Geography is more important than life history in the recent diversification of the tiger salamander complex.

The North American tiger salamander species complex, including its best-known species, the Mexican axolotl, has long been a source of biological fascination. The complex exhibits a wide range of variation in developmental life history strategies, including populations and individuals that undergo metamorphosis; those able to forego metamorphosis and retain a larval, aquatic lifestyle (i.e., paedomorphosis); and those that do both. The evolution of a paedomorphic life history state is thought to lead to increased population genetic differentiation and ultimately reproductive isolation and speciation, but the degree to which it has shaped population- and species-level divergence is poorly understood. Using a large multilocus dataset from hundreds of samples across North America, we identified genetic clusters across the geographic range of the tiger salamander complex. These clusters often contain a mixture of paedomorphic and metamorphic taxa, indicating that geographic isolation has played a larger role in lineage divergence than paedomorphosis in this system. This conclusion is bolstered by geography-informed analyses indicating no effect of life history strategy on population genetic differentiation and by model-based population genetic analyses demonstrating gene flow between adjacent metamorphic and paedomorphic populations. This fine-scale genetic perspective on life history variation establishes a framework for understanding how plasticity, local adaptation, and gene flow contribute to lineage divergence. Many members of the tiger salamander complex are endangered, and the Mexican axolotl is an important model system in regenerative and biomedical research. Our results chart a course for more informed use of these taxa in experimental, ecological, and conservation research.

Microbial assemblages reflect environmental heterogeneity in alpine streams.

Alpine streams are dynamic habitats harboring substantial biodiversity across small spatial extents. The diversity of alpine stream biota is largely reflective of environmental heterogeneity stemming from varying hydrological sources. Globally, alpine stream diversity is under threat as meltwater sources recede and stream conditions become increasingly homogeneous. Much attention has been devoted to macroinvertebrate diversity in alpine headwaters, yet to fully understand the breadth of climate change threats, a more thorough accounting of microbial diversity is needed. We characterized microbial diversity (specifically Bacteria and Archaea) of 13 streams in two disjunct Rocky Mountain subranges through 16S rRNA gene sequencing. Our study encompassed the spectrum of alpine stream sources (glaciers, snowfields, subterranean ice, and groundwater) and three microhabitats (ice, biofilms, and streamwater). We observed no difference in regional (γ) diversity between subranges but substantial differences in diversity among (ß) stream types and microhabitats. Within-stream (α) diversity was highest in groundwater-fed springs, lowest in glacier-fed streams, and positively correlated with water temperature for both streamwater and biofilm assemblages. We identified an underappreciated alpine stream type-the icy seep-that are fed by subterranean ice, exhibit cold temperatures (summer mean <2°C), moderate bed stability, and relatively high conductivity. Icy seeps will likely be important for combatting biodiversity losses as they contain similar microbial assemblages to streams fed by surface ice yet may be buffered against climate change by insulating debris cover. Our results show that the patterns of microbial diversity support an ominous trend for alpine stream biodiversity; as meltwater sources decline, stream communities will become more diverse locally, but regional diversity will be lost. Icy seeps, however, represent a source of optimism for the future of biodiversity in these imperiled ecosystems.

Innovative Models of Dental Care Delivery and Coverage: Patient-Centric Dental Benefits Based on Digital Oral Health Risk Assessment.

Innovative models of dental care delivery and coverage are emerging across oral health care systems causing changes to treatment and benefit plans. A novel addition to these models is digital risk assessment, which offers a promising new approach that incorporates the use of a cloud-based technology platform to assess an individual patient's risk for oral disease. Risk assessment changes treatment by including risk as a modifier of treatment and as a determinant of preventive services. Benefit plans are being developed to use risk assessment to predetermine preventive benefits for patients identified at elevated risk for oral disease.

The Impact of Risk-Based Care on Early Childhood and Youth Populations.

This quality improvement project explored dental caries risk among children residing in El Monte, Calif., a low-income area 16 miles east of Los Angeles. In an attempt to decrease oral health disparities, Western University of Health Sciences, College of Dental Medicine established school-based oral health centers in El Monte and implemented a modified caries risk assessment protocol. Results showed a statistically significant decrease in caries risk following disease management interventions.

Species discovery and validation in a cryptic radiation of endangered primates: coalescent-based species delimitation in Madagascar's mouse lemurs.

Implementation of the coalescent model in a Bayesian framework is an emerging strength in genetically based species delimitation studies. By providing an objective measure of species diagnosis, these methods represent a quantitative enhancement to the analysis of multilocus data, and complement more traditional methods based on phenotypic and ecological characteristics. Recognized as two species 20 years ago, mouse lemurs (genus Microcebus) now comprise more than 20 species, largely diagnosed from mtDNA sequence data. With each new species description, enthusiasm has been tempered with scientific scepticism. Here, we present a statistically justified and unbiased Bayesian approach towards mouse lemur species delimitation. We perform validation tests using multilocus sequence data and two methodologies: (i) reverse-jump Markov chain Monte Carlo sampling to assess the likelihood of different models defined a priori by a guide tree, and (ii) a Bayes factor delimitation test that compares different species-tree models without a guide tree. We assess the sensitivity of these methods using randomized individual assignments, which has been used in bpp studies, but not with Bayes factor delimitation tests. Our results validate previously diagnosed taxa, as well as new species hypotheses, resulting in support for three new mouse lemur species. As the challenge of multiple researchers using differing criteria to describe diversity is not unique to Microcebus, the methods used here have significant potential for clarifying diversity in other taxonomic groups. We echo previous studies in advocating that multiple lines of evidence, including use of the coalescent model, should be trusted to delimit new species.

Patient and family involvement in contemporary health care.

OBJECTIVE: The objective of this article was to provide a guide to health care providers on patient and family involvement in health care. METHODS: This article evaluated the latest published studies for patient and family involvement and reexamined the objectives, the requirements for achieving these objectives, and the evidence of how to involve patients and families. RESULTS: Critical components for patient safety include changing the organizational culture; including patients and families on teams; listening to patients and families; incorporating their input into leadership structures and systems; providing full detail about treatment, procedures, and medication adverse effects; involving them on patient safety and performance improvement committees; and disclosing medical errors. CONCLUSIONS: The conclusion of this article is that, for the future, patient and family involvement starts with educating patients and families and ends with listening to them and taking them seriously. If patient and family input is emphatically built into systems of performance improvement, and if patients and families are taken seriously and are respected for their valuable perspectives about how care can be improved, then organizations can improve at improving. Resources in health care are in short supply, yet the resources of patient and family help and time are almost limitless, are ready to be tapped, and can have a huge impact on improving the reliability and overall success for any health care organization.

X-linked agammaglobulinemia in a 10-year-old child: a case study.

PURPOSE: To discuss the advanced practice nurse's diagnosis and management of an unsuspected primary immunodeficiency (PI) disease, X-linked agammaglobulinemia (XLA), in a child. DATA SOURCES: Review of historical and current scientific literature, practice guidelines, and a case study. CONCLUSIONS: While a diagnosis of XLA is most commonly made in the first 3 years of life, this case study presents a 10-year-old boy's circuitous route to this diagnosis. A diagnosis of an immune defect should be considered for patients with chronic, recurrent, or unusual infections. For patients who lack immune globulins and antibodies, intravenous immune globulin, given monthly and continued throughout life, is the standard of care. IMPLICATIONS FOR PRACTICE: Diagnosis of children and adults with primary immune deficiency diseases may be delayed if practitioners fail to find the root cause of recurrent infections. Nurses as patient advocates should recognize the need for a referral in clinical cases where immunodeficiency may not be suspected. Evaluation of the immune system is performed by a panel of blood tests. There is a need to increase awareness of PI, their manifestations, and treatment among nurses both at the bedside and in advanced practice settings.

Hormone replacement therapy counseling: prevalence and predictors.

OBJECTIVES: To evaluate the prevalence of hormone replacement therapy (HRT) counseling and to investigate the relationship between patients' cultural background and healthcare professionals' counseling practices. HRT is the principal preventive intervention for reducing risk of menopause-related pathologic conditions. This study assessed self-reports of HRT counseling among women receiving care in an urban community hospital. METHODS: A descriptive self-reported survey study of 134 women aged 45-65 was conducted in the medical clinic at an urban community teaching hospital in a multicultural area in New York. Questionnaires asked about age, ethnicity, HRT use, contraindications, health professional counseling, and barriers to HRT counseling. Possible predictors of HRT counseling were analyzed with logistic regression models. Categorical variables were compared with chi-square statistics. RESULTS: Overall prevalence of HRT counseling was 25%. Prevalence of HRT use was 19%; among those using HRT, only 12.7% reported receiving HRT counseling. Physicians were more likely to discuss HRT than other healthcare professionals. Over 90% of the patients reported a desire for HRT counseling. CONCLUSIONS: The low rates of HRT counseling suggest physicians have limited daily experience with HRT counseling practices. Public health efforts should focus on increasing physician and general population awareness to promote HRT counseling strategies and ensure public access to HRT information.

Innovative Clinical Addiction Research Training Track in Preventive Medicine.

Medical education related to identification, diagnosis and management of alcohol and other drug problems receives inadequate attention in the undergraduate curriculum and during residency training. This article describes the design, implementation, and evaluation of a new track in Clinical Addiction Research Training (CART) in a General Preventive Medicine (GPM) residency program. CART is comprised of a new course in Addiction Medicine, new practicum sites in addiction medicine research and treatment, and a CART-designated resident. An Advisory Group of educators, researchers, scholars, and administrators in addiction medicine, has provided guidance and support for this new track. Evaluation of the CART track suggested improvements in residents' knowledge and attitudes. Residents engaged in high caliber clinical addiction research projects. The development of the CART track within the GPM residency is an approach that can be integrated into other specialties, such as internal medicine, family practice, and adolescent medicine, to develop residents' interest and expertise in the addictive behaviors.