor seals (Phoca vitulina) are suspected of impeding the recovery of culturally and ecologically critical Pacific salmon (Oncorhynchus spp.). In Fall 2020, a novel deterrent called Targeted Acoustic Startle Technology (TAST) was deployed at Whatcom Creek to deter harbor seals from preying on fall runs of hatchery chum (O. keta) and Chinook (O. tshawytscha) salmon in Bellingham, Washington, USA. Field observations were conducted in 2020 to compare the presence and foraging success of individual harbor seals across sound exposure (TAST-on) and control (TAST-off) conditions. Observations conducted the previous (2019) and following (2021) years were used to compare the effects observed in 2020 to two control years. Using photo-identification, individual seals were associated with foraging successes across all 3 years of the study. Generalized linear mixed models showed a significant 45.6% reduction in the duration (min) individuals remained at the creek with TAST on, and a significant 43.8% reduction in the overall foraging success of individuals. However, the observed effect of TAST varied across individual seals. Seals that were observed regularly within one season were more likely to return the year after, regardless of TAST treatment. Generalized linear models showed interannual variation in the number of seals present and salmon consumed. However, the effect of TAST in 2020 was greater than the observed variation across years. Our analyses suggest TAST can be an effective tool for managing pinniped predation, although alternate strategies such as deploying TAST longer-term and using multi-unit setups to increase coverage could help strengthen its effects. Future studies should further examine the individual variability found in this study.

A novel pharmacy liaison program to address health-related social needs at an urban safety-net hospital.

PURPOSE: Patients with unmet health-related social needs (HRSNs) often experience poor health outcomes and have high levels of healthcare utilization. We describe a program where dually trained pharmacy liaison-patient navigators (PL-PNs) screen for and address HRSNs while providing medication management services to patients with high levels of acute care utilization in a Medicaid Accountable Care Organization. We are unaware of prior studies that have described this PL-PN role. METHODS: We analyzed case management spreadsheets for the 2 PL-PNs who staffed the program to identify the HRSNs that patients faced and the ways PL-PNs addressed them. We administered surveys, including an 8-item client satisfaction questionnaire (CSQ-8), to characterize patient perceptions of the program. RESULTS: Initially, 182 patients (86.6% English speaking, 80.2% from a marginalized racial or ethnic group, and 63.2% with a significant medical comorbidity) were enrolled in the program. Non-English-speaking patients were more likely to receive the minimum intervention dose (completion of an HRSN screener). Case management spreadsheet data (available for 160 patients who engaged with the program) indicated that 71% of participants faced at least one HRSN, most often food insecurity (30%), lack of transportation (21%), difficulty paying for utilities (19%), and housing insecurity (19%). Forty-three participants (27%) completed the survey with an average CSQ-8 score of 27.9, indicating high levels of satisfaction with the program. Survey participants reported receiving medication management services, social needs referrals, health-system navigation assistance, and social support. CONCLUSION: Integration of pharmacy medication adherence and patient navigation services is a promising approach to streamline the HRSN screening and referral process at an urban safety-net hospital.

A Pharmacy Liaison-Patient Navigation Intervention to Reduce Inpatient and Emergency Department Utilization Among Primary Care Patients in a Medicaid Accountable Care Organization: A Nonrandomized Controlled Trial.

Importance: Patients with unmet health-related social needs are at high risk for preventable health care utilization. Prior interventions to identify health-related social needs and provide navigation services with community resources have not taken place in pharmacy settings. Objective: To evaluate an enhancement of pharmacy care to reduce hospital admissions and emergency department (ED) visits among primary care patients in a Medicaid accountable care organization (ACO). Design, Setting, and Participants: This nonrandomized controlled trial was conducted from May 1, 2019, through March 4, 2021, with 1 year of follow-up. Study allocation was determined by odd or even medical record number. The study was performed at a general internal medicine practice at a large safety-net hospital in Boston, Massachusetts. Patients who qualified for the hospital's pharmacy care program (aged 18-64 years and within the third to tenth percentile for health care utilization and cost among Medicaid ACO membership) who attended a visit with a primary care clinician were eligible. Of 770 eligible patients, 577 were approached, 127 declined, and 86 could not be contacted. Interventions: Patients in the control group received usual pharmacy care focused on medication adherence. Patients in the intervention group received enhanced pharmacy care with an additional focus on identification of and intervention for health-related social needs. The intervention took place for 1 year. Main Outcomes and Measures: The primary outcome was inpatient hospital admissions and ED visits (composite outcome) in the 12 months after enrollment during the intervention period. Results: Among 364 allocated patients (mean [SD] age, 50.1 [10.1] years; 216 women [59.3%]), 35 were Hispanic of any race (9.6%) and 214 were non-Hispanic Black (58.8%). All participants were included in the intention-to-treat analysis. In analyses controlling for baseline hospital admissions and ED visits the year prior to enrollment, the enhanced pharmacy care group was not associated with the odds of having any hospital admission or ED visit (adjusted odds ratio, 0.62 [95% CI, 0.23-1.62]; P = .32) among all patients and was not associated with the visit rates among those with any visit (adjusted rate ratio, 0.93 [95% CI, 0.71-1.22]; P = .62) relative to the usual pharmacy care group in the year following enrollment. Conclusions and Relevance: The findings of this nonrandomized controlled trial suggest that inpatient and ED utilization among Medicaid ACO members at a safety-net hospital was not significantly different between groups at 1-year follow-up. Trial Registration: ClinicalTrials.gov Identifier: NCT03919084.

Key questions in marine mammal bioenergetics.

Bioenergetic approaches are increasingly used to understand how marine mammal populations could be affected by a changing and disturbed aquatic environment. There remain considerable gaps in our knowledge of marine mammal bioenergetics, which hinder the application of bioenergetic studies to inform policy decisions. We conducted a priority-setting exercise to identify high-priority unanswered questions in marine mammal bioenergetics, with an emphasis on questions relevant to conservation and management. Electronic communication and a virtual workshop were used to solicit and collate potential research questions from the marine mammal bioenergetic community. From a final list of 39 questions, 11 were identified as 'key' questions because they received votes from at least 50% of survey participants. Key questions included those related to energy intake (prey landscapes, exposure to human activities) and expenditure (field metabolic rate, exposure to human activities, lactation, time-activity budgets), energy allocation priorities, metrics of body condition and relationships with survival and reproductive success and extrapolation of data from one species to another. Existing tools to address key questions include labelled water, animal-borne sensors, mark-resight data from long-term research programs, environmental DNA and unmanned vehicles. Further validation of existing approaches and development of new methodologies are needed to comprehensively address some key questions, particularly for cetaceans. The identification of these key questions can provide a guiding framework to set research priorities, which ultimately may yield more accurate information to inform policies and better conserve marine mammal populations.

Measuring speed of vessels operating around endangered southern resident killer whales (Orcinus orca) in Salish Sea critical habitat.

Motorized vessels are a major source of anthropogenic noise and can have adverse effects on species relying on sound for communication and feeding. Monitoring noise levels received by endangered southern resident killer whales (SRKWs) requires knowing the number, distance, and speed of surrounding vessels, including small boats that do not have Automatic Identification Systems (AIS). A method for estimating their speed is required to predict received noise levels and compliance with vessel regulations. We compared theodolite and photogrammetry methods to estimate the number, distance, and speed of vessels in SRKW Salish Sea summertime critical habitat. By treating AIS as "truth", we found photogrammetry-derived ranges and speeds were more variable than theodolite estimates. Error in photogrammetry-derived speeds increased with range. Overall, we found time saved in the field using photogrammetry was more than offset by long analysis time. Theodolite data were relatively easy to collect, and produced accurate and precise results.

Behavioural responses of wild Pacific salmon and herring to boat noise.

There is growing concern about impacts of ship and small boat noise on marine wildlife. Few studies have quantified impacts of anthropogenic noise on ecologically, economically, and culturally important fish. We conducted open net pen experiments to measure Pacific herring (Clupea pallasii) and juvenile salmon (pink, Oncorhynchus gorbuscha, and chum, Oncorhynchus keta) behavioural response to noise generated by three boats travelling at different speeds. Dose-response curves for herring and salmon estimated 50% probability of eliciting a response at broadband received levels of 123 and 140 dB (re 1 µPa), respectively. Composite responses (yes/no behaviour change) were evaluated. Both genera spent more time exhibiting behaviours consistent with anti-predator response during boat passings. Repeated elicitation of vigilance or anti-predatory responses could result in increased energy expenditure or decreased foraging. These experiments form an important step toward assessing population-level consequences of noise, and its ecological costs and benefits to predators and prey.

Climate change complicates efforts to ensure survival and recovery of St. Lawrence Estuary beluga.

Decades after a ban on hunting, and despite focused management interventions, the endangered St. Lawrence Estuary (SLE) beluga (Delphinapterus leucas) population has failed to recover. We applied a population viability analysis to simulate the responses of the SLE beluga population across a wide range of variability and uncertainty under current and projected changes in environmental and climate-mediated conditions. Three proximate threats to recovery were explored: ocean noise; contaminants; and prey limitation. Even the most optimistic scenarios failed to achieve the reliable positive population growth needed to meet current recovery targets. Here we show that predicted effects of climate change may be a more significant driver of SLE beluga population dynamics than the proximate threats we considered. Aggressive mitigation of all three proximate threats will be needed to build the population's resilience and allow the population to persist long enough for global actions to mitigate climate change to take effect.

Destroying and Restoring Critical Habitats of Endangered Killer Whales.

Endangered species legislation in the United States and Canada aims to prevent extinction of species, in part by designating and protecting critical habitats essential to ensure survival and recovery. These strict laws prohibit adverse modification or destruction of critical habitat, respectively. Defining thresholds for such effects is challenging, especially for wholly aquatic taxa. Destruction of critical habitat (e.g., prey reduction and ocean noise) threatens the survival and recovery of the 75 members of the endangered southern resident killer whale population found in transboundary (Canada-United States) Pacific waters. The population's dynamics are now driven largely by the cumulative effects of prey limitation (e.g., the endangered Chinook salmon), anthropogenic noise and disturbance (e.g., reducing prey accessibility), and toxic contaminants, which are all forms of habitat degradation. It is difficult to define a single threshold beyond which habitat degradation becomes destruction, but multiple lines of evidence suggest that line may have been crossed already.

Reducing vessel noise increases foraging in endangered killer whales.

Disturbance from underwater noise is one of the primary threats to the critically endangered southern resident killer whales (SRKWs). Previous studies have demonstrated that SRKWs spend less time feeding when vessels are present. In 2018, we measured the effects of a voluntary vessel slowdown action in SRKW critical habitat to assess whether ship speed (and related source level) affects foraging behaviour. Observations of SRKWs and ships were collected from land-based sites on San Juan Island, WA, USA, overlooking the Haro Strait slow-down area. Exploratory analyses found little support for a linear relationship between ship speed and SRKW behaviour, but strong support between received noise level from ships and the probability of SRKWs engaging in foraging activity. Reducing ship speed, and therefore ship noise amplitude will help decrease the probability of ship noise disrupting SRKW foraging activity and may help to increase the proportion of accessible salmon.

Integrating substance use care into primary care for adolescents and young adults: Lessons learned.

BACKGROUND: Substance use disorders are common chronic conditions that often begin and develop during adolescence and young adulthood, yet the delivery of primary care is not developmentally tailored for youth who use substances. Very few primary care-based substance use treatment programs exist in the United States for adolescents and young adults and no clear guidance is available about how to provide substance use treatment in primary care. METHODS: We conducted a retrospective evaluation from July 2016 to December 2018 of a newly established primary care-based, multidisciplinary, outpatient program for youth who use substances. Components of the program include primary care, addiction treatment, harm reduction, naloxone distribution, psychotherapy, recovery support, and navigation addressing social determinants of health. We report the following patient characteristics and outcomes: demographics; proportion with substance use and mental health diagnoses; receipt of medications for opioid use disorder; retention in care at three, six, nine, and 12 months; and re-engagement in medical care. RESULTS: From July 2016 through December 2018, 148 patients had at least one visit. Demographic characteristics included: median age 21 years; 40.5% female; 94.0% spoke primarily English; 18.3% Black, 14.9% Hispanic, and 60.8% white. One-third of patients (33.8%) were homeless or housing insecure. The most common substance use disorder was opioid use disorder (60.8%), followed by nicotine (37.2%), cannabis (20.9%), and alcohol (18.2%). Overall, 29.7% of patients had depression, 32.4% had anxiety disorder, and 18.9% had post-traumatic stress disorder. Retention in care was 29.7% at six months and 12.2% at 12 months. Among the 90 patients with OUD, 90.0% received medication for OUD, and 35.5% and 15.5% of patients with OUD were retained at six and 12 months, respectively. For patients lost to follow-up (no contact during a three-month period), the median time to re-engagement was 4.8 months, and 33.3% (37/111) of patients re-engaged. The most common reason for re-engagement was to access mental health treatment (59.5%) and primary care (51.4%). CONCLUSIONS: Youth who sought care in a primary care-based substance use program presented most commonly with opioid, nicotine, cannabis, and alcohol use disorders. Co-morbid mental health diagnoses were common. While continuous retention at 12 months was low, one in three of the patients who fell out of care re-engaged. For youth receiving substance use care integrated into primary care, key components for pursing optimal retention in substance use treatment are a flexible model that anticipates the need for the treatment of mental health disorders and the use of re-engagement strategies.

Race/Ethnicity, Underlying Medical Conditions, Homelessness, and Hospitalization Status of Adult Patients with COVID-19 at an Urban Safety-Net Medical Center - Boston, Massachusetts, 2020.

As of July 5, 2020, approximately 2.8 million coronavirus disease 2019 (COVID-19) cases and 130,000 COVID-19-associated deaths had been reported in the United States (1). Populations historically affected by health disparities, including certain racial and ethnic minority populations, have been disproportionally affected by and hospitalized with COVID-19 (2-4). Data also suggest a higher prevalence of infection with SARS-CoV-2, the virus that causes COVID-19, among persons experiencing homelessness (5). Safety-net hospitals,† such as Boston Medical Center (BMC), which provide health care to persons regardless of their insurance status or ability to pay, treat higher proportions of these populations and might experience challenges during the COVID-19 pandemic. This report describes the characteristics and clinical outcomes of adult patients with laboratory-confirmed COVID-19 treated at BMC during March 1-May 18, 2020. During this time, 2,729 patients with SARS-CoV-2 infection were treated at BMC and categorized into one of the following mutually exclusive clinical severity designations: exclusive outpatient management (1,543; 56.5%), non-intensive care unit (ICU) hospitalization (900; 33.0%), ICU hospitalization without invasive mechanical ventilation (69; 2.5%), ICU hospitalization with mechanical ventilation (119; 4.4%), and death (98; 3.6%). The cohort comprised 44.6% non-Hispanic black (black) patients and 30.1% Hispanic or Latino (Hispanic) patients. Persons experiencing homelessness accounted for 16.4% of patients. Most patients who died were aged ≥60 years (81.6%). Clinical severity differed by age, race/ethnicity, underlying medical conditions, and homelessness. A higher proportion of Hispanic patients were hospitalized (46.5%) than were black (39.5%) or non-Hispanic white (white) (34.4%) patients, a finding most pronounced among those aged <60 years. A higher proportion of non-ICU inpatients were experiencing homelessness (24.3%), compared with homeless patients who were admitted to the ICU without mechanical ventilation (15.9%), with mechanical ventilation (15.1%), or who died (15.3%). Patient characteristics associated with illness and clinical severity, such as age, race/ethnicity, homelessness, and underlying medical conditions can inform tailored strategies that might improve outcomes and mitigate strain on the health care system from COVID-19.

A pharmacy liaison-patient navigation intervention to reduce inpatient and emergency department utilization among primary care patients in a Medicaid accountable care organization: A pragmatic trial protocol.

OBJECTIVE: To determine whether employing the services of a pharmacy liaison to promote medication adherence (usual care), relative to a pharmacy liaison with training in motivational interviewing and as a patient navigator who systematically screens for health-related social needs and provides targeted navigation services to connect patients with appropriate community resources in partnership with a community-based organization (enhanced usual care), will reduce inpatient hospital admissions and emergency department visits among patients who are members of a Medicaid ACO and receive primary care at a large urban safety-net hospital. BACKGROUND: Prior studies have demonstrated only modest effects in reducing utilization among safety-net patient populations. Interventions that address health-related social needs have the potential to reduce utilization in these populations. DESIGN/METHODS: Assignment to treatment condition is by medical record number (odd vs. even) and is unblinded (NCT03919084). Adults age 18-64 within the 3rd to 10th percentile for health care utilization and cost among Medicaid Accountable Care Organization membership attending a primary care visit in the general internal medicine practice at Boston Medical Center enrolled. DISCUSSION: Our study will advance the field in two ways: 1) by providing evidence about the effectiveness of pharmacy liaisons who also function as patient navigators; and 2) by de-implementing patient navigators. Patients in the enhanced usual care arm will no longer receive the services of a clinic-based patient navigator. In addition, our study includes a novel collaboration with a community-based organization, and focuses on an intermediate-cost patient population, rather than the most costly patient population.

Provision of Utility Shut-off Protection Letters at an Urban Safety-Net Hospital, 2009-2018.

Most states prohibit utility companies from terminating service to low-income households when occupants present a medical letter confirming a household member has a chronic serious illness. It is unclear how many patients receive these letters and whether screening for health-related social needs (HRSN) identifies these patients. We analyzed characteristics of adult patients at a safety-net hospital with a utility shut-off protection letter 2009-2018. A total of 2973 patients received a letter; most were non-Hispanic black, and had government insurance. Among patients who received a letter in 2018, 70% were screened for HRSN. Among these, only 16% screened positive for difficulty paying utility bills.

Approaches to reduce noise from ships operating in important killer whale habitats.

Shipping is key to global trade, but is also a dominant source of anthropogenic noise in the ocean. Chronic noise from ships can affect acoustic quality of important whale habitats. Noise from ships has been identified as one of three main stressors-in addition to contaminants, and lack of Chinook salmon prey-in the recovery of the endangered southern resident killer whale (SRKW) population. Managers recognize existing noise levels as a threat to the acoustical integrity of SRKW critical habitat. There is an urgent need to identify practical ways to reduce ocean noise given projected increases in shipping in the SRKW's summertime critical habitat in the Salish Sea. We reviewed the literature to provide a qualitative description of mitigation approaches. We use an existing ship source level dataset to quantify how some mitigation approaches could readily reduce noise levels by 3-10 dB.

Evaluating anthropogenic threats to endangered killer whales to inform effective recovery plans.

Understanding cumulative effects of multiple threats is key to guiding effective management to conserve endangered species. The critically endangered, Southern Resident killer whale population of the northeastern Pacific Ocean provides a data-rich case to explore anthropogenic threats on population viability. Primary threats include: limitation of preferred prey, Chinook salmon; anthropogenic noise and disturbance, which reduce foraging efficiency; and high levels of stored contaminants, including PCBs. We constructed a population viability analysis to explore possible demographic trajectories and the relative importance of anthropogenic stressors. The population is fragile, with no growth projected under current conditions, and decline expected if new or increased threats are imposed. Improvements in fecundity and calf survival are needed to reach a conservation objective of 2.3% annual population growth. Prey limitation is the most important factor affecting population growth. However, to meet recovery targets through prey management alone, Chinook abundance would have to be sustained near the highest levels since the 1970s. The most optimistic mitigation of noise and contaminants would make the difference between a declining and increasing population, but would be insufficient to reach recovery targets. Reducing acoustic disturbance by 50% combined with increasing Chinook by 15% would allow the population to reach 2.3% growth.

Quiet(er) marine protected areas.

A core task in endangered species conservation is identifying important habitats and managing human activities to mitigate threats. Many marine organisms, from invertebrates to fish to marine mammals, use acoustic cues to find food, avoid predators, choose mates, and navigate. Ocean noise can affect animal behavior and disrupt trophic linkages. Substantial potential exists for area-based management to reduce exposure of animals to chronic ocean noise. Incorporating noise into spatial planning (e.g., critical habitat designation or marine protected areas) may improve ecological integrity and promote ecological resilience to withstand additional stressors. Previous work identified areas with high ship noise requiring mitigation. This study introduces the concept of "opportunity sites" - important habitats that experience low ship noise. Working with existing patterns in ocean noise and animal distribution will facilitate conservation gains while minimizing societal costs, by identifying opportunities to protect important wildlife habitats that happen to be quiet.

Marine mammals and ocean noise: future directions and information needs with respect to science, policy and law in Canada.

Marine mammals are ecologically and culturally important species, and various countries have specific legislation to protect the welfare of individual marine mammals and the conservation of their populations. Anthropogenic noise represents a particular challenge for conservation and management. There is a large and growing body of research to support the conclusion that anthropogenic noise can affect marine mammal behavior, energetics, and physiology. The legal, policy, and management issues surrounding marine mammals and noise are similarly complex. Our objective is twofold. First, we discuss how policy and legal frameworks in Canada have some important differences from other jurisdictions covered in previous reviews, and provide a useful general case study. Secondly, we highlight some priority research areas that will improve marine mammal conservation and management. Our examples focus on the research needed to meet stated conservation objectives for marine mammal species in waters under Canadian jurisdiction.

Identifying modeled ship noise hotspots for marine mammals of Canada's Pacific region.

The inshore, continental shelf waters of British Columbia (BC), Canada are busy with ship traffic. South coast waters are heavily trafficked by ships using the ports of Vancouver and Seattle. North coast waters are less busy, but expected to get busier based on proposals for container port and liquefied natural gas development and expansion. Abundance estimates and density surface maps are available for 10 commonly seen marine mammals, including northern resident killer whales, fin whales, humpback whales, and other species with at-risk status under Canadian legislation. Ship noise is the dominant anthropogenic contributor to the marine soundscape of BC, and it is chronic. Underwater noise is now being considered in habitat quality assessments in some countries and in marine spatial planning. We modeled the propagation of underwater noise from ships and weighted the received levels by species-specific audiograms. We overlaid the audiogram-weighted maps of ship audibility with animal density maps. The result is a series of so-called "hotspot" maps of ship noise for all 10 marine mammal species, based on cumulative ship noise energy and average distribution in the boreal summer. South coast waters (Juan de Fuca and Haro Straits) are hotspots for all species that use the area, irrespective of their hearing sensitivity, simply due to ubiquitous ship traffic. Secondary hotspots were found on the central and north coasts (Johnstone Strait and the region around Prince Rupert). These maps can identify where anthropogenic noise is predicted to have above-average impact on species-specific habitat, and where mitigation measures may be most effective. This approach can guide effective mitigation without requiring fleet-wide modification in sites where no animals are present or where the area is used by species that are relatively insensitive to ship noise.

Severity of killer whale behavioral responses to ship noise: a dose-response study.

Critical habitats of at-risk populations of northeast Pacific "resident" killer whales can be heavily trafficked by large ships, with transits occurring on average once every hour in busy shipping lanes. We modeled behavioral responses of killer whales to ship transits during 35 "natural experiments" as a dose-response function of estimated received noise levels in both broadband and audiogram-weighted terms. Interpreting effects is contingent on a subjective and seemingly arbitrary decision about severity threshold indicating a response. Subtle responses were observed around broadband received levels of 130 dB re 1 µPa (rms); more severe responses are hypothesized to occur at received levels beyond 150 dB re 1 µPa, where our study lacked data. Avoidance responses are expected to carry minor energetic costs in terms of increased energy expenditure, but future research must assess the potential for reduced prey acquisition, and potential population consequences, under these noise levels.